CLN-POL-001: Staffing levels and skill mix

Policy · CLN-POL-001 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 1.1

At a glance

Staffing is calculated from patient volume and acuity, not from a fixed roster.
Skill mix is set for each shift, with a named senior clinician in charge.
The calculation is reviewed each month and after any change in demand.
Gaps are recorded and escalated the same shift.
Stop and get help straight away if: a shift runs below the calculated safe level with no escalation recorded.

1. Purpose

To make sure there are enough staff with the right skills for the patients in the care area (1.1).

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

Too few nurses for the number of patients, or too few with the right skills, leads to missed care and avoidable harm. Staffing should be calculated from real demand, not from habit.

5. Responsibilities

Role	Responsibility	Competence
Chief nurse or clinical director	Owns the calculation and approves the skill mix	Management
Duty manager	Checks each shift against the calculation	Senior clinician

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. Calculate.

Use the patient numbers and acuity for the last 4 weeks to calculate the staff needed for each shift (CLN-FRM-001).

Key point: Calculated from real demand.

Step 2. Check each shift.

Compare the rota with the calculation before each shift.
Escalate any gap to the duty manager.

Key point: Gap found before the shift, not during.

Step 3. Review.

Review the calculation each month and after any change in case mix.

Key point: The calculation follows the patients.

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
Shifts at or above the calculated level	At least 90%	Monthly	Chief nurse	Escalate to chief executive
Gaps with escalation recorded	100%	Monthly	Duty manager	Escalate to chief executive

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
CLN-FRM-001	Staffing calculation record	Calculation

17. Evidence

Reference	Note
E-009	ASF Expert Committee consensus.
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

Correct Patient Identification (—)
Patient Identification, Informed Consent and Patient Rights (T-07)
Governance & Management (H-07)
Care & Treatment: Clinical Standards for Accreditation (H-04)

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)

Download this document as PDF

Download this document as an editable Word file