Standards › Standard 23 › Policies
Policy · NET-POL-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 23.4
At a glance
- Credentials and privileges are verified once, through the central process, for each clinician.
- Each site recognises a clinician only after the central check for that site is recorded (NET-REG-003).
- No clinician practises at a site without current credentials and privileges confirmed for that site.
- Credentials are rechecked at each expiry.
- Stop and get help straight away if: a clinician is granted privileges at one site with no check at the central office.
1. Purpose
To make sure every clinician is verified centrally and recognised only for sites where the check is recorded (23.4).
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 clinician who is verified at one site and not at another can practise where they are not safe. One central verification, recognised everywhere, closes that gap.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Central credentialing lead | Verifies and records each clinician | Manager |
| Site managers | Confirm the central record before rostering | 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 centrally.
- Verify each clinician’s credentials and privileges through the central process.
Key point: Verified.
Step 2. Recognise per site.
- Record the site recognition in NET-REG-003 before the clinician practises there.
Key point: Recognised.
Step 3. Recheck.
- Recheck credentials at each expiry and update the register.
Key point: Rechecked.
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 |
|---|---|---|---|---|
| Clinicians practising with current site recognition | 100% | Monthly | Central credentialing lead | 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-REG-003 | Verified clinician and site recognition register | Register |
| STF-SOP-001 | Staff credential verification and recheck (existing, reused) | Procedure |
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
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)