Standards › Standard 25 › Policies
Policy · HMG-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 25.2
At a glance
- Each patient is given plain-language information on their care and on how to use the health system.
- Understanding is checked by teach-back, not assumed from silence or a nod (HMG-FRM-002).
- Information is given in the patient’s language, through a competent interpreter.
- A patient who has not returned is followed up, and the reason recorded.
- Stop and get help straight away if: a patient does not return because no one explained the follow-up.
1. Purpose
To make sure each patient understands their care and how to move through the health system (25.2).
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
A migrant who does not know how the health system works, or how to book a visit, may give up on care. Helping them understand their own care and how to use the system keeps them engaged.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead for migrant health | Owns the information rule | Clinician |
| Treating clinician and navigator | Gives the information and checks understanding | Clinician or 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. Explain in plain language.
- Explain the care and the health system in plain language, in the patient’s language.
Key point: Explained.
Step 2. Check understanding.
- Check understanding by teach-back, and record it (HMG-FRM-002).
Key point: Checked.
Step 3. Follow up.
- Follow up any patient who does not return, and record the reason.
Key point: Followed up.
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 |
|---|---|---|---|---|
| Patients whose understanding is checked by teach-back | 90% | Monthly | Clinical lead for migrant health | 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 |
|---|---|---|
| HMG-FRM-002 | Understanding check record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO and IOM Global Competency Standards for Refugee and Migrant Health and the WHO mhGAP Intervention Guide (2019). |
| 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)