Standards › Standard 39 › Policies
Policy · HUM-POL-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 39.3
At a glance
- All staff and volunteers are trained in protection from sexual exploitation and abuse before they work with beneficiaries.
- Community engagement is in place for each activity and recorded.
- Safe referral pathways are set up before activity starts (HMG-SOP-001).
- Any concern is reported at once through a route that protects the reporter.
- Stop and get help straight away if: a staff member or volunteer works with beneficiaries before training, or a concern is not reported.
1. Purpose
To make sure no activity causes harm, and that anyone who is harmed can report and be helped (39.3).
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
In humanitarian settings, people who depend on aid are vulnerable to sexual exploitation and abuse by those who should protect them. Training, reporting routes and a do-no-harm approach protect them.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Deployment lead | Owns the protection standard and the referral pathways | Operations director |
| All staff and volunteers | Complete the training and report any concern | Deployment lead |
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. Train.
- Train every staff member and volunteer before they work with beneficiaries.
Key point: Trained.
Step 2. Engage.
- Engage the community in each activity and record the engagement.
Key point: Engaged.
Step 3. Refer.
- Set up and use safe referral pathways for each concern.
Key point: Referred.
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 |
|---|---|---|---|---|
| Staff and volunteers trained before first contact | 100% | Quarterly | Deployment lead | Escalate to the operations 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-SOP-001 | Referral and handover to social services (existing) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the Sphere Handbook (2018) minimum standards, the IASC Six Core Principles relating to sexual exploitation and abuse (2019), and the WHO Global Patient Safety Action Plan 2021–2030. |
| 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)