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Policy · APR-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: B2.1
At a glance
- One named person holds documented accountability for the safety and quality of the service.
- Staff and patients can identify that person, and how to contact them.
- A named deputy covers absences, and every handover of accountability is recorded.
- The appointment is reviewed each year, and whenever the person changes.
- Stop and get help straight away if: there is no named accountable person, or staff and patients cannot identify that person.
1. Purpose
To make sure one named person is accountable for the safety and quality of the service, and that everyone knows who that is (B2.1).
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 |
|---|---|
| Accountable person | The named individual who holds overall accountability for the safety and quality of the service. |
| Deputy | The named person who holds accountability while the accountable person is absent. |
4. Background
To make sure one named person is accountable for the safety and quality of the service, and that everyone knows who that is (B2.1).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Governing body | Appoints the accountable person in writing, and reviews the appointment each year | Board or owner |
| Accountable person | Holds accountability for safety and quality, signs the annual statement, and chairs the quality meeting | Governing body |
| Deputy | Holds accountability during absences, and records each handover | Accountable person |
| All staff | Know who the accountable person is and how to reach them | Ward or department 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. Appoint.
- The governing body appoints the accountable person in writing and names a deputy.
- Record the appointment in the appointment record (APR-FRM-001).
Key point: Appointment recorded.
Step 2. Declare.
- Publish the name, role and contact route on the noticeboard, on the website and in patient information.
- Tell all staff at induction and in the annual update.
Key point: Name published.
Step 3. Cover.
- When the accountable person is absent, the deputy holds accountability, and the handover is recorded with the dates.
Key point: Cover recorded.
Step 4. Review.
- Review the appointment each year, and whenever the person changes. Record the review date and the signature of the governing body.
Key point: Appointment 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 |
|---|---|---|---|---|
| Named accountable person and deputy in place | 100% | Quarterly | Governing body | Escalate to the governing body at once |
| Staff sampled who can name the accountable person | 9 in 10 or more | Annually | Accountable person | Republish the name and retrain at induction |
| Annual review completed and signed | 100% | Annually | Governing body | Escalate to the owner |
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
- The accountable person completes governance and leadership training within six months of appointment.
- Staff are told the name of the accountable person at induction.
16. Related documents
| ID | Title | Use |
|---|---|---|
| APR-FRM-001 | Accountable person appointment record (existing) | Form |
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 |
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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)