Standards › Standard 9 › Policies
Policy · FLD-POL-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 9.6
At a glance
- Each volunteer and temporary worker has a written scope before first duty (FLD-FRM-002).
- Each shift has a named supervisor.
- A volunteer works only within their scope, and calls a supervisor outside it.
- Credentials for clinical roles are checked (STF-FRM-001).
- Stop and get help straight away if: a volunteer performs a procedure outside their scope, or works with no supervisor.
1. Purpose
To keep volunteers and temporary staff within a defined scope and under supervision (9.6).
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 keep volunteers and temporary staff within a defined scope and under supervision (9.6).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Field unit lead | Approves each scope and names the supervisors | Clinician |
| Rota lead | Keeps the rota with a supervisor on each shift | Nurse |
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. Define the scope.
- Record each person’s scope and supervisor on FLD-FRM-002 before their first duty.
Key point: Scope before duty.
Step 2. Name the supervisor.
- Put a named supervisor on every shift in the rota.
Key point: No unsupervised shift.
Step 3. Check credentials.
- Check the credentials of clinical volunteers and record them.
Key point: Clinical roles are 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 |
|---|---|---|---|---|
| Volunteers with a signed scope before first duty | 100% | Each shift | Rota lead | Escalate to field unit lead |
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 |
|---|---|---|
| FLD-FRM-002 | Volunteer scope and supervision record | Record |
| STF-FRM-001 | Staff credential record (existing, reused) | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on WHO classification and minimum standards for emergency medical teams (2013). |
| 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)