Standards › Standard 6 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · DAY-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 6.7
At a glance
- Each planned day case admitted unplanned is reviewed.
- The review asks why the patient was not sent home as planned.
- Each finding has an action with an owner.
- Findings are reported each quarter.
- Stop and get help straight away if: an unplanned admission is not reviewed, or a finding has no action.
1. Purpose
To learn from each day case that could not go home as planned (6.7).
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
When a patient planned for same-day discharge is admitted, something went wrong in the planning. Reviewing each one shows the cause and stops it happening again.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical director | Leads the quarterly review | Clinician |
| Lead nurse | Completes the review for each admission | Nurse |
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. Review.
- Within 7 days, complete the review for each unplanned admission (DAY-REG-002).
Key point: Within 7 days.
Step 2. Find the cause.
- Record the reason: selection, complication, pain, nausea, or other.
Key point: The cause, not the blame.
Step 3. Act.
- Agree an action with an owner and a date, and close it at the next review.
Key point: Learning is an action.
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 |
|---|---|---|---|---|
| Unplanned admissions reviewed within 7 days | 100% | Quarterly | Clinical director | Escalate to chief executive |
| Review actions closed on time | At least 90% | Quarterly | Clinical director | 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 |
|---|---|---|
| DAY-REG-002 | Unplanned admission review register | Register |
| DAY-POL-001 | Patient selection for same-day surgery | Selection |
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
- Incident Reporting, Just Culture and Open Disclosure (T-09)
- Aftercare & Follow-up: Standards for Safe Discharge (H-06)
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)