Standards › Standard 2A › Plans and templates
Plan / template · GOV-PLN-001 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2A.2
At a glance
- Write the mission, values and the code of conduct as one plan.
- Set the goals for the next 3 to 5 years, each with a measure.
- Link the budget to each goal.
- Approve the plan and tell all staff.
- Review the plan every year against the budget and the measures.
- Stop and get help straight away if: the plan has no link to the budget, no measures, or staff have not been told about it.
1. Purpose
To set out what the facility is for, what it values, how staff are expected to behave, and where resources will go over the coming years [EC].
2. Scope
| Applies to | The governing body, chief executive, senior managers and all staff who plan or use resources |
| Locations | The whole facility |
| When | Written every 3 to 5 years; reviewed yearly |
| Does not apply to | Operational plans for individual wards, which must match this plan |
3. Definitions
| Term | Meaning |
|---|---|
| Mission | Why the facility exists, in one or two sentences |
| Values | The principles that guide decisions and behaviour |
| Goal | A result the facility will achieve, with a measure and a date |
4. Background
A plan that is not linked to money and staff time is a poster. A plan that does not state how staff should behave gives no standard to hold people to. Criterion 2A.2 requires both, and the link between them.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Governing body | Approves the plan; reviews progress each year | Governance training |
| Chief executive | Writes or leads the plan; links it to the budget; reports on progress | Executive leadership |
| Financial director | Prepares the budget linked to each goal | Financial planning |
| All managers | Cascade the plan to their teams and report progress | Management training |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Plan template (this document) | Standard headings | Current version |
| Budget (linked to goals) | Each goal has a budget line | Matches the approved budget |
7. Safety
- The plan must not promise services or staffing the facility cannot deliver safely.
8. Before you start
- Gather the current quality, safety and financial data.
- Consult staff, patients and the patient council (section 5).
9. Procedure
Step 1. Write the mission and values.
- State the mission in one or two sentences, matched to the services provided (see GOV-POL-001 and the service declaration).
- Choose three to five values and describe what each means in practice.
Key point: Values should change how people behave, otherwise they are words.
Step 2. Write the code of conduct.
- Include the expected standards for honesty, respect, safety reporting, conflicts of interest, confidentiality and speaking up.
- Link to the code of conduct policy (GOV-POL-002).
Key point: The code tells staff what the facility expects. It is the reference when behaviour falls short.
Step 3. Set the goals and measures.
- Write three to six goals for the period.
- For each goal, set one measure, a target and a date.
- Consult staff and patients before final approval.
Key point: A goal without a measure cannot be checked.
Step 4. Link the budget to the goals.
- Show how each goal is funded, with a budget line or staff time.
- If a goal is unfunded, say so and state the decision the governing body must make.
Key point: Criterion 2A.2 is failed when the plan and the budget do not match.
Step 5. Approve, publish and tell staff.
- The governing body approves the plan and records the decision (GOV-FRM-003).
- Give every member of staff a summary within 30 days, and explain the code of conduct at induction.
- Publish the plan on the facility’s website or notice board, as the transparency policy requires.
Key point: A plan no one knows about does not change anything.
Step 6. Review each year.
- Report progress on each goal to the governing body yearly.
- Adjust the goals and the budget link where needed, and record the change.
Key point: The annual review keeps the plan current and shows that it guides decisions.
10. Decision points
- If a goal cannot be funded, the governing body decides whether to fund it, change it, or remove it, and records the reason.
11. Special situations
| Situation | Action |
|---|---|
| Mergers, new services or closures | Update the plan within 3 months of the decision (EC). |
12. Escalation
- If the budget and the plan diverge by more than an agreed amount, the financial director reports it to the governing body (EC).
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Plan approved and dated within the last 5 years | Yes | Yearly | Governance lead | Escalate to chief executive |
| Each goal has a measure, target and budget line | 100% | Yearly | Financial director | Revise plan |
| Staff who know the plan and the code (sample) | 80% (EC) | Yearly | HR lead | Briefing and re-check |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Signed plan and approval minute | Governance file | the period set by the facility’s records policy years |
| Annual progress report | Governance file | the period set by the facility’s records policy years |
15. Training
- Managers are briefed on the plan and the code at appointment.
- All staff receive the summary and code at induction (EC).
16. Related documents
| ID | Title | Use |
|---|---|---|
| GOV-POL-002 | Code of Conduct for Staff | The code within the plan |
| GOV-POL-001 | Governing Body Terms of Reference | Authority to approve |
| GOV-REG-001 | Register of Governing Body Members | Approval records |
| SOP-N03 | Code of Conduct (catalogue) | Same content, catalogue entry |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. |
| E-009 | ASF Expert Committee consensus. Planning period and review cycle are EC decisions. |
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
- Quality Management in Healthcare (A-02)
- Safety Management System & Leadership (MGMT-01)
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)