Standards › Standard 7 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · EDP-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 7.7
At a glance
- Review a sample of calls each month, chosen at random and across shifts.
- Score each call against the protocol and the standard.
- Use the findings to change the protocols and the training.
- Report the findings to the operations meeting.
- Stop and get help straight away if: a review finding has no action, or the sample is not random.
1. Purpose
To find where the protocols and the training fall short, and to improve them (7.7).
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
Reviewing a sample of calls shows where the protocols and the training fall short. The findings are useful only if they change the protocols and the training.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Quality lead | Runs the review and the report | Clinician or quality lead |
| Operations manager | Acts on the findings | Management |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Sample.
- Choose a random sample of calls each month across all shifts.
Key point: Random, not selected.
Step 2. Score.
- Score each call on the review form (EDP-FRM-002).
Key point: Against the standard.
Step 3. Improve.
- Agree a change to the protocol or the training for each finding, with an owner and a date.
Key point: A finding leads to a change.
10. Decision points
- No decision points in this procedure.
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
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Calls reviewed each month | At least 1% of calls | Monthly | Quality lead | Escalate to chief executive |
| Findings with an action | 100% | 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
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| EDP-FRM-002 | Call review form | Form |
| EDP-REG-002 | Call-taker training and competence register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. |
| 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
- Incident Reporting, Just Culture and Open Disclosure (T-09)
- Safety Training Programme & Competency Assessment (TRAIN-01)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)