Standards › Standard 44 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · WAY-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 44.4
At a glance
- The route to each key service is marked on the site.
- Each route is tested with real users at the defined interval (WAY-REG-002).
- Each building change triggers a new route test.
- Problems found in testing are fixed and retested.
- Stop and get help straight away if: a key route is never tested with patients or users.
1. Purpose
To make sure the route to each key service works for the people who use it, not only for staff (44.4).
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 patient who gets lost on the way to a service may miss their appointment or arrive late. Routes marked and tested with real people show where the problems are.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Facilities manager | Owns the route marking and the test schedule | Service director |
| Patient experience lead | Runs the user tests with patients and records them | 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.
- Mark each key route on the site.
Key point: Marked.
Step 2. Test.
- Test each route with real users at the defined interval and record the result (WAY-REG-002).
Key point: Tested.
Step 3. Fix and retest.
- Fix any problem found and retest the route.
Key point: Retested.
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 |
|---|---|---|---|---|
| Key routes tested at the defined interval | 100% | Quarterly | 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-002 | Route test register | Register |
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)