Foreword

Many hospitals ASF's own standards govern genuinely cannot afford a full-time accreditation coordinator, a structured patient feedback system, or ongoing staff training on their own. That is a real, practical gap — and refusing to fill it does not make an accreditation body more independent, it just leaves under-resourced organizations further behind. The honest question is not whether ASF or its partners should offer paid advisory support. It is whether that support is kept structurally, verifiably separate from the accreditation decision itself, and whether ASF says so plainly rather than pretending the two are unconnected while quietly running both.

This policy states the actual rule ASF's Local Advisory Services, and any comparable offering, operate under: advisory support and accreditation decisions are organizationally separated, and this separation is disclosed publicly, not managed as a discreet internal arrangement.

1. Purpose

This policy governs any paid advisory, coordination, training, or technical support service offered by ASF or an ASF-authorized local delivery partner to an organization seeking or holding ASF accreditation — including the ASF Local Advisory Services catalog. It states the organizational separation that keeps such services from ever influencing an accreditation outcome, consistent with the ASF Independence & Non-Influence Statement and Principle 4 of the ASF Code of Conduct.

2. Why This Matters: The Real Regulatory Precedent

This is not a novel problem ASF is solving from first principles. The same structural conflict — an organization providing both paid advisory work and independent assessment to the same client — is precisely what the Sarbanes-Oxley Act of 2002 was written to address in financial auditing, following major audit failures where an auditing firm's own consulting relationship with a client was later found to have compromised its independent judgment [1]. Section 201 of that Act prohibits an auditing firm from providing certain categories of non-audit consulting service to a company it also audits, and requires independent pre-approval for any permitted non-audit service [1–2]. Section 206 goes further: it restricts an auditor from conducting an audit where a senior member of the client's own team came directly from the audit firm within the preceding year, recognizing that the conflict can run through people, not only through contracts [1].

ASF is not a financial regulator, and this policy does not adopt Sarbanes-Oxley's specific legal thresholds. What it adopts is the real, tested principle behind them: paid advisory work and independent assessment cannot be provided by the same actual people, on the same actual timeline, without a documented separation — and that separation has to be structural, not merely a stated intention.

3. The Organizational Separation Principle

Advisory services and accreditation decisions are functionally separated within ASF's own structure:

• An individual who provides advisory, coordination, or training services to an organization—whether directly employed by ASF or by an ASF-authorized local delivery partner—does not serve as a surveyor assessing that same organization's accreditation
• The Council decision on an organization's accreditation status is made without reference to whether that organization has purchased any advisory service, and without input from the individuals who delivered any such service
• Purchasing any level of advisory support — or purchasing none at all — has no bearing on accreditation outcome, timeline, or level, consistent with the ASF Independence & Non-Influence Statement

4. What Advisory Services May and May Never Do

4.1 What Advisory Services May Do

• Provide a dedicated coordinator to help an organization manage documentation, evidence, and internal preparation for its own accreditation process
• Deliver training, technical support, and patient-engagement infrastructure (such as a Patient Council secretariat or feedback system) that helps an organization genuinely meet ASF's published standards
• Charge real, published prices for this support, on the same transparent basis for every organization, regardless of size or relationship to ASF

4.2 What Advisory Services May Never Do

• Represent, imply, or allow an organization to believe that purchasing advisory support influences, expedites, or guarantees a favorable accreditation outcome
• Involve any individual who delivered advisory services to an organization in that same organization's survey, accreditation decision, or appeal
• Substitute for the organization's own responsibility to actually meet the standard — advisory services support an organization's own work; they do not do that work on the organization's behalf, and do not relieve the organization of accountability for its own compliance

5. Personnel Separation

Consistent with the real principle behind Sarbanes-Oxley Section 206 — that a conflict can run through people even where a contract appears clean [1] — an individual who has provided advisory services to a specific organization does not subsequently serve as a surveyor assessing that same organization until a minimum of three years has elapsed since the advisory engagement ended, mirroring the currency and independence principles already governing surveyor conflicts of interest under the ASF Surveyor Training Standard, Standard A5.

6. Local Delivery Partners

Where ASF authorizes a local organization — such as the Public Health Institute of Georgia (PHIG) operating ASF's Tbilisi advisory presence — to deliver advisory services in a specific country or region, that partner is governed by the ASF Local Partner Standard, which establishes the eligibility, quality oversight, and conflict-of-interest requirements a local delivery partner must meet. This policy's separation principle in Section 3 applies to a local partner's own personnel exactly as it applies to ASF's own staff — authorization to deliver advisory services never extends to any role in that same market's accreditation decisions.

7. The Public Disclosure Commitment

ASF publishes, rather than conceals, the existence and pricing of its advisory services. Any organization, journalist, or competitor can see exactly what ASF's Local Advisory Services cost, exactly what they include, and exactly how independence from accreditation decisions is structurally maintained. This is a deliberate choice, not a default: an accreditation body that quietly provides the same kind of support through an unnamed affiliate, while publicly denying any such relationship exists, has chosen concealment over the harder, more accountable path of disclosure. ASF's own credibility rests on choosing the harder path.

8. Relationship to Other ASF Documents

• The ASF Independence & Non-Influence Statement names Local Advisory Services explicitly as a specific application of its core assurance (Section 3 of that document)
• Principle 4 of the ASF Code of Conduct governs the individual conduct obligations this policy's organizational structure is built to support
• The ASF Local Partner Standard governs eligibility and oversight of any organization, such as PHIG, authorized to deliver advisory services on ASF's behalf in a given market
• The ASF Local Advisory Services catalog is the specific, priced service offering this policy governs; where the two documents differ, this policy's separation principle takes precedence

References

1. U.S. Congress. Sarbanes-Oxley Act of 2002, Title II (Auditor Independence), Sections 201 and 206. Public Law 107-204.
2. ManageEngine. Ensuring Financial Trust: A Guide to SOX Compliance — Title II Auditor Independence. 2026.

Annex A — Advisory Engagement Separation Record

Organization name: _____________________________________________

Advisory services provided: _____________________________________________

Individual(s) delivering advisory services: ________________________________________

☐ Confirmed: none of the above individuals will serve as a surveyor for this organization

☐ Confirmed: no advisory personnel have any role in this organization's accreditation decision

Local delivery partner (if applicable): ________________________________________

Record maintained by: ________________________________________

Index

Local Delivery Partners, Section 6

Organizational Separation, Section 3

Personnel Separation, Section 5

Public Disclosure Commitment, Section 7

Sarbanes-Oxley (real precedent), Section 2

What Advisory Services May Never Do, Section 4.2

An organization that cannot afford full-time accreditation expertise deserves real help, not a lecture about self-reliance. This policy exists so that help never has to be hidden to stay honest.