Standards › Standard 46 › Standard operating procedures (SOPs)
SOP · DIS-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 46.2
At a glance
- The assessment covers natural hazards, technical failures, violence, outbreaks and the effects of climate change (DIS-FRM-001).
- Each hazard is scored for likelihood and impact.
- The assessment is updated each year and after any event or change in risk.
- Climate risks are assessed with the climate and health emergency risk assessment (FAC-SOP-003).
- Stop and get help straight away if: a hazard that has happened at the facility is not in the current assessment.
1. Purpose
To find the hazards the facility faces, and how badly each would affect patients and services (46.2).
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
Hospitals face different hazards: floods, earthquakes, heat, power loss. A regular hazard assessment, including climate and utilities, shows which ones matter most.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Incident lead | Leads the assessment and keeps it current | Hospital director |
| Facilities manager | Assesses technical and utility hazards | Incident lead |
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. List.
- List the hazards: natural, technical, violence, outbreak and climate-related (FAC-SOP-003).
Key point: Listed.
Step 2. Score.
- Score each hazard for likelihood and impact on patients and services (DIS-FRM-001).
Key point: Scored.
Step 3. Act and update.
- Set a control or plan for each high-scoring hazard.
- Update the assessment each year and after any event.
Key point: Updated.
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 |
|---|---|---|---|---|
| Hazards in the current assessment | 100% | Yearly | Incident lead | Complete the assessment within 30 days |
| High-scoring hazards with a control or plan | 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 |
|---|---|---|
| DIS-FRM-001 | Hazard and vulnerability assessment record | Record |
| FAC-SOP-003 | Climate and health emergency risk assessment (existing, reused) | SOP |
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)