Standards › Standard 2C › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · ENV-SOP-005 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2C.3
At a glance
- Report progress on each sustainability goal to governance every quarter.
- Use ENV-FRM-003 for the report.
- Governance must discuss the report and record the decision.
- Keep the last four quarterly reports on file.
- Stop and get help straight away if: a quarter passes without a report, or the report is received without discussion.
1. Purpose
To make sure progress against the sustainability goals is seen, discussed and acted on by the governing body on a set schedule [EC].
2. Scope
| Applies to | Facilities manager, governing body secretary, chief executive |
| Locations | Governing body meetings at the facility |
| When | Every quarter |
| Does not apply to | Clinical quality reporting, which follows the quality plan (GOV-PLN-002) |
3. Definitions
| Term | Meaning |
|---|---|
| Governance | The board or governing body that sets institutional priorities |
| Decision record | The minute showing what governance decided because of the report |
4. Background
Goals that governance never sees are easily dropped. Criterion 2C.3 needs a regular report, real discussion and a recorded decision.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Facilities manager | Prepares the report each quarter | Facilities management |
| Chief executive | Presents the report and proposes decisions | Executive leadership |
| Governing body secretary | Records the discussion in the minutes (GOV-FRM-003) | Governance administration |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Quarterly progress report (ENV-FRM-003) | Current | Ready 5 working days before the meeting |
7. Safety
- Report figures accurately. Do not present a target as achieved without data.
8. Before you start
- Collect the quarter data from ENV-FRM-008 and the other records.
9. Procedure
Step 1. Prepare the report.
- Complete ENV-FRM-003 for each goal: baseline, target, current value, trend and actions.
- Check the figures against the source records.
Key point: Governance decides on what it is shown. Accuracy matters.
Step 2. Present to governance.
- Present the report at the next governance meeting.
- Ask governance to review the progress and to say whether the goals should change.
Key point: The question to governance must be a decision, not “for information”.
Step 3. Record the decision.
- The secretary records the discussion and any decision in the minutes (GOV-FRM-003).
- Record the actions and owners.
Key point: The minute is the evidence that governance acted.
Step 4. Follow up.
- Track each governance action to closure in the programme.
- Report the status of decisions at the next quarter.
Key point: Follow-up closes the loop.
10. Decision points
- If a goal is off track for two quarters, governance decides whether to change the action, the target or the resources.
11. Special situations
| Situation | Action |
|---|---|
| Governance meeting missed | Send the report in writing and ask for it to be taken at the next meeting. |
12. Escalation
- If a goal is significantly off track, the chief executive informs governance between meetings.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Quarterly reports sent on time | 100% | Quarterly | Facilities manager | Escalate to chief executive |
| Reports with minuted discussion | 100% | Quarterly | Governing body secretary | Remind governance |
| Last four quarters on file | Yes | Yearly | Chief executive | Correct within 30 days |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| ENV-FRM-003 Quarterly Progress Report | Governance file | the period set by the facility’s records policy years |
| GOV-FRM-003 Minutes (extract) | Governance file | the period set by the facility’s records policy years |
15. Training
- Governing body members are briefed on the reports at appointment (EC).
16. Related documents
| ID | Title | Use |
|---|---|---|
| ENV-FRM-003 | Sustainability Progress Report | Used in step 1 |
| GOV-FRM-003 | Governing Body Minutes Template | Used in step 3 |
| GOV-PLN-002 | Quality Improvement Plan | Related reporting |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. Quarter schedule set by the ASF Expert Committee with governance. |
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: Reporting sustainability progress to governance. New course planned.
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)