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International Accreditation of Healthcare Facilities

ASF Governance & Policy Manual · ASF-POL-46

Policy Development, Approval and Review

Part of the ASF Governance & Policy Manual. Adapted from the PHIG Institutional Policy Manual (consolidated edition, September 2026).

This policy governs how the 45 other policies in this manual — and this one itself — are created, approved and kept current. It sits alongside, and does not replace, the Five-Stage Development Process and Three-Year Revision Cycle that govern ASF’s accreditation standards specifically (Standards Development, Sections 04–05); this policy governs ASF’s organisational policies. Owner: International Standards Council.

Approval

A new or revised organisational policy is drafted by the Secretariat, reviewed for conflicts against the Conflict-of-Interest Policy, and circulated for comment to the stakeholders it directly affects — for a training-programme policy specifically, this includes current trainees, trainers, and certified Coordinators/Monitors — before approval by the International Standards Council and publication. The level and method of stakeholder consultation is proportionate to the policy’s impact, documented in the policy’s own revision history.

Review cycle

Every policy in this manual carries a 3-year scheduled review, shown against its entry in the Public Standards Register, matching the cycle ASF already applies to its standards. A policy may be revised sooner if an incident (ASF-POL-21) or audit finding (ASF-POL-17) identifies a gap.

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