Standards › Standard 2E › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · WRK-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 2E.1
At a glance
- Assess each staff member once a year against their job description, using WRK-FRM-001.
- Observe or review evidence for every competency listed for the role.
- Agree one learning action for each gap, with an owner and a date.
- Re-assess each gap when its learning action is due.
- Stop and get help straight away if: a staff member is in a clinical role and has not been assessed in the last 12 months.
1. Purpose
To describe how the annual competency assessment is run, so that it is the same in every service [EC].
2. Scope
| Applies to | Every staff member in a clinical role |
| Locations | All services of the facility |
| When | Annually, at appointment, and at change of role |
| Does not apply to | Non-clinical staff (see the job description for their own assessment) |
3. Definitions
| Term | Meaning |
|---|---|
| Evidence | What the assessor sees or reviews to show a competency, such as observation, a case record or a logged procedure |
| Assessor | A manager or senior clinician trained in the method |
4. Background
A consistent method lets the organisation compare results between teams and see where training is needed.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Assessor | Runs the assessment and records the result | Trained in the method |
| Line manager | Agrees learning actions and checks closure | Management |
| Human resources lead | Schedules assessments and keeps records | HR administration |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Competency assessment form (WRK-FRM-001) | Current for the role | Version number matches the role |
| Job description | Current | Signed and dated |
7. Safety
- Assessment of a clinical skill is done with a patient safety focus; any unsafe practice seen stops the assessment and is reported at once.
8. Before you start
- Confirm the list of competencies for the role. Confirm the assessor is trained and is not assessing a direct report alone where the policy requires two assessors.
9. Procedure
Step 1. Prepare the assessment.
- Send the staff member the date, the competencies and the evidence to bring.
- Print WRK-FRM-001 for the role.
Key point: Preparation is what makes the assessment fair.
Step 2. Carry out the assessment.
- For each competency, observe the task or review a case record.
- Mark the result as met, partly met or not met, with a note of the evidence.
Key point: Record the evidence, not an opinion.
Step 3. Agree learning actions.
- For each partly met or not met item, agree one action, owner and date.
- Both the staff member and the assessor sign the form.
Key point: An agreed action is the start of closure.
Step 4. Close the gaps.
- Re-assess the item when the action is due.
- Update the record and the training matrix (WRK-REG-001).
Key point: Closure is proven by re-assessment.
10. Decision points
- If any competency is not met and it is needed for safe practice now, the staff member is supervised until the gap is closed.
11. Special situations
| Situation | Action |
|---|---|
| Assessor not available | Another trained assessor completes the assessment. The change is recorded on the form. |
12. Escalation
- Any unsafe practice found during an assessment is reported to the clinical director on the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Assessments completed on time | 100% | Monthly | Human resources lead | Escalate to clinical director |
| Forms with evidence recorded for every item | 100% | Quarterly | Clinical managers | Re-assess the incomplete items |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| WRK-FRM-001 Competency assessment form | Personnel file | Employment plus the period set by the facility’s records policy years |
15. Training
- Assessors complete a short course on the method and observe at least one assessment before assessing alone.
16. Related documents
| ID | Title | Use |
|---|---|---|
| WRK-POL-001 | Ongoing competency evaluation policy | Policy this procedure supports |
| WRK-FRM-001 | Competency assessment form by role | Record used in step 2 |
| WRK-REG-001 | Training matrix register | Updated after each closure |
17. Evidence
| Reference | Note |
|---|---|
| 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 |
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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)