Standards › Standard 60 › Standard operating procedures (SOPs)
SOP · SSC-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 60.1
At a glance
- Each surgeon has documented privileges for the procedures they perform (SSC-REG-001).
- The operating list is checked against privileges before each session.
- A short-notice addition is checked and approved before it is done.
- Stop and get help straight away if: a procedure is started by a surgeon with no privileges for it.
1. Purpose
To make sure surgeons operate only within their granted privileges (60.1).
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
To make sure surgeons operate only within their granted privileges (60.1).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical director | Grants and reviews privileges | Hospital director |
| Theatre coordinator | Checks each operating list against the register before the session | Clinical 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. Register.
- Record each surgeon’s privileges for each procedure (SSC-REG-001).
Key point: Registered.
Step 2. Check the list.
- Check each operating list against the register before the session.
Key point: Checked.
Step 3. Approve additions.
- Check and approve any short-notice addition before it is done.
Key point: Approved.
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 |
|---|---|---|---|---|
| Operating lists checked before the session | 100% | Monthly | Clinical director | Stop the session until checked |
| Procedures done within privileges | 100% | Monthly | Clinical director | Review the surgeon’s privileges |
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 |
|---|---|---|
| SSC-REG-001 | Surgeon privileges register | Register |
| SPM-REG-002 | Clinician qualification and scope register (existing, reused) | Register |
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)