Standards › Standard 24 › Policies
Policy · MTR-POL-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 24.8
At a glance
- Any facilitator or agent is verified before the first patient is referred, and signs a written agreement.
- The agreement sets a standard of conduct and the fees the clinic has agreed.
- No fee is charged to a patient that the clinic has not agreed in writing.
- Each agent is verified again each year (MTR-REG-004).
- Stop and get help straight away if: an agent charges patients a fee the clinic never agreed.
1. Purpose
To make sure every facilitator or agent is verified, bound by a written standard of conduct, and accountable to the clinic (24.8).
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
A facilitator or agent who brings patients to a clinic may promise things the clinic cannot deliver, or take money without a service. The clinic is responsible for who it works with.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| International patient coordinator | Verifies and keeps the agreements | Manager |
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. Verify.
- Verify each agent before the first referral.
Key point: Verified.
Step 2. Agree in writing.
- Sign a written agreement with the standard of conduct and the agreed fees.
Key point: Agreed in writing.
Step 3. Re-verify yearly.
- Re-verify each agent each year and update MTR-REG-004.
Key point: Re-verified.
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 |
|---|---|---|---|---|
| Agents verified and with a signed agreement before referral | 100% | Yearly | International patient coordinator | 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 |
|---|---|---|
| MTR-REG-004 | Verified agents register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Patient Safety Curriculum Guide (2011) and the NICE guidance on venous thromboembolic diseases (NG158, 2020). |
| 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)