Standards › Standard 46 › Policies
Policy · DIS-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 46.1
At a glance
- A written disaster plan covers the whole facility (HOS-PLN-001).
- A named incident lead is responsible for the plan and can act at any hour.
- A deputy incident lead is named for when the lead is unavailable.
- The plan is reviewed each year and whenever the facility, services or risks change.
- Stop and get help straight away if: no named incident lead can be reached at any hour, or the plan does not cover the whole facility.
1. Purpose
To make sure one named person owns the disaster plan and can activate it at any hour (46.1).
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
A hospital hit by a disaster must know who leads the response and what to do. A written plan that covers the whole facility, with a named lead, is the basis of the response.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Hospital director | Names the incident lead and deputy and approves the plan | Board or owner |
| Incident lead | Owns the plan, keeps the contact rota and activates the plan when needed | Hospital 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. Name.
- Name the incident lead and deputy, and record their contact details on the on-call rota.
Key point: Named.
Step 2. Write and cover.
- Keep the written plan current, covering every building, service and department (HOS-PLN-001).
Key point: Covered.
Step 3. Review.
- Review the plan each year and after any change to the facility, services or risks.
Key point: Reviewed.
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 |
|---|---|---|---|---|
| Incident lead reachable at any hour in a test call | 100% | Quarterly | Hospital director | Name a new lead within 7 days |
| Plan reviewed on schedule | 100% | Yearly | Incident lead | Escalate to the hospital 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 |
|---|---|---|
| HOS-PLN-001 | Mass-casualty and utility failure plan (existing, reused) | Plan |
| FAC-PLN-002 | Climate and health emergency continuity plan (existing, reused) | Plan |
17. Evidence
| Reference | Note |
|---|---|
| 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)