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International Accreditation of Healthcare Facilities

Standards › Standard 7 › Policies

Policy · EDP-POL-001 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 7.1, 7.3

At a glance

  • Every emergency call is answered within the set time, at all hours.
  • The time to answer is measured on every call and reported each month.
  • The nearest suitable resource is dispatched within the set time.
  • Every dispatch time is measured, and the caller is given instructions while help is on the way.
  • Stop and get help straight away if: calls are answered outside the set time without escalation, or a dispatch time is not measured.

1. Purpose

To make sure every caller in an emergency is answered, and that help is sent quickly (7.1, 7.3).

2. Scope

Applies to Clinical and support staff in the hospital
Locations All wards, clinics and departments of the facility
When Whenever the activity described is carried out
Does not apply to Activities covered by another document listed in section 15

3. Definitions

Term Meaning
Clinical lead The doctor or nurse in charge of the area at the time

4. Background

The nearest suitable resource must reach the caller within a set time. Measuring dispatch time, and giving the caller clear instructions while they wait, closes the gap between call and arrival.

5. Responsibilities

Role Responsibility Competence
Operations manager Owns the times and the monthly report Management
Shift supervisor Watches the queue and the times in each shift Supervisor

6. Materials and equipment

Item Requirement Condition
Records and forms named in this document Current version Checked before use

7. Safety

8. Before you start

9. Procedure

Step 1. Answer.

  • Answer each emergency call within the set time, and measure it on the call record (EDP-FRM-001).

Key point: Every call, every time.

Step 2. Dispatch.

  • Send the nearest suitable resource, and record the dispatch time (EDP-REG-001).

Key point: Nearest suitable, within the time.

Step 3. Instruct.

  • Give the caller clear instructions while help is on the way.

Key point: The caller is not left alone.

10. Decision points

11. Special situations

Situation Action
Out of hours Follow the same steps. Use the on-call contact on the wall of the area.

12. Escalation

13. Monitoring

Measure Target Frequency Owner If not met
Calls answered within the set time At least 90% Monthly Operations manager Escalate to chief executive
Dispatches within the set time At least 90% Monthly Operations manager Escalate to chief executive

14. Records

Record Kept in Retention
Record named in this document Patient record or the area file the period set by the facility’s records policy years

15. Training

16. Related documents

ID Title Use
EDP-REG-001 Dispatch time register Register
EDP-SOP-002 Dispatch and pre-arrival instructions Procedure

17. Evidence

Reference Note
E-009 Set times to be confirmed against the national emergency service standard.
E-006 ASF Policy Framework v1.2. Adapted.
E-009 ASF Expert Committee consensus.

18. Change history

Version Date What changed Approval
1.0 the date of approval First version set Expert Committee approval

E-learning for this document

References

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