1. Purpose

This policy exists because accreditation is only credible if the people making decisions about a facility have no financial, personal, or institutional interest in the outcome of those decisions. A conflict of interest does not make someone dishonest — it creates a structural condition in which even an honest person cannot be trusted to be objective, and in which the appearance of bias undermines the value of the credential.

ASF’s constitutional protections require the ADC to maintain an external majority — meaning the majority of ADC members must have no financial relationship with ASF. This policy operationalises that requirement and extends it to all ASF governance and accreditation functions.

2. Scope

This policy applies to all individuals in the following roles:

• Board of Directors members
• Accreditation Decision Committee (ADC) members
• International Standards Council members
• Patient and Public Council members
• ASF Supervisors
• Certified Accreditation Monitors (AM-XXXXX)
• Certified Accreditation Coordinators (AC-XXXXX)
• ASF employees and contractors
• NAP partner organisations and their staff

3. What Constitutes a Conflict of Interest

Category	Examples	Level
Financial interest	Employment by, ownership of, or significant financial interest in a facility under review or seeking accreditation	Absolute — automatic disqualification
Family relationship	Spouse, parent, child, sibling, or domestic partner employed by or owning the facility under review	Absolute — automatic disqualification
Recent employment	Employment by the facility under review within the preceding 3 years	Absolute — automatic disqualification
Advisory or consultancy	Paid advisory or consultancy relationship with the facility under review within the preceding 2 years	Absolute — automatic disqualification
Personal relationship	Close personal friendship with the facility Director, Coordinator, or Responsible Person	Declarable — Board/ADC Chair decides
Institutional relationship	Member of a professional body that has taken a formal position on the facility or its accreditation	Declarable — Board/ADC Chair decides
Competitive relationship	Ownership of or significant interest in a competing facility in the same catchment area	Declarable — Board/ADC Chair decides
Previous involvement	Served as Coordinator or Monitor for the same facility in the preceding cycle	Absolute — automatic disqualification for Monitor; declarable for standards decisions

4. Declaration Requirements

5. What Happens When a Conflict Is Declared

Conflict level	Action	Who decides
Absolute (financial, family, recent employment, recent advisory)	Automatic disqualification from all involvement in the matter. No exception possible.	Automatic — no discretion
Declarable — Board/ADC Chair rules it a conflict	Person recuses from the specific decision. Remains in role for all other matters. Recusal recorded in minutes.	Board Chair or ADC Chair
Declarable — Board/ADC Chair rules it not a conflict	Declaration is recorded. Person may participate. Rationale for the ruling is published in the conflict of interest register.	Board Chair or ADC Chair
Undisclosed conflict discovered after decision	Decision reviewed. If the conflict was absolute, decision is void and a new panel constituted. Person’s credential or role suspended pending investigation.	ADC (for accreditation) / Board (for governance)

6. Monitor-Specific Rules

Monitors carry heightened conflict of interest obligations because their independent verification is the primary evidence base for the ADC’s decision.

• Cannot verify a facility where they are employed, even part-time or casually.
• Cannot verify a facility where a family member is employed in a clinical or management role.
• Cannot verify a facility they have verified in the immediately preceding cycle (mandatory rotation).
• Internal Monitor maximum tenure: 3 years at one facility, then mandatory gap of one full cycle.
• External Monitor maximum tenure: 5 years per facility, then mandatory gap of one full cycle.
• Cannot be Coordinator and Monitor for the same facility in the same or immediately preceding cycle.

7. Breaches and Consequences

Breach	Consequence
Failure to declare a declarable conflict	Formal warning. Mandatory ethics training. Second breach: suspension from role pending review.
Participating in a decision with an absolute conflict	Immediate suspension from role. Decision reviewed for validity. ADC or Board investigation.
Knowingly providing false information in annual declaration	Immediate termination from role. Credential revoked if Monitor or Coordinator. 5-year minimum exclusion from all ASF roles. Published on the public register.
Retaliating against a person who reported a conflict	Same consequences as for knowingly providing false information. No appeal within ASF — external legal recourse available.

8. The Public Conflict of Interest Register

The register covers all Board, ADC, and Standards Council members. For each member it records: name, role, term, all declared interests, any recusals in the past 12 months, and the rationale for any ruling on a declarable conflict. It is updated within 30 days of any change.

The register is maintained by the Board secretariat and reviewed annually by the Standards Council as part of the annual accountability report.

9. Review

This policy is reviewed every two years by the Board of Directors with input from the ADC and Standards Council. Proposed changes are published for 30-day public comment before adoption. The current version and all previous versions are available in the document library.