Standards › Standard 23 › Policies
Policy · NET-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 23.3
At a glance
- Core clinical policies are the same at every site, using the network standard list.
- Any local variation is written down and justified in the variation register (NET-REG-002).
- A variation with no justification is not permitted.
- Sites review the variation register at each policy review.
- Stop and get help straight away if: two sites give the same drug with different protocols and no reason.
1. Purpose
To keep core clinical policy the same across sites, with any local difference explicitly justified (23.3).
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
Each site doing clinical care in its own way makes the network hard to trust and hard to audit. Core policies should be the same everywhere, and any local difference should be written and justified.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Central clinical lead | Owns the network standard and approves variations | Clinician |
| Site clinical leads | Propose and record local variations | Clinician |
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. Set the standard.
- Keep the core clinical policy list as the network standard.
Key point: Standard kept.
Step 2. Justify variation.
- Propose any local variation with its justification, and record it in NET-REG-002.
Key point: Justified.
Step 3. Review.
- Review the variation register at each policy review.
Key point: Reviewed.
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 |
|---|---|---|---|---|
| Local variations with a recorded justification | 100% | Each policy review | Central clinical lead | Escalate to governing body |
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 |
|---|---|---|
| NET-REG-002 | Register of justified local variations | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Framework on integrated people-centred health services (2016) and ISO 9001:2015 quality management principles. |
| 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
- Governance & Management (H-07)
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)