Standards › Standard BASIS › Standard operating procedures (SOPs)
SOP · PCA-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: B2.3
At a glance
- Each policy the service has is audited in practice at least once a year, using the audit tool in the register (PCA-REG-001).
- The audit samples real practice on the wards and departments, not only the paperwork.
- Each gap found has an action with an owner and a due date, and is checked at the next audit.
- The results go to the governing body each year.
- Stop and get help straight away if: a policy has never been checked in practice, or a gap found in an audit has no action.
1. Purpose
To check that policies are followed in day-to-day practice, not only written down, and to close the gaps found (B2.3).
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 |
|---|---|
| Policy audit | A check of practice against a written policy, using observation, records and staff interviews. |
| Gap | A difference between what the policy says and what staff do in practice. |
4. Background
To check that policies are followed in day-to-day practice, not only written down, and to close the gaps found (B2.3).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Accountable person | Plans the audit programme, makes sure each policy is audited each year, and reports to the governing body | Governing body |
| Policy owner | Carries out the audit of their policy, records the results, and owns the actions | Accountable person |
| Ward or department lead | Acts on the gaps in their area and checks the change at the next audit | Policy owner |
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. Plan.
- Use the policy register (OPR-REG-001) to list every policy and its audit date for the year.
- Pick the sample: the areas and times where practice is observed, and the records to check.
Key point: Audit planned.
Step 2. Audit.
- Observe practice, check the records and interview staff against the policy.
- Record each gap with the area, the date and what was found.
Key point: Audit done and recorded.
Step 3. Act.
- Agree an action for each gap, with an owner and a due date, and record it in the register.
Key point: Actions agreed.
Step 4. Check and report.
- Check each action at the next audit and record whether the gap is closed.
- Report the results to the governing body each year.
Key point: Results reported.
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 |
|---|---|---|---|---|
| Policies audited in practice in the last 12 months | 100% | Annually | Accountable person | Add the missing audits to the next year’s plan |
| Gaps with an action, owner and due date | 100% | Quarterly | Accountable person | Escalate to the governing body |
| Gaps closed at the next audit | 90% or more | Annually | Accountable person | Review the actions and the support given |
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
- Policy owners are trained in how to audit practice and record a gap fairly, at induction and each year.
16. Related documents
| ID | Title | Use |
|---|---|---|
| PCA-REG-001 | Policy compliance audit register (existing) | Register |
| OPR-REG-001 | Policy register (existing) | 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
No e-learning course is linked to this document yet.
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)