Standards › Standard 36 › Policies
Policy · ED-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 36.3
At a glance
- A named senior clinician is responsible for the department at all times (ED-FRM-001).
- The name and contact are shown at the nurse station and in the on-call list.
- Specialist escalation follows a defined pathway with a stated response time.
- A call with no response within the stated time goes to the next level.
- Stop and get help straight away if: the department has no named senior clinician for any period.
1. Purpose
To make sure someone senior is always responsible for the department and that specialist help is reachable (36.3).
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
When something goes wrong in the department, someone senior must be in charge and reachable. Without a named senior clinician, decisions are delayed or made by nobody.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Emergency department lead | Owns the rota and the escalation pathway | Clinical director |
| Senior clinician on duty | Holds responsibility for the department for the shift | Emergency department lead |
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. Name.
- Name the senior clinician on duty for each period and publish the name and contact (ED-FRM-001).
Key point: Named.
Step 2. Escalate.
- Escalate each specialist need through the defined pathway and record the call.
Key point: Escalated.
Step 3. Follow up.
- If the response time is not met, escalate to the next level at once.
Key point: Followed up.
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 |
|---|---|---|---|---|
| Periods with a named senior clinician | 100% | Monthly | Emergency department lead | Escalate to the 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 |
|---|---|---|
| ED-FRM-001 | Senior clinician on duty record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Emergency Care Systems framework and the Emergency Triage Assessment and Treatment guidance, the WHO Global Patient Safety Action Plan 2021–2030 for handover, and the ASF Hospital standard for senior clinician responsibility. |
| 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)