Standards › Standard 7 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · EDP-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 7.8
At a glance
- A call that cannot be sent at once is queued, with its priority.
- The queue is reviewed as the clinical picture changes.
- If a queued call is still waiting when the set time has passed, it goes to the named duty manager.
- Each escalation is recorded.
- Stop and get help straight away if: a queued call passes the set time without escalation to the duty manager.
1. Purpose
To keep a waiting call from getting worse without anyone knowing (7.8).
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
A call that cannot be sent at once can become more urgent while it waits. A queue that is reviewed and escalated stops a waiting call from being forgotten.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Shift supervisor | Reviews the queue | Supervisor |
| Duty manager | Receives escalations and acts | Manager |
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. Queue.
- Place the call in the queue with its priority and the time it was received.
Key point: Every queued call has a time.
Step 2. Review.
- Review the queue each time the clinical picture changes, and re-triage where needed.
Key point: The call can change.
Step 3. Escalate.
- Escalate to the duty manager at the set time, and record it (EDP-REG-004).
Key point: The time is the trigger.
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 |
|---|---|---|---|---|
| Queued calls re-reviewed | 100% | Monthly | Operations manager | Escalate to chief executive |
| Escalations at the set time | 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-REG-004 | Queue and escalation 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
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)