Standards › Standard 13 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · MOB-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 13 (Mobile Clinic and Outreach), criterion 13.8
At a glance
- Coverage is reviewed each quarter against the population the service is for.
- Groups not reached, such as people with disability or displaced people, are named.
- The schedule is changed to reach them, and the change is recorded (MOB-REG-002).
- Results are shared with the clinical lead.
- Stop and get help straight away if: a group known to be missed is not named or not reached, with no schedule change.
1. Purpose
To find the people a mobile service does not reach, and change the schedule (13.8).
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
To find the people a mobile service does not reach, and change the schedule (13.8).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Outreach lead | Runs the review | Clinician |
| Community liaison | Reports the groups not reached | Community worker |
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. Review.
- Compare people reached against the population each quarter (MOB-REG-002).
Key point: Each quarter.
Step 2. Name the gap.
- Name each group not reached and why.
Key point: Groups named.
Step 3. Change.
- Change the schedule to reach each group, and record the change.
Key point: Changed and recorded.
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 |
|---|---|---|---|---|
| Quarterly coverage reviews completed | 100% | Quarterly | Outreach lead | Escalate to clinical 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 |
|---|---|---|
| MOB-REG-002 | Coverage review register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO guideline on health policy and system support to optimize community health worker programmes (2018). |
| 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 |
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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)