Standards › Standard 32 › Policies
Policy · AES-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 32.1
At a glance
- Each practitioner works only within the procedures in their recorded scope.
- Each procedure type has a qualified practitioner recorded (STF-FRM-001).
- Competence is assessed and renewed for each procedure (WRK-SOP-001).
- A procedure outside the scope is not performed, and is referred.
- Stop and get help straight away if: a practitioner performs a procedure they are not qualified or competent for.
1. Purpose
To make sure only qualified and competent practitioners perform each aesthetic procedure (32.1).
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
Each practitioner must hold the qualification and training for the specific procedure they perform, not only a general licence. This is what keeps each procedure in the right hands.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical director | Sets the scope for each practitioner and approves the list | Medical director |
| Practitioner | Works within the recorded scope | 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. Set the scope.
- Record the procedures each practitioner is qualified and competent to perform.
Key point: Scope set.
Step 2. Check before each procedure.
- Confirm the procedure is within the practitioner’s scope.
Key point: Checked.
Step 3. Renew.
- Renew the competence assessment at the set interval.
Key point: Renewed.
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 |
|---|---|---|---|---|
| Practitioners with a current scope and competence | 100% | Quarterly | Clinical director | Escalate to the medical director |
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 |
|---|---|---|
| STF-FRM-001 | Staff credential register (existing, reused) | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO guidance on patient rights and informed consent, the WHO Global Patient Safety Action Plan 2021–2030, the American Dental Association guidelines on sedation and general anaesthesia (2016) for the sedation principles adapted to aesthetic practice, and the American Heart Association guidelines for cardiopulmonary resuscitation (2020). |
| 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)