Standards › Standard 39 › Policies
Policy · HUM-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 39.2
At a glance
- Each deployment has a written exit plan, handover or a defined time limit (FLD-PLN-003).
- The handover is agreed with the local health system before it takes place.
- Continuity after handover is tracked (HUM-REG-001).
- A deployment with no exit plan does not start.
- Stop and get help straight away if: a deployment ends with no handover and no agreed continuity.
1. Purpose
To make sure services do not stop abruptly when a deployment ends (39.2).
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
Humanitarian services are often meant to be temporary. Without a planned exit, the population is left without care when the team leaves. A written handover makes the end of the service safe.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Deployment lead | Writes and agrees the exit plan | Operations director |
| Local health authority liaison | Agrees the handover with the local system | Deployment 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. Plan the exit.
- Write the exit plan with the handover or the time limit, before services start.
Key point: Planned.
Step 2. Agree handover.
- Agree the handover with the local health system and record the agreement.
Key point: Agreed.
Step 3. Track.
- Track the continuity of each handed-over service (HUM-REG-001).
Key point: Tracked.
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 |
|---|---|---|---|---|
| Deployments with an agreed exit plan | 100% | Quarterly | Deployment lead | Escalate to the operations 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 |
|---|---|---|
| HUM-REG-001 | Handover tracking register | Register |
| FLD-PLN-003 | Closure and handover plan (existing) | Plan |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the Sphere Handbook (2018) minimum standards, the IASC Six Core Principles relating to sexual exploitation and abuse (2019), and the WHO Global Patient Safety Action Plan 2021–2030. |
| 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)