Standards › Standard 44 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · WAY-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 44.2
At a glance
- The emergency entrance is marked from the road and inside the site.
- The entrance is open whenever emergency patients may arrive (WAY-REG-001).
- The ambulance bay is kept clear at all times.
- Any obstruction is cleared at once and recorded.
- Stop and get help straight away if: the emergency entrance is closed or obstructed while emergency patients may arrive.
1. Purpose
To make sure an emergency patient can always find and reach the emergency entrance (44.2).
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
In an emergency the patient must find the entrance at once. A marked, lit and open emergency entrance is part of the emergency plan.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Facilities manager | Owns the marking and the access standard | Service director |
| Security and reception staff | Keep the entrance open and clear and record checks | Facilities manager |
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. Mark.
- Keep the emergency entrance marked from the road and inside the site.
Key point: Marked.
Step 2. Open.
- Keep the entrance open at all times emergency patients may arrive (WAY-REG-001).
Key point: Open.
Step 3. Clear.
- Keep the ambulance bay clear and clear any obstruction at once.
Key point: Cleared.
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 |
|---|---|---|---|---|
| Checks showing the entrance open and clear | 100% | Weekly | Facilities manager | Escalate to the service 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 |
|---|---|---|
| WAY-REG-001 | Emergency entrance open-hours and clear-access check register | Register |
| ACS-POL-001 | Environment and accessibility for safe movement (existing) | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Global Patient Safety Action Plan 2021–2030 for communication and patient access, the WHO Emergency Care Systems framework for emergency access, and the ASF Hospital standard for facility access. |
| 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)