Standards Development Committee — Terms of Reference (ASF-GOV-002)

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1. Purpose

1.1These Terms of Reference (ToR) establish the mandate, composition, responsibilities, and operating procedures of the ASF Standards Development Committee (SDC). The Committee is the principal governance body responsible for the oversight, approval, and strategic direction of all ASF healthcare accreditation standards development and revision activities.

1.2These ToR are established under the authority of the ASF President and are read alongside the Standards Development Methodology (ASF-GOV-001) and the Impartiality Policy (ASF-GOV-003).

1.3The purposes of the Committee are: (a) to ensure that ASF standards are developed through a rigorous, evidence-informed, and transparent methodology; (b) to provide independent technical and scientific oversight; (c) to ensure stakeholder perspectives are appropriately considered; (d) to safeguard the impartiality of ASF’s standards from commercial or other undue influence; and (e) to ensure ASF standards remain aligned with current international accreditation practice.

2. Mandate and Authority

2.1The Committee holds the following authorities delegated by the ASF President: (a) final technical approval of all new standards prior to the President’s signature; (b) final technical approval of all major revisions; (c) approval of the annual standards review schedule; (d) approval of ASF-EV-001 (evidence bibliography) at each major revision; (e) authorisation of stakeholder consultation processes; (f) review and endorsement of ASF-EV-002 (consultation summary) and ASF-EV-003 (pilot summary); (g) decisions on whether consultation responses are accepted, modified, or rejected; and (h) recommendation to the President on member appointments.

2.2Minor revisions may be approved by the SDC Chair without convening a full meeting, subject to notification at the next scheduled meeting.

2.3The Committee does not hold authority over operational accreditation decisions (ASF-OPS-001), surveyor appointments (ASF-OPS-002), or financial matters, which remain with the President.

3. Membership

3.1The Committee comprises a minimum of five and a maximum of nine members appointed by the ASF President, ensuring: (a) multidisciplinary professional representation; (b) geographical diversity; (c) a majority of independent members; and (d) at least one member with international accreditation assessment experience.

3.2Membership composition:

3.3No more than two members may be drawn from the same institution at any one time. Members serve in a personal capacity and are not remunerated.

3.6The ASF President serves as ex officio observer at Committee meetings without voting rights on standards approval decisions.

4. Quorum and Decision-Making

4.1A quorum is a simple majority of appointed members entitled to vote (excluding any member who has declared a conflict of interest on the agenda item under discussion).

4.2Standards approval decisions require a quorum and simple majority. In the event of a tied vote, the Chair has a casting vote.

4.5All decisions, including vote counts and dissenting positions, are recorded in the meeting minutes. Minutes are circulated within 10 working days and retained as controlled records.

5. Meetings

5.1The Committee meets at least twice per calendar year: once in H1 to review post-implementation monitoring data and the annual review schedule, and once in H2 to review and approve standards developments.

5.2Extraordinary meetings may be convened to consider: a material patient safety signal; a regulatory change affecting standards validity; or a formal complaint raising a systemic standards issue.

5.4The agenda and supporting papers are circulated at least 14 calendar days in advance. Papers for standards approval include the draft standard, updated ASF-EV-001, ASF-EV-002, expert review findings, and ASF-EV-003 where applicable.

6. Conflict of Interest Management

6.1All members complete a written conflict-of-interest declaration on appointment and update it annually or whenever a new conflict arises. Declarations are retained as controlled records.

6.2A conflict of interest exists when a member has a financial, professional, personal, or institutional interest that could influence their independent judgement. Examples include: (a) a direct financial relationship with a facility seeking ASF accreditation; (b) authorship of a standard being incorporated into ASF standards; (c) employment or consultancy for an organisation with a commercial interest in the outcome; or (d) a personal relationship with the lead drafter.

6.4A member with a declared conflict shall: (a) withdraw from the room for the duration of the discussion and vote; (b) not receive the supporting papers for that item; and (c) not be counted toward quorum for that item.

7. Confidentiality

Members are required to treat as confidential all unpublished draft standards, consultation responses received in confidence, Committee deliberations, conflict-of-interest declarations of fellow members, and any commercially or personally sensitive information. The confidentiality obligation continues after a member’s term ends. The full framework is set out in ASF-GOV-004 (Confidentiality Policy).

8. Accountability and Reporting

The Committee reports to the ASF President. Following each meeting, the Chair provides a written decision summary. An annual Committee report is submitted by end of Q1 each year, covering: meetings held; standards approved, revised, or initiated; review schedule status; post-implementation monitoring findings; and any material risks to standards integrity.

9. ISQua EEA Alignment

These Terms of Reference address: Principle 1 (Evidence — the Committee’s oversight of evidence-informed development); Principle 2 (Stakeholder Engagement — Committee responsibility to authorise and review consultation); Principle 3 (Transparency — public availability of these ToR and Committee decisions); Principle 4 (Independence — membership independence requirements and CoI procedures); and Principle 5 (Review — the Committee’s role in periodic standards review). The ASF ISQua EEA Crosswalk (ASF-EV-004) maps these provisions to the applicable EEA criteria.

10. References

Document code: ASF-GOV-002  ·  Version: V3.0  ·  Effective: 2026-09-30  ·  Next review: September 2031  · 
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ASF-GOV-002 — Standards Development Committee — Terms of Reference · Version V3.0

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