Standards › Standard 46 › Standard operating procedures (SOPs)
SOP · DIS-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 46.5
At a glance
- After each real activation, or a drill with significant findings, a structured review is held within 14 days.
- The review records what worked, what did not and why.
- Each finding becomes a written change to the plan, with an owner and a date.
- Serious incidents also go through root cause analysis (INC-SOP-001).
- Stop and get help straight away if: a finding from an activation has no written change to the plan.
1. Purpose
To make sure every activation or significant drill improves the plan in writing (46.5).
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
After a real disaster, or a drill that exposes gaps, the plan must be changed. Reviewing it after each activation keeps it realistic.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Incident lead | Holds the review and owns the changes | Hospital director |
| Staff involved | Take part and give their account | 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. Hold.
- Hold the structured review within 14 days, with the staff involved.
- Record the debrief (PTR-FRM-007).
Key point: Held.
Step 2. Change.
- Write each change to the plan with an owner and a date.
- Carry out a root cause analysis for any serious incident (INC-SOP-001).
Key point: Changed.
Step 3. Check.
- Confirm each change is in the approved plan before the next drill.
Key point: Checked.
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 |
|---|---|---|---|---|
| Activations and significant drills with a review within 14 days | 100% | Each event | Incident lead | Escalate to the hospital director |
| Review findings with a written plan change | 100% | Each event | Incident lead | Reopen the review |
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 |
|---|---|---|
| PTR-FRM-007 | Post-incident debrief record (existing, reused) | Record |
| INC-SOP-001 | Root cause analysis of serious incidents (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)