Standards › Standard 45 › Standard operating procedures (SOPs)
SOP · WTG-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 45.4
At a glance
- Written information uses short sentences, common words and one idea at a time.
- Each item is tested with a sample of the people who will use it before it is issued (WTG-REG-001).
- Each item is available in the languages the population uses (MTR-POL-002).
- Each item is reviewed every two years, or sooner when its content changes.
- Stop and get help straight away if: an item is issued without a recorded test with people who will use it.
1. Purpose
To make sure written health information can be understood by the people who will use it, in the languages they use (45.4).
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
Health information that is hard to understand does not help. Writing in plain language, and testing it with the people who will use it, makes it usable.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Communications lead | Writes the items and arranges the user test | Service director |
| Clinical lead | Checks the medical content is correct and current | 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. Write.
- Write the item in plain language, with the most important point first.
Key point: Written.
Step 2. Test.
- Test the item with a sample of the people who will use it, and change it where they do not understand it.
- Record the test (WTG-REG-001).
Key point: Tested.
Step 3. Translate and issue.
- Translate the item into each language the population uses.
- Issue the item and record the date.
Key point: Issued.
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 |
|---|---|---|---|---|
| Items tested before issue | 100% | Each issue | Communications lead | Withdraw the item until tested |
| Items reviewed on schedule | 100% | Yearly | Communications lead | Review at once |
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-REG-001 | Patient information test register | Register |
| MTR-POL-002 | Language access and interpreters (existing, reused) | Policy |
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
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)