Standards › Standard 43 › Policies
Policy · TXP-POL-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 43.3
At a glance
- No payment or material incentive is offered to a donor or donor family.
- Only documented direct costs are reimbursed, with a receipt (TXP-REG-002).
- Each reimbursement is approved before it is paid.
- Any offer of incentive is reported at once.
- Stop and get help straight away if: a payment or incentive is offered to a donor or family.
1. Purpose
To keep donation free of commercial gain, as the WHO principles require (43.3).
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
Paying a donor or their family for an organ is exploitation and is banned in most places. Only legitimate costs, such as travel, may be covered, and only with a record.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Transplant programme director | Owns the policy and approves reimbursements | Clinical director |
| Finance officer | Checks each reimbursement against a receipt | 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. Check cost.
- Check each cost against a receipt and the direct-cost list.
Key point: Checked.
Step 2. Approve.
- Approve the reimbursement before it is paid and record it (TXP-REG-002).
Key point: Approved.
Step 3. Report.
- Report any offer of payment or incentive at once to the programme director.
Key point: Reported.
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 |
|---|---|---|---|---|
| Reimbursements with receipt and prior approval | 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-002 | Payments and reimbursement 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)