Standards › Standard 37 › Policies
Policy · NEO-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 37.2
At a glance
- Each neonatal area is assigned a defined level of care (NEO-REG-001).
- Staffing is set for that level and checked each shift.
- A documented pathway moves a baby to a higher level of care (NEO-FRM-001).
- The step-up decision and the time it was made are recorded.
- Stop and get help straight away if: a neonatal area has no defined level of care or no staff to match it.
1. Purpose
To make sure each newborn is cared for in a unit and with staff that match the baby’s needs (37.2).
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 newborn needs the right level of care for their condition. A neonatal unit that is staffed for a lower level of care cannot keep a sick baby safe.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Neonatal lead clinician | Owns the level of care and the step-up pathway | Clinical director |
| Nurse in charge of the unit | Checks staffing each shift and records it | Neonatal lead 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. Assign.
- Assign the level of care for each neonatal area and publish it.
Key point: Assigned.
Step 2. Staff.
- Set staffing for the level and record it on each shift (NEO-REG-001).
Key point: Staffed.
Step 3. Step up.
- When a baby needs more care, follow the pathway and record the decision (NEO-FRM-001).
Key point: Stepped 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 |
|---|---|---|---|---|
| Shifts meeting the level of care staffing | 100% | Monthly | Neonatal lead clinician | 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 |
|---|---|---|
| NEO-FRM-001 | Neonatal level of care assessment record | Record |
| NEO-REG-001 | Neonatal staffing against level of care register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO recommendations on newborn health (2017), the WHO Global Patient Safety Action Plan 2021–2030, and the ASF Ambulatory and Hospital standards for paediatric and neonatal care. |
| 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
- Pediatric Ambulatory Care (AMB-23)
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)