Standards › Standard 44 › Policies
Policy · WAY-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 44.1
At a glance
- Public information states the address, opening hours, travel by public transport and by road, languages spoken and the emergency contact (WAY-FRM-001).
- Interpreter access is stated and provided on request (MTR-POL-002).
- Public information is checked each quarter against the current service.
- Printed and online information are kept the same.
- Stop and get help straight away if: public information gives an address or hours that are no longer correct.
1. Purpose
To make sure people can find the service and know how to reach it before they arrive (44.1).
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 cannot find the clinic before arriving may give up or arrive at the wrong place. Clear public information about the address, hours and how to get there helps the patient reach care.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Communications lead | Owns the public information and the quarterly check | Service director |
| Reception lead | Keeps the printed information and the listings current | Communications 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. Write.
- Write the public information with the address, hours, travel, languages and emergency contact.
Key point: Written.
Step 2. Check.
- Check each public source against the current service each quarter (WAY-FRM-001).
Key point: Checked.
Step 3. Correct.
- Correct any out-of-date information at once across every source.
Key point: Corrected.
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 |
|---|---|---|---|---|
| Public sources matching the current service | 100% | Quarterly | Communications lead | Escalate to the service 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 |
|---|---|---|
| WAY-FRM-001 | Public information check record | Record |
| MTR-POL-002 | Language access and interpreters (existing) | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Global Patient Safety Action Plan 2021–2030 for communication and patient access, the WHO Emergency Care Systems framework for emergency access, and the ASF Hospital standard for facility access. |
| 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)