Accreditation Decision Framework (ASF-OPS-001)

Version History

1. Purpose

1.1This document establishes the framework within which all ASF accreditation decisions are made, documented, communicated, and reviewed. It defines the five decision types, the criteria thresholds that determine each type, the ADC’s composition and operating procedures, CAP requirements, and decision communication timelines.

1.2This framework ensures that: (a) every decision is based on objective evidence assessed against published criteria; (b) the decision-making process is independent of the survey team; (c) all decisions are documented with full reasoning; and (d) facilities receive clear, actionable guidance following every survey.

1.3Aligned with ISQua EEA Principle 8 (Accreditation Decisions) and the decision frameworks of JCI, Accreditation Canada, and ACHS.

2. Accreditation Decision Committee

2.1.1All accreditation decisions are made by the ASF Accreditation Decision Committee (ADC) — the sole decision-making body. Individual surveyors do not make or recommend accreditation decisions.

2.1.2The ADC comprises: (a) a Chair — experienced healthcare quality professional, independent of operational survey management; (b) a minimum of two additional voting members; and (c) the Lead Surveyor as non-voting rapporteur — presents findings but does not vote.

2.1.3–2.1.4No voting member may have served on the survey under consideration or have a conflict of interest. A quorum is the Chair plus at least one additional voting member. Simple majority; Chair has casting vote on a tie.

2.2.2The Lead Surveyor presents findings at the start of the ADC session then withdraws before deliberation and voting, in accordance with ASF-GOV-003, §7.1(a). Full decision reasoning is documented in the ADC session record before the session closes.

3. Scoring Methodology

3.1Each criterion is assessed as: Met (fully demonstrated with objective evidence); Partially Met (counts as not met for threshold calculations); or Not Met.

3.2Tier roles in decision thresholds: Critical — any single unmet Critical criterion is a barrier to Accreditation and Conditional Accreditation; Essential — compliance rate is the primary threshold distinguishing the three positive decision types; Significant and Developmental — contribute to overall compliance percentage but do not independently determine decision type.

3.3Overall compliance % = (criteria Met) ÷ (total scored criteria) × 100. Critical criteria are weighted at 2× their nominal value, reflecting their life-safety significance.

3.4The ADC is not bound to apply thresholds mechanically. Documented professional judgement may be applied in exceptional circumstances, with full rationale recorded in session minutes.

4. The Five Decision Types

Accreditation (§4.3)

Granted where all Critical criteria are Met, ≥70% of Essential criteria are Met, and overall compliance is ≥60%. Certificate valid 3 years. Accreditation mark licence granted under ASF-OPS-004.

Conditional Accreditation (§4.4)

Granted where all Critical criteria are Met and Essential compliance is 50–69%, or overall compliance is 50–59%. Valid 12 months with mandatory mid-term review at 6 months. Facility must submit a CAP within 30 days. A full-cycle survey is conducted before expiry; one 12-month extension only.

Recognition Award (§4.5)

Granted where all Critical criteria are Met, Essential compliance is below 50%, but the facility demonstrates genuine commitment to quality improvement with a credible CAP submitted within 30 days. Valid 12 months, non-renewable. Does not confer accreditation status or permit use of the ASF mark. Reflects ASF’s commitment to supporting quality improvement in resource-constrained settings.

Non-Accreditation (§4.6)

Issued where any Critical criterion is not met, or Essential compliance is below 50% without a Recognition Award pathway. Written finding with specific deficiencies. Facility may reapply after minimum 12 months; post-decision briefing available on request.

Suspension and Withdrawal (§4.7)

Suspension is triggered by failure of mid-term review, a significant post-accreditation patient safety concern, or failure to submit required CAP or progress reports. Maximum 6 months; remediation plan required within 14 calendar days. Review at end of suspension: reinstate, extend by up to 3 months (one extension), or withdraw. Withdrawal is permanent; reapplication after minimum 24 months.

5. Corrective Action Plans

A CAP is required within 30 days of decision notification for Conditional Accreditation and Recognition Award decisions; within 60 days for full Accreditation with residual Significant-level nonconformances. Each CAP entry must include: (a) criterion reference and nonconformance description; (b) root cause analysis; (c) specific corrective action; (d) responsible person; (e) target completion date; and (f) evidence of completion for review at the next survey. Failure to submit a required CAP within the specified timeframe may trigger a suspension decision.

6. Decision Communication

All decisions are communicated in writing with: decision type and effective dates; basis including compliance percentages; CAP requirement (where applicable); right to appeal referencing ASF-GOV-005 and the 30-day window; and the name of the ADC Chair.

Timelines: Accreditation, Conditional, Recognition Award, Non-Accreditation — within 20 calendar days of ADC session. Suspension or Withdrawal — within 5 working days. Accreditation certificate issued within 10 working days of notification. Public registry updated within 5 working days.

7. ISQua EEA Alignment

This framework addresses ISQua EEA Principle 8: decisions by a body independent of the survey team; published and consistently applied criteria; written decisions with reasons; access to appeals (ASF-GOV-005); and public registry disclosure. The ASF ISQua EEA Crosswalk (ASF-EV-004) maps these provisions to the applicable EEA criteria.

8. References

Appendix 1 — Survey Report Template

The ASF Survey Report Template (ASF-OPS-001 Appendix 1) is the structured form completed by the survey team for every accreditation survey. It contains nine parts: facility and survey details; opening meeting record; survey conduct; domain-by-domain assessment summary with NC count matrix; nonconformance log with individual NC blocks; observations and best practices; Lead Surveyor narrative and ADC recommendation; closing meeting record; and surveyor declarations. The completed report is submitted to the QMS Coordinator within 15 working days of the survey and reviewed before presentation to the ADC.

Accreditation Decision Committee (ADC)

The Accreditation Decision Committee is constituted as a standing body, permanently separate from the ASF survey team. ADC members do not conduct surveys; surveyors do not sit on the ADC. Full membership, mandate, operating rules, and the complete separation-of-functions overview are published on the dedicated ADC page.

→ View ADC Members and Mandate

Document code: ASF-OPS-001  ·  Version: V3.0  ·  Effective: 2026-09-30  ·  Next review: September 2031  · 
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ASF-OPS-001 — Accreditation Decision Framework · Version V4.0

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