Standards › Standard 14 › Policies
Policy · OHS-POL-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 14 (Occupational Health), criterion 14.7
At a glance
- An assessor does not assess a worker where they also treat that worker, manage them, or have a stake in the outcome.
- Each assessor declares any conflict on OHS-FRM-006 before the assessment.
- A conflict is handed to another assessor at once.
- Declarations are reviewed each year.
- Stop and get help straight away if: an assessor carries out an assessment for a worker they manage or treat.
1. Purpose
To keep assessments free of conflicts of interest (14.7).
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 keep assessments free of conflicts of interest (14.7).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Occupational physician | Owns the conflict rule and reassigns | Clinician |
| Each assessor | Declares any conflict before each assessment | Clinician |
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. Declare.
- Declare any conflict on OHS-FRM-006 before each assessment.
Key point: Before each assessment.
Step 2. Reassign.
- Hand a conflicted assessment to another assessor at once.
Key point: At once.
Step 3. Review.
- Review the declarations each year.
Key point: Yearly.
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 |
|---|---|---|---|---|
| Assessments with a conflict declaration | 100% | Monthly | Occupational physician | 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 |
|---|---|---|
| OHS-FRM-006 | Conflict of role declaration | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the ICOH International Code of Ethics for Occupational Health Professionals, 3rd edition (2014). |
| 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)