Standards › Standard 49 › Policies
Policy · DGN-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 49.4
At a glance
- Patients are treated with respect for privacy, dignity, and cultural and religious needs (HSP-SOP-002).
- Care is not withheld or delayed because of a patient’s identity, status or background.
- Interpreters and cultural mediators are used where needed (HMG-POL-003).
- Breaches of dignity are reported, and each report is reviewed (DGN-FRM-001).
- Stop and get help straight away if: a patient is refused or delayed care because of their identity, status or background.
1. Purpose
To make sure every patient is treated with dignity, privacy and respect for their cultural and religious needs (49.4).
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
Patients who are dying or seriously ill still have privacy, dignity and their own beliefs. Respecting them in every interaction is part of care, not an extra.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Every staff member | Treats each patient with dignity and reports any breach | Ward manager |
| Ward manager | Reviews breaches and makes sure privacy is protected | Clinical 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. Respect.
- Protect privacy and respect cultural and religious needs in every interaction.
Key point: Respected.
Step 2. Report.
- Report any breach of dignity or any refusal of care on identity or background.
Key point: Reported.
Step 3. Review.
- Review each report and act on the findings (DGN-FRM-001).
Key point: Reviewed.
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 |
|---|---|---|---|---|
| Dignity observations with no breach | 100% | Monthly | Ward manager | Review the ward’s practice within 7 days |
| Reports reviewed within 7 days | 100% | Monthly | Ward manager | Escalate to the clinical lead |
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 |
|---|---|---|
| DGN-FRM-001 | Dignity observation and report record | Record |
| HSP-SOP-002 | Spiritual, cultural and psychological needs (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
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)