Standards › Standard BASIS › Standard operating procedures (SOPs)
SOP · PFB-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: B2.7
At a glance
- Every patient who uses the service is asked for feedback at least once in each 12-month period.
- The feedback is collected with the survey form (PFB-FRM-001), in a way that allows the patient to answer privately.
- The results are analysed, shared with staff and patients, and produce at least one action each year.
- Patients who cannot read or who need help are supported to give their feedback.
- Stop and get help straight away if: the service has not asked its patients for feedback in the last 12 months.
1. Purpose
To hear directly from patients about their experience each year, and to act on what they say (B2.7).
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 |
|---|---|
| Patient feedback | What a patient says about their experience of care, collected with a survey or structured interview. |
| Sample | The patients chosen to be asked. It must include a range of services and ages, and patients who are unable to read or speak the service’s language. |
4. Background
To hear directly from patients about their experience each year, and to act on what they say (B2.7).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Quality lead | Plans the annual survey, runs it, analyses the results, and reports them | Accountable person |
| Accountable person | Receives the results and makes sure at least one action is taken each year | Governing body |
| Ward and department leads | Help patients complete the survey and share the results with their teams | Quality lead |
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. Plan.
- Set the survey period, the services included and the sample size each year.
- Make sure the survey is available in the languages patients use.
Key point: Survey planned.
Step 2. Ask.
- Give each patient in the sample the survey form (PFB-FRM-001), and help those who need it.
- Let the patient return it privately, for example in a sealed box or online.
Key point: Patients asked.
Step 3. Analyse.
- Count the responses and summarise the results by service and theme.
- Record the response rate and the main findings.
Key point: Results analysed.
Step 4. Act and share.
- Agree at least one action from the findings, with an owner and a due date.
- Share the results with staff, and publish a short summary for patients.
Key point: Actions agreed and results shared.
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 |
|---|---|---|---|---|
| Patients in the sample asked for feedback in the last 12 months | 100% | Annually | Quality lead | Repeat the survey for the missed services |
| Response rate | At least 30% (draft) | Annually | Quality lead | Review the survey method and the access for patients |
| Results with at least one action agreed | 100% | Annually | Accountable person | Escalate to the 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 who help patients complete the survey are briefed on how to do it without influencing the answers.
16. Related documents
| ID | Title | Use |
|---|---|---|
| PFB-FRM-001 | Patient feedback survey form (existing) | Form |
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 |
E-learning for this document
No e-learning course is linked to this document yet.
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)