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Plan · OPR-PLN-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: B2.2
At a glance
- The service has a written operating plan that describes what it provides, to whom, with what staff and equipment, and how it is governed.
- The plan is approved by the governing body and reviewed at least once a year.
- Every service the facility provides is listed in the plan, and any new service is added before it starts.
- The plan is shared with staff and is available to patients on request.
- Stop and get help straight away if: there is no written operating plan, or a service runs that is not in the plan.
1. Purpose
To make sure the service is clearly described, planned and approved, so that staff, patients and regulators know what the facility does and how it is run (B2.2).
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 |
|---|---|
| Operating plan | The written description of the services, the staffing, the premises and equipment, and the governance arrangements for the facility. |
| Service | Any clinical or support activity the facility provides to patients. |
4. Background
To make sure the service is clearly described, planned and approved, so that staff, patients and regulators know what the facility does and how it is run (B2.2).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Accountable person | Writes and maintains the operating plan, and brings changes to the governing body | Governing body |
| Governing body | Approves the plan and each change, and reviews it each year | Owner or board |
| Service leads | Keep their part of the plan accurate and tell the accountable person of any change | Accountable person |
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. Write.
- Describe each service, the patients it serves, the staff and equipment it needs, and the governance arrangements.
- Link the plan to the policies listed in the policy register (OPR-REG-001).
Key point: Plan drafted.
Step 2. Approve.
- The governing body approves the plan and records the approval date and the version number.
Key point: Plan approved.
Step 3. Change.
- Before a new service starts, or an existing one changes, update the plan and have it approved.
- Record each change in the version history.
Key point: Change approved and recorded.
Step 4. Review.
- Review the plan each year against the services actually provided, and record the review.
Key point: Annual review 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 |
|---|---|---|---|---|
| Services provided that are listed in the plan | 100% | Annually | Accountable person | Update the plan and stop the unlisted service until it is approved |
| Plan reviewed and approved in the last 12 months | 100% | Annually | Governing body | Escalate to the owner |
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
- Service leads are briefed on the plan when it is approved and each time it changes.
16. Related documents
| ID | Title | Use |
|---|---|---|
| OPR-REG-001 | Policy register (existing) | Register |
17. Evidence
| Reference | Note |
|---|---|
| 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)