Standards › Standard 26 › Policies
Policy · DIA-POL-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 26.11
At a glance
- Staffing levels, roles and competence requirements are written for dialysis.
- Each member of staff is competent for their role before working unsupervised, and the training is recorded (WRK-REG-001).
- No shift runs with a nurse who has not been trained on the machines.
- Competence is reviewed each year.
- Stop and get help straight away if: a shift is run by one nurse who has not been trained on the machines.
1. Purpose
To make sure dialysis staffing and competence are defined, and no one works unsupervised before they are competent (26.11).
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 dialysis unit needs enough trained staff, and each person needs the right skills for their role. Defining staffing and competence keeps the unit safe on every shift.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Dialysis unit lead | Sets staffing and competence requirements | Clinician or 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. Define.
- Write the staffing levels, roles and competence requirements.
Key point: Defined.
Step 2. Confirm competence.
- Confirm each member is competent before unsupervised work, and record it.
Key point: Confirmed.
Step 3. Review.
- Review competence each year.
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 |
|---|---|---|---|---|
| Shifts staffed to the defined levels with competent staff | 100% | Monthly | Dialysis unit lead | Escalate to medical 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 |
|---|---|---|
| WRK-REG-001 | Training matrix register (existing, reused) | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on ISO 23500:2019 (fluids for haemodialysis) and the KDIGO Clinical Practice Guideline for Hemodialysis Adequacy (2015 update). |
| 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)