Standards › ASF Health Standards v10 › Standard 23
Standard 23
Multi-Site Governance
Multi-site governance: decision rights, shared incident learning, standard clinical policy with justified variation, central credentialing, safety review of central decisions and central quality review.
For an organisation operating multiple sites, explicit, documented governance defines which decisions belong to central/corporate leadership and which belong to site-level leadership, with no ambiguity about who holds authority for a given decision — not an informal or assumed division that leaves gaps when a decision needs to be made.
Why it matters. A multi-site organisation where no one knows which decisions belong to the centre and which to the site leads to disputes and missed safety decisions. A written split of authority settles it.
How the surveyor verifies this criterion
Sample. Review the decision rights table, and the record of sharing with each site lead.
1. Every decision type has an owner in central or site leadership.
Method. Check the table for an owner against each decision type.
Evidence to show. Decision rights table (NET-FRM-001).
Pass when. Every decision type has an owner recorded.
2. The table is shared with every site lead.
Method. Check the sharing record for each site lead.
Evidence to show. Decision rights table (NET-FRM-001).
Pass when. Every site lead has the table with a sharing date recorded.
3. A decision made is recorded against the table.
Method. Check the last 3 site decisions for the owner recorded.
Evidence to show. Decision rights table (NET-FRM-001).
Pass when. Every sampled decision has an owner from the table recorded.
Immediate fail (any one means the criterion is not met)
- A site closes a ward with no central decision and no record.
Documents
E-learning
- Governance & Management (H-07)
References
- World Health Organization. Framework on integrated people-centred health services. Geneva: WHO; 2016.
A serious incident identified at one site triggers a review and dissemination process reaching every other site under the same governance structure, with lessons learned reaching relevant staff elsewhere in the network — not confined to the originating site as though it carries no relevance to the rest of the organisation.
Why it matters. A serious incident at one site that is not shared with the others means the same thing can happen again elsewhere. Sharing the learning across all sites prevents repeats.
How the surveyor verifies this criterion
Sample. Review the incident learning log for the last 12 months, with the sites informed and the actions recorded.
1. Each serious incident triggers a review and is shared across the sites.
Method. Check each serious incident for the review and the sites informed.
Evidence to show. Incident learning log (NET-REG-001).
Pass when. Every serious incident has a review and sites informed recorded.
2. Lessons reach relevant staff at the other sites.
Method. Check each entry for the lessons shared and to whom.
Evidence to show. Incident learning log (NET-REG-001).
Pass when. Every entry records lessons shared with relevant staff.
3. Actions are recorded at each site informed.
Method. Check each site informed for an action recorded.
Evidence to show. Incident learning log (NET-REG-001).
Pass when. Every site informed has an action recorded.
Immediate fail (any one means the criterion is not met)
- A fall death at one site is never mentioned to the others.
Documents
E-learning
References
- World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Geneva: WHO. https://www.who.int/publications-detail-redirect/9789240032705
Core clinical policies are standardised across every site in the network, with any permitted local variation explicitly documented and specifically justified — not silent, unexplained drift between sites that leaves patients receiving different standards of care depending on which site they visit.
Why it matters. Each site doing clinical care in its own way makes the network hard to trust and hard to audit. Core policies should be the same everywhere, and any local difference should be written and justified.
How the surveyor verifies this criterion
Sample. Review the network standard list of core clinical policies and the register of justified local variations.
1. Core clinical policies are standardised across every site.
Method. Compare each site’s core policy against the network standard list.
Evidence to show. Register of justified local variations (NET-REG-002).
Pass when. Every site follows the network standard for each core policy, or a variation is recorded.
2. Each local variation is documented.
Method. Check each site variation against the register.
Evidence to show. Register of justified local variations (NET-REG-002).
Pass when. Every variation found is in the register.
3. Each local variation is specifically justified and approved.
Method. Check each entry for the justification and the approval.
Evidence to show. Register of justified local variations (NET-REG-002).
Pass when. Every entry has a justification and an approval.
Immediate fail (any one means the criterion is not met)
- Two sites give the same drug with different protocols and no reason.
Documents
E-learning
- Governance & Management (H-07)
References
- International Organization for Standardization. ISO 9001:2015 Quality management systems: requirements. Geneva: ISO; 2015.
A clinician’s credentials and clinical privileges are verified through a single, central process and consistently recognised across every site where that clinician practises, with no site allowing a clinician to practise without their current credentials and privileges being confirmed for that specific site.
Why it matters. A clinician who is verified at one site and not at another can practise where they are not safe. One central verification, recognised everywhere, closes that gap.
How the surveyor verifies this criterion
Sample. Review the central credentialing procedure, the verified clinician register and the site recognition record for 5 clinicians.
1. Each clinician’s credentials and privileges are verified through a single central process.
Method. Check each clinician for the central verification record.
Evidence to show. Verified clinician and site recognition register (NET-REG-003).
Pass when. Every clinician has a central verification recorded.
2. Each site recognises the clinician only after the central check.
Method. Check each site recognition against the central verification date.
Evidence to show. Verified clinician and site recognition register (NET-REG-003).
Pass when. Every site recognition follows a recorded central check.
3. Credentials are current at each site where the clinician practises.
Method. Check the expiry for each recognised site against the rota.
Evidence to show. Verified clinician and site recognition register (NET-REG-003).
Pass when. No clinician practises at a site with expired credentials.
Immediate fail (any one means the criterion is not met)
- A clinician is granted privileges at one site with no check at the central office.
Documents
E-learning
References
- World Health Organization. Framework on integrated people-centred health services. Geneva: WHO; 2016.
A central decision affecting staffing, equipment, or resource allocation at a specific site is evaluated for its patient safety impact at that site before being finalised, with a documented process for that evaluation — not a purely network-level financial or operational decision made without consideration of site-level patient safety consequences.
Why it matters. A central decision to cut staff or move equipment can be safe on paper and dangerous at one site. Checking the patient safety impact at the site before the decision takes effect prevents that.
How the surveyor verifies this criterion
Sample. Review the template for central decisions and the safety impact evaluation for the last 3 decisions.
1. Each central decision on staffing, equipment or resources is evaluated for site patient safety impact.
Method. Check each decision in the sample for the evaluation.
Evidence to show. Central decision safety impact evaluation (NET-FRM-002).
Pass when. Every sampled decision has a safety impact evaluation.
2. The evaluation is completed before the decision is finalised.
Method. Check each evaluation date against the decision date.
Evidence to show. Central decision safety impact evaluation (NET-FRM-002).
Pass when. Every evaluation is completed before the decision is finalised.
3. Any impact found has a mitigation agreed.
Method. Check each evaluation for the mitigation recorded.
Evidence to show. Central decision safety impact evaluation (NET-FRM-002).
Pass when. Every impact found has a mitigation recorded.
Immediate fail (any one means the criterion is not met)
- A site loses its night nurse with no safety review.
Documents
E-learning
- Governance & Management (H-07)
References
- World Health Organization (2017). Hospital Safety Index: Guide for Evaluators, second edition. Geneva: WHO. https://www.who.int/publications/i/item/9789241548984
Quality and safety metrics reported upward from each site are reviewed by central governance, with follow-through action when a metric indicates a problem — not merely collected and filed as a reporting formality with no actual review or consequence.
Why it matters. Quality data sent up from each site means little if no one at the centre reads it or acts on a warning. Central review, with follow-up, is what turns the data into safer care.
How the surveyor verifies this criterion
Sample. Review the central quality review record for the last 4 quarters, with the actions taken for each site.
1. Quality and safety metrics from each site are reviewed by central governance each quarter.
Method. Check the register for each site in each quarter.
Evidence to show. Central quality review register (NET-REG-004).
Pass when. Every site is reviewed in every quarter.
2. Each metric showing a problem has an action.
Method. Check each problem metric for the action recorded.
Evidence to show. Central quality review register (NET-REG-004).
Pass when. Every problem metric has an action and follow-up date.
3. Follow-up is checked at the next review.
Method. Check the next quarter’s review for the follow-up.
Evidence to show. Central quality review register (NET-REG-004).
Pass when. At least 90% of actions are followed up at the next review.
Immediate fail (any one means the criterion is not met)
- A site with a rising infection rate is not noticed at the centre.
Documents
E-learning
- Governance & Management (H-07)
References
- World Health Organization (2017). Hospital Safety Index: Guide for Evaluators, second edition. Geneva: WHO. https://www.who.int/publications/i/item/9789241548984
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