CON-POL-003: Patient Council Terms of Reference

Standards › Standard 1 › Policies

Policy · CON-POL-003 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 1.12

1. Purpose

To set up a patient council that learns about the service, decides on priorities and shapes change, with minutes kept [ASF Policy 54 adapted, E-006].

2. Scope

Patients, carers and community representatives of the facility.

3. Responsibilities

Role	Responsibility
patient representative	Chairs the council and keeps the minutes.
chief executive	Receives and responds to recommendations.

4. Procedure

• Meet at least every three months [EC].
• Members are patients or carers who have used the service; no member is an employee in a decision role [EC].
• Minutes are anonymised and kept for the period set by the facility’s records policy years [EC].
• Each recommendation is answered in writing within 30 days [EC].

5. Records

Terms of reference and two most recent sets of minutes (anonymised).

6. Evidence

Reference	Note
E-006	ASF Policy Framework v1.2.
E-009	ASF Expert Committee consensus.

7. Change history

Version	Date	What changed	Approval
1.0	—	First approved version	Approved by the ASF Expert Committee

E-learning for this document

• Complaints Handling and Patient Feedback (T-12)
• Patient Rights and Responsibilities (A-01)

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)