Standards › Standard 2D › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · DIG-SOP-003 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2D.2
At a glance
- Offer every digital service with a non-digital alternative of equal quality.
- Ask each patient at booking which route they prefer. Never assume.
- Test each new digital service with patients who may struggle before launch.
- Record each alternative offered and used.
- Stop and get help straight away if: a patient is refused care or delayed because they cannot use a digital route.
1. Purpose
To make sure patients who cannot or prefer not to use digital care are never disadvantaged by it, and receive the same service through another route [EC].
2. Scope
| Applies to | Reception, booking, clinical and patient support staff, digital service leads |
| Locations | All patient-facing digital services at the facility |
| When | At booking, at each new digital service, and at each review |
| Does not apply to | Clinical content decisions, covered by clinical protocols |
3. Definitions
| Term | Meaning |
|---|---|
| Digital exclusion | Being unable to use or access digital services, because of skills, devices, internet, language, disability or choice |
| Equivalent route | An alternative giving the same clinical result, timeliness and quality |
4. Background
Digital convenience for most patients can become a barrier for the patients least able to adapt. Criterion 2D.2 requires a defined alternative and testing with those who might struggle [SOP-023, generic].
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Digital service lead | Owns each service and its alternative route | Digital service management |
| Reception and booking staff | Ask the patient’s preferred route; offer the alternative | Induction |
| Clinical leads | Confirm the alternative gives equal clinical care | Clinical |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Alternative route description per service | Current | Published with the service |
| Patient preference record (DIG-FRM-003) | Current | Held in the patient file |
7. Safety
- A patient must never be refused care because they chose not to use a digital route.
8. Before you start
- Check the alternative route for each service is open and staffed.
9. Procedure
Step 1. Define the alternative.
- For each digital service, write the alternative route, its timeliness and its clinical equivalence.
Key point: The alternative must be as good, not just available.
Step 2. Pre-test with patients.
- Before launch, test the service with patients who might struggle: older people, people with disabilities, people with limited literacy or language.
- Record the findings and the changes made.
Key point: Testing with the users most at risk finds the barriers that the design team misses.
Step 3. Ask and offer.
- At booking, ask the patient which route they prefer and record it on DIG-FRM-003.
- Offer the alternative without requiring the patient to ask for it.
Key point: Patients are often too embarrassed to ask.
Step 4. Confirm equivalence.
- Check that patients on the alternative route get the same timeliness and clinical quality.
- Sample 10 patients each quarter.
Key point: Equivalence is shown by the outcome, not by the existence of a form.
Step 5. Review.
- Review each service each year, with the findings from patients who used the alternative.
Key point: The people using the alternative are the best source of improvements.
10. Decision points
- If the alternative route causes a delay longer than the standard for that service, the service lead fixes the delay within 30 days.
11. Special situations
| Situation | Action |
|---|---|
| Patient with no phone or internet | Offer a phone or in-person route, and an assisted digital option if the patient wants one. |
12. Escalation
- Complaints about exclusion go to INC-POL-002 and the digital service lead.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Patients offered the alternative (sample) | 100% | Quarterly | Digital service lead | Re-brief staff |
| Alternative routes with equal timeliness (sample) | Set by committee (EC) | Quarterly | Clinical lead | Fix within 30 days |
| Services pre-tested with at-risk patients before launch | 100% | Each launch | Digital service lead | Do not launch |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| DIG-FRM-003 Digital Alternative Record | Patient file | As the patient record (EC) |
15. Training
- Reception staff are trained in offering the alternative at induction and yearly (EC).
16. Related documents
| ID | Title | Use |
|---|---|---|
| DIG-FRM-003 | Digital Alternative Record | Used in step 3 |
| SOP-023 | Digital Exclusion Support Process (generic) | Basis |
| CON-POL-002 | Non-Discrimination and Equal Access to Care | Equal access duty |
| DIG-SOP-002 | Digital Care System Assessment and Management | Assessment before launch |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. Pre-test group and sample size to be agreed. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | Approved by the ASF Expert Committee |
| 1.1 | the date of approval | Internal quality review: corrected cross-references, status wording and document control | Approved by the ASF Expert Committee |
E-learning for this document
No e-learning course is linked to this document yet.
Planned course: Digital inclusion: care that never disadvantages a patient who cannot use digital tools. New course planned.
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)