Standards › Standard 44 › Policies
Policy · WAY-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 44.5
At a glance
- The service names who is responsible for access information.
- Each change to the site, entrance, hours or services triggers an update (WAY-REG-003).
- Public information is checked against the site after each change.
- The responsible person signs off each update.
- Stop and get help straight away if: a change to the entrance, hours or services is made and public information is not updated.
1. Purpose
To keep access information correct through every change to the site or the service (44.5).
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
Access information changes when a building is altered, a door is moved or a route is closed. Someone must be responsible for keeping it current, or the information becomes wrong.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Service director | Names the responsible person and approves the policy | Board or governing body |
| Responsible access lead | Triggers, makes and signs off each update | Service director |
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 responsible access lead and publish the name internally.
Key point: Named.
Step 2. Trigger.
- Trigger an update for each change to the site, entrance, hours or services (WAY-REG-003).
Key point: Triggered.
Step 3. Verify.
- Check the public information against the site after each change and sign off.
Key point: Verified.
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 |
|---|---|---|---|---|
| Changes with public information updated within the defined time | 100% | Quarterly | Responsible access 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-REG-003 | Access information change log | Register |
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)