Standards › Standard 9 › Plans and templates
Plan · FLD-PLN-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 9.9
At a glance
- A security risk assessment is done before opening and reviewed each year.
- The plan names who protects patients and staff, and how.
- The whole unit can be evacuated, and the evacuation is rehearsed each year.
- Each security incident is reported.
- Stop and get help straight away if: the unit has no evacuation plan, or a security incident is not reported.
1. Purpose
To protect patients and staff from violence and the security situation, including evacuation of the unit (9.9).
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
To protect patients and staff from violence and the security situation, including evacuation of the unit (9.9).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Field unit lead | Owns the plan and the evacuation | Clinician |
| Security lead | Runs the risk assessment | Security |
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. Assess the risk.
- Do the security risk assessment before opening, and review it every year.
Key point: Dated and reviewed.
Step 2. Plan the evacuation.
- Name the exit routes, the assembly point and the transport for patients.
Key point: The whole unit can leave.
Step 3. Rehearse and report.
- Rehearse the evacuation each year (HOS-REG-004) and report each incident (WRK-FRM-003).
Key point: Practised and reported.
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 |
|---|---|---|---|---|
| Security assessments reviewed in the last 12 months | 100% | Yearly | Security lead | Escalate to the coordinating authority |
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 |
|---|---|---|
| WRK-SOP-006 | Violence and aggression prevention and response (existing, reused) | Procedure |
| HOS-REG-004 | Rehearsal and drill record (existing, reused) | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the Sphere Handbook, Humanitarian Charter and Minimum Standards in Humanitarian Response (2018). |
| 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 |
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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)