Standards › Standard 43 › Policies
Policy · TXP-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 43.2
At a glance
- Organ allocation follows the written protocol and its clinical criteria.
- Each allocation is recorded with the criteria used (TXP-REG-001).
- Any departure from the protocol is recorded with its reason and reviewed.
- The protocol is published and available to the public.
- Stop and get help straight away if: an organ is allocated outside the protocol with no reason recorded.
1. Purpose
To make sure organs are given on clinical grounds, openly and consistently (43.2).
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 |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Organs are scarce. Allocating them by a written, transparent rule, based on clinical need, is the only fair way to decide who receives one.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Transplant programme director | Owns the protocol and reviews departures | Clinical director |
| Allocation coordinator | Applies the protocol and records each decision | Transplant programme director |
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. Apply.
- Apply the protocol criteria to each organ offered.
Key point: Applied.
Step 2. Record.
- Record the allocation and the criteria used (TXP-REG-001).
Key point: Recorded.
Step 3. Review departures.
- Record any departure with its reason and review it.
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 |
|---|---|---|---|---|
| Allocations recorded with criteria | 100% | Quarterly | Transplant programme director | Escalate to the clinical 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 |
|---|---|---|
| TXP-REG-001 | Allocation decision register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation (2010), including the principles on donation without commercial gain, and the ASF Hospital standard for consent. |
| 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)