Standards › Standard 13 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · MOB-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 13 (Mobile Clinic and Outreach), criterion 13.8
At a glance
- Coverage is reviewed each quarter against the population the service is for.
- Groups not reached, such as people with disability or displaced people, are named.
- The schedule is changed to reach them, and the change is recorded (MOB-REG-002).
- Results are shared with the clinical lead.
- Stop and get help straight away if: a group known to be missed is not named or not reached, with no schedule change.
1. Purpose
To find the people a mobile service does not reach, and change the schedule (13.8).
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 mobile clinic can miss the people who most need it, if it does not look at who it reaches. Reviewing coverage finds the groups who are left out and sends the clinic to them.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Outreach lead | Runs the review | Clinician |
| Community liaison | Reports the groups not reached | Community worker |
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. Review.
- Compare people reached against the population each quarter (MOB-REG-002).
Key point: Each quarter.
Step 2. Name the gap.
- Name each group not reached and why.
Key point: Groups named.
Step 3. Change.
- Change the schedule to reach each group, and record the change.
Key point: Changed and recorded.
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 |
|---|---|---|---|---|
| Quarterly coverage reviews completed | 100% | Quarterly | Outreach lead | Escalate to clinical director |
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 |
|---|---|---|
| MOB-REG-002 | Coverage review register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO guideline on health policy and system support to optimize community health worker programmes (2018). |
| 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 |
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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)