Standards › Standard 43 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · TXP-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 43.6
At a glance
- Each recipient is followed up on the defined schedule.
- Graft and patient outcomes are recorded and reported (TXP-REG-004).
- A recipient who misses a visit is traced.
- Outcomes are reported at the set interval.
- Stop and get help straight away if: a recipient is lost to follow-up with no tracing attempt recorded.
1. Purpose
To keep every recipient in care after surgery and to learn from outcomes (43.6).
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
After a transplant, the graft and the patient must be followed for years. Tracking outcomes shows whether the service is succeeding, and catches problems early.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Transplant programme director | Owns the follow-up schedule and the outcome report | Clinical director |
| Transplant coordinator | Books the visits, traces missed patients and records outcomes | 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. Schedule.
- Book follow-up on the defined schedule for each recipient.
Key point: Scheduled.
Step 2. Record outcomes.
- Record graft and patient outcomes at each visit (TXP-REG-004).
Key point: Recorded.
Step 3. Trace.
- Trace each missed recipient and record the attempts.
Key point: Traced.
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 |
|---|---|---|---|---|
| Recipients followed up on schedule | 95% | 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-004 | Graft and patient outcome 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
No e-learning course is linked to this document yet.
Planned course: No e-learning course is linked to this criterion yet. A course is planned to cover it.
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)