Standards › Standard 30 › Standard operating procedures (SOPs)
Procedure · FW-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 30.8
At a glance
- Sessions are supervised by staff with a recognised qualification for the activity (FW-REG-001).
- Each member receives instruction on correct technique before using equipment or a group activity.
- Supervisor-to-member ratios are set for each activity.
- Instruction is recorded.
- Stop and get help straight away if: a heavy-lifting class runs with an unqualified supervisor.
1. Purpose
To make sure exercise is supervised by qualified staff and taught correctly (30.8).
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
Exercise sessions with no qualified instructor are a common cause of injury. Supervision by people who hold a recognised qualification for the activity keeps the sessions safe.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Fitness service lead | Owns the supervision rule | Clinician or manager |
| Qualified instructor | Supervises and instructs | Staff |
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. Check qualification.
- Check the instructor’s qualification on FW-REG-001 before each session.
Key point: Checked.
Step 2. Instruct.
- Instruct each member on technique before equipment or group use.
Key point: Instructed.
Step 3. Record.
- Record the session and the instruction given.
Key point: Recorded.
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 |
|---|---|---|---|---|
| Sessions led by a qualified instructor | 100% | Monthly | Fitness service lead | Escalate to medical director |
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 |
|---|---|---|
| FW-REG-001 | Staff qualification register | Register |
| WRK-SOP-001 | Annual competency assessment (existing, reused) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO guidance on digital health and data protection, the American College of Sports Medicine Guidelines for Exercise Testing and Prescription (11th ed., 2021), and the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care (2020). |
| 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)