Standards › Standard 7 › Policies
Policy · EDP-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 7.6
At a glance
- The dispatch system has back-up power, communication and equipment.
- Each back-up is tested on a set schedule, and the test is recorded.
- A failure moves calls to the back-up within the set time.
- The back-up is part of the contingency plan.
- Stop and get help straight away if: the system fails and calls cannot be answered or dispatched on the back-up.
1. Purpose
To keep calls answered when the power, the lines or the system fail (7.6).
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
When the power, phone lines or the system fail during a busy shift, calls must still be answered. A back-up that has been tested is the only way to know it will work.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Operations manager | Owns the back-up and its tests | Management |
| IT and facilities lead | Tests and maintains the back-up | Technical |
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. Have a back-up.
- Keep back-up power, a second communication line and a back-up dispatch system.
Key point: Each failure has a back-up.
Step 2. Test.
- Test each back-up on the schedule and record it (EDP-REG-003).
Key point: A back-up not tested is not a back-up.
Step 3. Switch.
- Switch to the back-up within the set time when a failure happens, and record the switch.
Key point: Switch within the time.
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 |
|---|---|---|---|---|
| Back-ups tested on schedule | 100% | Quarterly | IT and facilities lead | Escalate to chief executive |
| Failures switched to back-up within the set time | 100% | Yearly | 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-REG-003 | Back-up test log | Log |
| PTR-SOP-012 | Contingency, breakdown, surge and diversion | Contingency |
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
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)