Standards › Standard 42 › Policies
Policy · AFT-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 42.6
At a glance
- A complaint or feedback route can be used after discharge, by phone, online and in person.
- Each complaint is read and answered within the defined time (AFT-REG-003).
- Complaints are used to change practice where a pattern is found.
- No complaint is closed without an answer.
- Stop and get help straight away if: a complaint after discharge is logged and never answered.
1. Purpose
To make sure patients can complain after they leave, and that complaints lead to a reply and to action (42.6).
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 patient who leaves may still have a complaint, and may find it hard to raise it from home. A complaint route that works after discharge, and answers are given, keeps the service accountable.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Patient experience lead | Owns the route and the response standard | Clinical director |
| Responding manager | Answers each complaint and records the action | Patient experience 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. Receive.
- Receive the complaint by any of the routes offered and log it (AFT-REG-003).
Key point: Received.
Step 2. Answer.
- Answer the complaint within the defined time.
Key point: Answered.
Step 3. Act.
- Act on the complaint where needed and record the action.
Key point: Acted.
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 |
|---|---|---|---|---|
| Complaints answered within the defined time | 95% | Monthly | Patient experience 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 |
|---|---|---|
| AFT-REG-003 | Post-discharge complaint response register | Register |
| INC-POL-002 | Complaints and feedback (existing) | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Global Patient Safety Action Plan 2021–2030 for transitions of care, the WHO Emergency Care Systems framework for urgent help, and the ASF Hospital standard for discharge and aftercare. |
| 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)