Standards › Standard 2A › Policies
Policy · GOV-POL-003 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2A.3
At a glance
- Every policy has one named owner, a version, an approval and a review date.
- Policies are approved by the governing body or the delegated committee and recorded in the register.
- Check, at least once a year, that staff can explain how a sample of policies is applied in practice.
- Act on the results: update the policy, the training or the practice.
- Stop and get help straight away if: a policy is in use but has no owner or review date, or staff cannot describe how it applies to their work.
1. Purpose
To make sure policies are written, approved, kept current and applied in practice, not only filed [E-006, EC].
2. Scope
| Applies to | Policy owners, the governing body, committees that approve policies, and all staff who apply them |
| Locations | The whole facility |
| When | When a policy is written, changed or reviewed; and at the yearly application check |
| Does not apply to | Clinical protocols issued by professional bodies, which are referenced in the policy rather than rewritten |
3. Definitions
| Term | Meaning |
|---|---|
| Policy | A statement of what the facility requires and why |
| Owner | The role responsible for keeping a policy current |
| Application audit | A check of how staff apply a sample of policies in practice |
4. Background
Policy that is filed but not followed does not protect patients. Criterion 2A.3 requires that staff can explain how policies are applied, and that the facility checks.
This policy governs the lifecycle of all policies. The register of policies is GOV-REG-002; the application audit form is GOV-FRM-002.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Governing body | Approves the policy framework and receives the yearly application report | Governance training |
| Chief executive | Owns the framework; ensures owners are named | Executive leadership |
| Policy owners | Write, review and update their policies on time; answer questions on them | Subject competence |
| Quality lead | Runs the application audit and reports results | Audit competence |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Policy register (GOV-REG-002) | Current | All policies listed with owner and date |
| Policy template | Standard headings: purpose, scope, responsibilities, procedure, records, evidence, review | Current version |
7. Safety
- A policy must not require a practice that breaks the law or places patients at risk. Raise the conflict at once.
8. Before you start
- Check the register for the policy’s current version and owner.
- Check whether the policy refers to a professional standard that has changed.
9. Procedure
Step 1. Write the policy on the standard template.
- Use the headings: purpose, scope, responsibilities, procedure, records, evidence and review date.
- Cite the evidence and the legal basis for each requirement.
Key point: A policy without a reason and a source cannot be defended or updated.
Step 2. Approve and register the policy.
- Send the draft to the approving body, which is the governing body for governance policies and the relevant committee for others.
- Record the approval, version and date, and enter it on GOV-REG-002.
Key point: Approval is what makes a policy binding. Record it.
Step 3. Tell staff and train them.
- Publish the policy where staff can find it.
- Brief staff on the parts that change their work, and record the briefing.
- Staff sign the policy acknowledgement (FRM-N10) for policies that set personal duties.
Key point: A policy staff have not been told about is not applied.
Step 4. Check application each year.
- Choose a sample of at least five policies each year, including the high-risk ones.
- Ask staff from at least two areas how they apply each policy, and observe practice where possible.
- Record the results on GOV-FRM-002 with a score for each policy.
Key point: The check is in practice, not in the file. Asking staff is the test.
Step 5. Act on the results.
- For each gap, decide whether to change the policy, the training or the practice, and set an owner and a date.
- Report the results and actions to the governing body yearly.
Key point: A finding without an action is only a finding.
Step 6. Review on the set date.
- Review every policy by its review date (at least every two years, or sooner after an incident or change in law).
- If a policy is retired, mark it as withdrawn on the register and keep the old version.
Key point: Out-of-date policies are dangerous because staff still follow them.
10. Decision points
- If a policy conflicts with another policy, the more protective requirement applies until the conflict is resolved, and the owners are told.
11. Special situations
| Situation | Action |
|---|---|
| Urgent change needed | The owner may issue an interim change approved by the chief executive, valid for up to three months, recorded on the register (EC). |
12. Escalation
- Gaps in application that affect safety go to the quality lead and the clinical director within 48 hours.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Policies with owner, version and review date | 100% | Quarterly | Quality lead | Owner to update within 30 days |
| Sampled policies applied as written (application audit) | 80% or above (EC) | Yearly | Quality lead | Action plan per policy |
| Policies past review date | 0 | Monthly | Quality lead | Escalate to governing body |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Policy register (GOV-REG-002) | Governance file | Current, plus history kept the period set by the facility’s records policy years |
| Application audit (GOV-FRM-002) | Quality file | the period set by the facility’s records policy years |
15. Training
- Policy owners are trained in writing policies on the template (EC).
- All staff are briefed on policies relevant to their role at induction and when a policy changes.
16. Related documents
| ID | Title | Use |
|---|---|---|
| GOV-REG-002 | Policy Register | Lists every policy |
| GOV-FRM-002 | Policy Application Audit Form | Used for the yearly check |
| GOV-PLN-002 | Quality Improvement Plan | Policies link to the QI plan |
| SOP-025 | Document Amendment Procedure (generic) | Change steps |
| SOP-026 | Document Approval Procedure (generic) | Approval steps |
| SOP-027 | Document Control Procedure (generic) | Control of copies |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. |
| E-009 | ASF Expert Committee consensus. Review intervals and sample size are EC decisions. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version adapted from ASF Policy 46 and generic SOP-025 to SOP-027 | 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
- Documentation Fundamentals (A-03)
- Document Control and the Records System (T-02)
- Document Control Fundamentals (A-06)
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)