Standards › Standard 23 › Policies
Policy · NET-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 23.1
At a glance
- Every decision is assigned to central or site leadership in the decision rights table (NET-FRM-001).
- The table is shared with every site lead, and the sharing is recorded.
- A decision not in the table is referred to central leadership and recorded.
- A site does not close a service without the central decision recorded.
- Stop and get help straight away if: a site closes a ward with no central decision and no record.
1. Purpose
To make clear which decisions belong to central leadership and which to site leadership, so no decision is left without an owner (23.1).
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 multi-site organisation where no one knows which decisions belong to the centre and which to the site leads to disputes and missed safety decisions. A written split of authority settles it.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Chief executive or governing body | Owns the decision rights table | Leadership |
| Site leads | Apply the table at their site | Leadership |
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. Assign decisions.
- Assign each type of decision to central or site leadership in the table (NET-FRM-001).
Key point: Assigned.
Step 2. Share.
- Share the table with every site lead, and record the sharing.
Key point: Shared and recorded.
Step 3. Refer the unassigned.
- Refer any decision not in the table to central leadership, and record it.
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 |
|---|---|---|---|---|
| Decisions recorded with an owner from the table | 100% | Quarterly | Chief executive | Escalate to governing body |
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 |
|---|---|---|
| NET-FRM-001 | Decision rights table | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Framework on integrated people-centred health services (2016) and ISO 9001:2015 quality management principles. |
| 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
- Governance & Management (H-07)
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)