Standards › Standard 2A › Policies
Policy · GOV-POL-001 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2A.1
At a glance
- Name every member of the governing body in writing, with their role and term.
- Set out the authority of the body over safety and quality, clinical governance and financial stewardship.
- Agree how often the body meets and what goes on the agenda each time.
- Review the terms of reference and the membership once a year.
- Stop and get help straight away if: the governing body has no named members, no written authority, or makes decisions on safety or money without a record.
1. Purpose
To set out who governs the facility, what authority they hold, and how they hold the service to account for safety, quality and money [E-006, E-009].
2. Scope
| Applies to | All members of the governing body and the chief executive, who attends as an adviser |
| Locations | Governing body meetings and the facility’s governance records |
| When | At all times; reviewed yearly and after any change in membership or structure |
| Does not apply to | Clinical decisions about individual patients, which are made under the clinical policies |
3. Definitions
| Term | Meaning |
|---|---|
| Governing body | The board or equivalent body with legal and final responsibility for the facility |
| Clinical governance | The system through which the facility is accountable for the quality and safety of its clinical care |
| Quorum | The minimum number of members needed for a valid decision |
4. Background
A governing body that has no written authority, or whose membership is unclear, cannot be held to account for safety. The body must be able to show who decides, how decisions are recorded, and how it knows what is happening in the service.
This SOP is the working document for criterion 2A.1. Evidence is the terms of reference, the list of named members, and the minutes of the last 12 months (see GOV-REG-001 and GOV-FRM-003).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Chair of the governing body | Leads meetings, makes sure safety and quality are on each agenda, signs the minutes | Governance training |
| Members | Attend, prepare, decide on safety and quality matters, declare conflicts (GOV-FRM-002 of the conflicts policy) | Induction to the role |
| Chief executive | Reports to the governing body on safety, quality and finance; implements decisions | Executive leadership |
| Company secretary or governance lead | Keeps the membership register and minutes; checks the terms of reference yearly | Administrative governance competence |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Terms of reference (this document) | Current signed version | Dated, signed, version shown |
| Membership register (GOV-REG-001) | Current names, roles and terms | Matches the people who attend |
| Minutes template (GOV-FRM-003) | Standard headings | Used for every meeting |
7. Safety
- Members must declare any personal interest in a decision before the decision is taken (see the conflict of interest policy, SOP-N01).
- Confidential patient information is not discussed at governing body level unless needed to make the decision, and then only in anonymised form.
8. Before you start
- Check the membership register is current before each meeting.
- Circulate the agenda and papers at least five working days before the meeting (EC).
9. Procedure
Step 1. Write and approve the terms of reference.
- Set out the purpose, the authority, the membership, the quorum and the reporting lines.
- State the areas of authority: safety and quality, clinical governance, financial stewardship, and appointments.
- Have the terms signed by the chair and the chief executive, and record the approval date.
Key point: A written authority is the basis for every decision the body takes. Without it, the body cannot be held to account.
Step 2. Name the members.
- List each member on GOV-REG-001 with name, role, start date, term end and any declared interest.
- Record the chair and the vice chair.
- Update the register within 10 working days of any change.
Key point: Named members give accountability. An unnamed group cannot be held responsible.
Step 3. Hold meetings on a set schedule.
- Hold at least four meetings a year, with at least one dedicated to safety and quality (EC).
- Check the quorum at the start of each meeting and record it on GOV-FRM-003.
- Record every decision on safety and quality, with the name of the member who raised it and the action owner.
Key point: Decisions that are not minuted are not decisions. Record them as they are taken.
Step 4. Keep and approve the minutes.
- Complete GOV-FRM-003 for each meeting: attendance, declarations, decisions, actions, owners and dates.
- Circulate draft minutes within 10 working days, and approve them at the next meeting.
- File signed minutes for the period in section 13.
Key point: Signed minutes are the evidence the auditor will ask for first.
Step 5. Review the terms of reference each year.
- Review the terms, the membership and the attendance record once a year.
- Record the review on the change history and the next review date.
- If the structure changes, update the terms before the change takes effect.
Key point: Structures drift. The yearly review keeps the written authority matched to the real one.
10. Decision points
- If a member has a declared interest in an item, they do not vote on it and the minutes record this.
- If the quorum is not met, the meeting may receive information but may not take decisions; the decisions are taken at the next quorate meeting or by written resolution where the terms allow (EC).
11. Special situations
| Situation | Action |
|---|---|
| Emergency decision between meetings | The chair and the chief executive may act within delegated authority, and the decision is ratified at the next meeting. Record the reason (EC). |
| Change of membership | The register is updated, and the new member signs the declaration of interests before first attendance. |
12. Escalation
- Concerns about the governing body’s own conduct go to the chair; if the concern involves the chair, to the vice chair or the regulator.
- Serious safety concerns are reported to the governing body within 24 hours of the chief executive becoming aware.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Terms of reference reviewed in the last 12 months | Yes | Yearly | Governance lead | Escalate to chair; complete within 30 days |
| Membership register matches attendance | 100% | Each meeting | Governance lead | Correct register; report to chair |
| Safety and quality decisions minuted with an owner and a date | 100% | Each meeting | Governance lead | Minutes corrected before approval |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Terms of reference (signed) | Governance file | Current version kept, plus the period set by the facility’s records policy years |
| GOV-REG-001 Register of Governing Body Members | Governance file | the period set by the facility’s records policy years |
| GOV-FRM-003 Minutes | Governance file | the period set by the facility’s records policy years |
15. Training
- Each new member receives an induction covering the terms of reference, safety and quality duties, and declarations (EC).
- Refresher training on governance responsibilities every two years (EC).
16. Related documents
| ID | Title | Use |
|---|---|---|
| GOV-REG-001 | Register of Governing Body Members | Membership record |
| GOV-FRM-003 | Governing Body Minutes Template | Used for each meeting |
| GOV-SOP-001 | Governing Body Meetings and Decisions on Safety and Quality | How meetings are run |
| SOP-N01 | Conflict of Interest and Impartiality Policy | Declarations |
| SOP-092 | Governing Body Terms of Reference (generic) | Source document |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. Quorum rules and meeting frequency are EC decisions. Legal requirements under national law set by the ASF Expert Committee. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version, adapted from generic SOP-092 and ASF Policy 51 | 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
- Governance & Management (H-07)
- Safety Management System & Leadership (MGMT-01)
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)