WTG-POL-001: Waiting time measurement and sharing

Policy · WTG-POL-001 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 45.1

At a glance

Waiting time is measured from arrival or booking, at the point written for each service.
Each service has a target waiting time set by the service.
Waiting times are compared with the target each month and shared with patients and staff (WTG-FRM-001).
Waits over the target are reviewed and the cause is recorded.
Stop and get help straight away if: waiting times are not measured or shared for a service that has a queue.

1. Purpose

To make sure waiting times are measured the same way, compared with a target and shared with patients and staff (45.1).

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

Patients who wait a long time for a service may leave, or be harmed by delay. Measuring the wait and sharing it against a target shows where action is needed.

5. Responsibilities

Role	Responsibility	Competence
Service lead	Sets the measurement point and the target for each service	Service director
Reception lead	Records the times and prepares the monthly comparison	Service 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. Set.

Set the start point, the end point and the target for each service with a queue.

Key point: Set.

Step 2. Measure.

Record the start and end time of every wait in the waiting time register (URG-REG-002).

Key point: Measured.

Step 3. Review and share.

Compare the waits with the target each month (WTG-FRM-001).
Share the result with patients and staff.

Key point: Shared.

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
Waits measured at the set points	100%	Monthly	Reception lead	Escalate to the service director
Services with a target and a monthly review	100%	Quarterly	Service director	Set the target within 30 days

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
WTG-FRM-001	Waiting time review record	Record
URG-REG-002	Waiting time register (existing, reused)	Register
ACC-SOP-001	Queue and wait-time management (existing, reused)	SOP

17. Evidence

Reference	Note
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

Reception & Information: The First Ten Minutes (H-02)

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)

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