Standards › Standard 2B › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · FAC-SOP-002 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2B.9
At a glance
- Log every failure of a critical service within the shift.
- Find the cause, using a simple method (for example, the five whys).
- Agree one change that prevents the failure from recurring.
- Review repeated failures each quarter.
- Stop and get help straight away if: a failure is not logged or is closed without a cause.
1. Purpose
To make sure each failure of a critical service is recorded, analysed and used to prevent recurrence [EC].
2. Scope
| Applies to | Facilities and IT staff who respond to failures, and clinical leads who report them |
| Locations | The whole facility |
| When | At each failure and at the quarterly review |
| Does not apply to | Serious incidents, which follow INC-SOP-001 |
3. Definitions
| Term | Meaning |
|---|---|
| Failure | Loss, reduction or fault in a critical service |
| Cause | The underlying reason, not the symptom |
4. Background
A failure log only protects patients if it leads to change. Criterion 2B.9 asks for failures to be analysed so they do not recur.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Responding engineer | Logs the failure; finds the cause | Engineering |
| Facilities manager | Reviews each entry; agrees the change | Facilities management |
| Quality lead | Reviews repeated failures quarterly | Quality |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Failure log (FAC-REG-002) | Current | Available to responders |
7. Safety
- Make the area safe before investigating.
8. Before you start
- Note the time the failure was first seen.
9. Procedure
Step 1. Log at once.
- Enter date, time, service, area, and the impact on patients.
Key point: The time is the start of the evidence.
Step 2. Restore and record.
- Restore the service and record how it was restored and for how long it was down.
Key point: Restoration details are needed to see whether back-up worked.
Step 3. Find the cause.
- Ask why the failure happened, at least five times, until you reach a cause you can change.
Key point: A cause such as “the fuse blew” needs another why.
Step 4. Agree the change.
- Agree one change to the equipment, maintenance, testing or procedure that prevents recurrence.
- Give it an owner and a due date.
Key point: A change is what closes the failure.
Step 5. Review repeats.
- Each quarter, look for repeated failures of the same service or area.
- Escalate any repeat to the chief executive.
Key point: Repeats show the change did not work.
10. Decision points
- If a cause cannot be found within 5 working days, a specialist review is arranged (EC).
11. Special situations
| Situation | Action |
|---|---|
| Failure affecting patients | Also report as an incident at once. |
12. Escalation
- Repeated failures go to the chief executive.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Failures logged within the shift | 100% | Each event | Facilities manager | Review of the event |
| Failures closed with a cause and a change | 100% | Monthly | Facilities manager | Escalate |
| Repeat failures reviewed quarterly | 100% | Quarterly | Quality lead | Escalate |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| FAC-REG-002 Failure Log | Facilities file | the period set by the facility’s records policy years |
15. Training
- Responding engineers are trained in simple root-cause methods (EC).
16. Related documents
| ID | Title | Use |
|---|---|---|
| FAC-REG-002 | Failure Log | The log |
| INC-SOP-001 | Root Cause Analysis of Serious Incidents | For serious failures |
| FAC-PLN-001 | Critical Services Testing and Back-up Plan | Parent plan |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. |
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
- Environment & Shared Spaces (H-03)
Planned course: Planned fault prevention and maintenance. New course planned.
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)