Foreword

Every ASF document built before this one assumes the concern originates from inside the system: a facility reporting its own sentinel event, an organization appealing its own accreditation decision, a surveyor candidate going through training. None of them give a patient, a family member, or a member of the public any way to tell ASF directly that something is wrong at an organization ASF has accredited.

This policy closes that gap. It exists because real accountability cannot depend entirely on the accredited organization to report on itself — the same reasoning that leads Joint Commission and Accreditation Canada to maintain a public complaint channel entirely separate from their internal reporting and appeals processes.

1. Purpose and Two Distinct Complaint Types

Consistent with the distinction drawn by ISO/IEC 17011, the international standard governing accreditation bodies themselves, this policy recognizes two genuinely different kinds of complaint, handled through two different tracks [1]:

• A complaint about an accredited organization — concerning whether that organization is genuinely meeting the ASF standard it was accredited against. Handled under Sections 3 through 6 of this policy.
• A complaint about ASF itself — concerning the conduct of an ASF surveyor, a Council decision, or a failure in ASF's own stated process. Handled under Section 7 of this policy.

These are not interchangeable. A concern about a facility's actual practice does not become a complaint about ASF merely because ASF is the accrediting body, and a concern about how ASF itself conducted a survey is not resolved by investigating the facility. Filing under the correct track from the outset gets a genuine response faster.

2. Why Protection Matters: The Real Risk of Retaliation

This policy's protections in Section 6 are not a procedural courtesy — they respond to a documented, serious real-world pattern. Analysis across documented whistleblower cases finds that a majority — an estimated fifty-seven to sixty-seven percent — of individuals who report a genuine concern face retaliation of some kind, most commonly harassment or unjust termination [2]. In one documented healthcare survey, half of respondents who reported a serious workplace concern to their employer said the employer took no action at all in response [3]. A separate healthcare provider survey found that although all respondents had personally experienced or witnessed a serious safety concern, a significant share — approximately twenty-nine percent — admitted avoiding reporting it at all, citing fear of retaliation, management inaction, or the concern simply being treated as normal [4].

This is precisely the pattern this policy is built to interrupt. A complaint channel that exists on paper, but that people reasonably fear using, produces the same silence as having no channel at all — the numbers above describe organizations that had a reporting mechanism and a workforce that used it anyway, at real risk to themselves.

3. Who Can File, and About What

3.1 Who Can File

Any patient, resident, service user, family member, staff member, or member of the public may file a complaint under this policy. A complainant does not need to be personally affected by the concern being raised, and does not need to be a current patient or client of the organization in question.

3.2 What Counts as a Reportable Concern

A reportable concern is one that suggests an ASF-accredited organization is not genuinely meeting a requirement of the ASF standard it holds — for instance, a concern about infection control practice, medication safety, how patient rights are handled, or a Priority Practice under ASF Priority Practices. A complaint under this policy is not a substitute for a clinical second opinion, a billing dispute, or a personal grievance unconnected to the accredited standard itself — those are directed to the organization or the relevant local authority.

3.3 If the Concern Involves a Serious Adverse Event

Where a complaint describes a serious patient safety event — death, permanent harm, or severe temporary harm — it is handled under the ASF Sentinel Event Policy rather than this one, since that policy's root-cause-analysis and corrective-action framework is the genuinely appropriate response to an event of that severity. A complaint submitted here that meets the Sentinel Event Policy's threshold is redirected there, and the complainant is told this has happened.

4. How to Submit a Complaint

A complaint is submitted through ASF's published complaint channel, in writing, and includes:

• The name of the accredited organization the complaint concerns
• A description of the concern, and the specific standard or practice it relates to, where known
• The complainant's contact information, unless the complainant specifically requests anonymity under Section 6

A complainant is not required to have read the full ASF standard to file a complaint, and is not required to have already raised the concern with the organization directly, though doing so first is not a precondition ASF requires.

5. Investigation and Response

5.1 Acknowledgment

ASF acknowledges receipt of a complaint and confirms which track (Section 1) it has been assigned to.

5.2 Organization Response Window

Where a complaint concerns an accredited organization, ASF forwards the substance of the complaint to that organization and requires a documented response describing what the organization found and what action, if any, it has taken, within four to six weeks — consistent with the real response window Accreditation Canada applies to comparable complaints [5]. This defined window exists specifically because, as the evidence in Section 2 shows, an open-ended or informal response process is exactly the condition under which a report can quietly receive no response at all.

5.3 Confirmation to the Complainant

Once ASF has received and reviewed the organization's response, the complainant is told that the organization has responded and that its response has been reviewed. Consistent with the confidentiality principle in Section 6, the complainant is not necessarily provided the organization's full internal response verbatim, but is told plainly whether the concern was substantiated and what came of it.

5.4 When a Complaint Reveals a Genuine, Ongoing Risk

Where a complaint, once investigated, reveals a genuine and ongoing risk to patient or resident safety that the organization's own response does not adequately address, ASF may require specific corrective action beyond the organization's initial response, up to and including a targeted interim review of the organization's accreditation status — the same escalation logic already governing an inadequate response under the ASF Sentinel Event Policy.

6. Confidentiality and Protection for Complainants

A complainant may request that their identity not be disclosed to the accredited organization under investigation. ASF honors this request wherever it can conduct a genuine investigation without disclosing the complainant's identity, and tells the complainant plainly where anonymity cannot be fully preserved because the nature of the concern would identify them regardless.

ASF does not disclose a complainant's identity to any party for any purpose other than the investigation itself, and an accredited organization is expected, as a condition of its own accreditation, not to take any retaliatory action against a patient, resident, family member, or staff member who has filed a complaint in good faith.

7. Complaints About ASF Itself

A complaint about the conduct of an ASF surveyor, the reasoning behind a Council decision, or a failure of ASF to follow its own published process — as described in How ASF Develops and Revises Standards, the ASF Surveyor Training Standard, or the ASF Accreditation Process Guide — is handled under this section, not Sections 3 through 6.

7.1 Independent Review

A complaint about ASF itself is reviewed by Council members who were not involved in the decision, survey, or conduct being complained about — the same independent-review principle already governing every appeal in ASF's system.

7.2 Relationship to Formal Appeals

Where the complaint concerns a specific accreditation decision an organization has the right to formally appeal under Section 4.3 of the ASF Accreditation Process Guide, that appeal process governs the decision itself; this section addresses the underlying conduct or process failure, which may be investigated in parallel with, rather than instead of, a formal appeal.

8. Relationship to Other ASF Processes

This policy is deliberately built to work alongside ASF's existing processes, not duplicate them:

• A serious adverse event is governed by the ASF Sentinel Event Policy, not this document (Section 3.3)
• An organization's own appeal of its accreditation decision is governed by Section 4.3 of the ASF Accreditation Process Guide, not this document
• An appeal within ASF's internal governance — by a Council or Revision Panel member — is governed by Section 14 of How ASF Develops and Revises Standards, not this document

Where a complaint touches more than one of these processes, ASF coordinates between them rather than requiring the complainant to navigate the distinction themselves.

References

1. International Organization for Standardization. ISO/IEC 17011:2017, Conformity Assessment — Requirements for Accreditation Bodies Accrediting Conformity Assessment Bodies. Geneva: ISO; 2017.
2. Insights for an AI Whistleblower Office from 30 Case Studies. Retaliation rates and forms among documented whistleblower cases. 2026.
3. American College of Emergency Physicians (ACEP). 2024 Member Poll on Workplace Violence Reporting and Employer Response.
4. Black Book Research, cited in CENTEGIX. The Silent Crisis: How Underreporting Undermines Safety in Healthcare. 2025.
5. Accreditation Canada. Feedback & Complaints. Ottawa: Accreditation Canada; 2026.

Annex A — Complaint Submission Form

Complainant name: _____________________________________________

☐ I request that my identity not be disclosed to the accredited organization (Section 6)

Contact information: _____________________________________________

Accredited organization the complaint concerns: _____________________________________________

Nature of Complaint

☐ Concern about an accredited organization's compliance (Sections 3–6)

☐ Concern about ASF's own conduct or process (Section 7)

Description of the concern:

_______________________________________________________________________

_______________________________________________________________________

Date submitted: ______________________________

Annex B — Complaint Tracking Record

Complaint reference number: ______________________________

Track assigned (organizational / ASF conduct): ________________________________________

Date received: ______________________________

Date acknowledged: ______________________________

Organization Response (if applicable)

Date requested: ______________________________

Date received (within 4–6 weeks): ______________________________

Outcome

☐ Substantiated — corrective action required

☐ Not substantiated

☐ Redirected to Sentinel Event Policy

Complainant notified (date): ______________________________

Index

Anonymity, 6

Complaints About ASF Itself, 7

Confidentiality, 6

Organization Response Window, 5.2

Reportable Concern, 3.2

Retaliation (real risk), 2

Sentinel Event Redirect, 3.3

Two Complaint Tracks, 1

Underreporting, 2

This policy exists so that accountability for meeting an ASF standard never depends solely on the accredited organization's own word — and so that the real, documented risk of retaliation never becomes the reason someone stays silent instead.