Standards › Standard 2A › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · GOV-SOP-001 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2A.1
At a glance
- Circulate the agenda and papers five working days before each meeting.
- Check the quorum and the declarations at the start.
- Put safety and quality on every agenda, with a report from the chief executive.
- Record each decision, its owner and its due date.
- Circulate minutes within 10 working days.
- Stop and get help straight away if: a decision on safety or patient care is taken without a quorum or without a recorded declaration of interest.
1. Purpose
To make sure the governing body meets regularly, takes decisions on safety and quality in the open, and records them so that actions can be followed up [EC].
2. Scope
| Applies to | Chair, members, chief executive and the governance lead |
| Locations | Governing body meetings, in person or by secure video link |
| When | At each scheduled meeting and any special meeting |
| Does not apply to | Clinical meetings, which follow the clinical governance SOP |
3. Definitions
| Term | Meaning |
|---|---|
| Quorum | The minimum number of members needed for a valid decision, set in the terms of reference |
| Declaration of interest | A written or spoken statement of any personal or financial interest in an item |
| Action owner | The named person who will carry out an action |
4. Background
The governing body is accountable only if its decisions are taken properly and recorded. This SOP sets how that is done, so that criterion 2A.1 can be evidenced at every meeting.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Chair | Runs the meeting, checks the quorum and declarations, signs the minutes | Chairing competence |
| Governance lead | Prepares agenda and papers; takes minutes; tracks actions | Minute-taking and governance administration |
| Chief executive | Presents the safety and quality report; implements decisions | Executive reporting |
| Members | Prepare papers; declare interests; take decisions | Induction |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Agenda template | Standard headings, including safety and quality | Current version |
| Minutes template (GOV-FRM-003) | Standard headings | Current version |
| Action log | Owner, due date, status | Updated after each meeting |
7. Safety
- Confidential patient or staff information is discussed only in anonymised form, unless needed for the decision.
- Papers are stored securely and returned or destroyed after the meeting if marked confidential.
8. Before you start
- Confirm the date, the venue or link, and the quorum.
- Prepare the chief executive’s safety and quality report using the quality dashboard.
- Send the agenda and papers five working days before the meeting (EC).
9. Procedure
Step 1. Open the meeting and check the quorum.
- Confirm the names of those present and the quorum.
- Ask for declarations of interest and record them.
- Approve the minutes of the previous meeting.
Key point: No decision is valid without a quorum and recorded declarations.
Step 2. Review safety and quality.
- Receive the chief executive’s report covering incidents, serious harm, complaints, audit results and staffing.
- Ask questions and record each question and the answer.
- Agree any action needed, with owner and date.
Key point: Every safety report is a question: what has happened, what is being done, and who is accountable.
Step 3. Take the other business decisions.
- Take decisions on the agenda items, recording the proposal, the vote or consensus, and the reasons.
- If a member has declared an interest, they leave the discussion and the minutes record it.
Key point: The reasons are as important as the decision. They show the decision was considered.
Step 4. Record actions.
- Enter every action in the action log with owner, due date and the link to the decision.
- Review overdue actions at each meeting.
Key point: An action without an owner and a date will not be done.
Step 5. Circulate and approve the minutes.
- Complete GOV-FRM-003 and circulate the draft within 10 working days.
- Approve the minutes at the next meeting, and sign them.
- File the signed minutes and the papers.
Key point: Signed minutes are the evidence that the decisions happened.
10. Decision points
- If the quorum is not met, the meeting receives information only, and decisions wait for the next quorate meeting or written resolution where the terms allow (EC).
- If a safety issue needs an urgent decision, the chair may call an extraordinary meeting within 48 hours.
11. Special situations
| Situation | Action |
|---|---|
| Urgent decision between meetings | Follow the delegated authority in the terms of reference and report it at the next meeting (EC). |
12. Escalation
- Serious safety concerns go to the chair within 24 hours.
- Concerns about a governance decision go to the chair or, if involving the chair, to the vice chair.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Meetings held with a quorum | 100% | Each meeting | Governance lead | Escalate to chair |
| Actions completed by due date | 90% (EC) | Monthly | Governance lead | Review at next meeting |
| Minutes approved within two meetings | 100% | Each meeting | Governance lead | Chair reviews |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Agenda and papers | Governance file | the period set by the facility’s records policy years |
| Minutes (GOV-FRM-003) | Governance file | the period set by the facility’s records policy years |
| Action log | Governance file | the period set by the facility’s records policy years |
15. Training
- Chairs and governance leads are trained in running meetings and minute-taking (EC).
- Members receive a briefing on declarations and decision records at induction.
16. Related documents
| ID | Title | Use |
|---|---|---|
| GOV-POL-001 | Governing Body Terms of Reference | Authority for the decisions |
| GOV-FRM-003 | Governing Body Minutes Template | Used in step 5 |
| GOV-REG-001 | Register of Governing Body Members | Quorum check in step 1 |
| INC-POL-001 | Incident Reporting and Management | Source of safety report items |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. Quorum and timing 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
- Governance & Management (H-07)
- Safety Management System & Leadership (MGMT-01)
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)