Standards › Standard 22 › Policies
Policy · TCH-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 22.1
At a glance
- Each trainee’s scope of independent practice is written down, and matched to their verified competency (TCH-REG-001).
- Supervision is available at the level the scope requires, and is recorded.
- Scope is not assumed from training year or programme level alone.
- A trainee does not operate alone outside the recorded scope.
- Stop and get help straight away if: a trainee operates alone with no record of scope.
1. Purpose
To make sure each trainee practises only within a recorded scope, with supervision at the level it requires (22.1).
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 trainee who operates alone before they are competent puts the patient at risk. Each trainee’s independent scope, matched to verified competency, makes sure the level of supervision fits the person.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Programme director | Owns the scope and supervision rule | Clinician |
| Supervising consultant | Sets and checks each trainee’s scope | 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. Set the scope.
- Set each trainee’s scope of independent practice from verified competency, and record it.
Key point: Scope set.
Step 2. Supervise.
- Make supervision available at the level the scope requires, and record it.
Key point: Supervised.
Step 3. Review.
- Review each trainee’s scope as competency is verified.
Key point: Reviewed.
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 |
|---|---|---|---|---|
| Trainees with a recorded scope before independent practice | 100% | Monthly | Programme director | 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 |
|---|---|---|
| TCH-REG-001 | Trainee scope and competency register | Register |
| WRK-SOP-001 | Annual competency assessment (existing, reused) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Transforming and scaling up health professionals’ education and training (2013) and the CIOMS International ethical guidelines (2016). |
| 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)