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.
Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.
Training colours: red means essential, green recommended, yellow optional. Each course shows its level for each setting: humanitarian, transition and fragile, and standard.
23.1Governance Structure Defines Authority Between Central and Site-Level LeadershipHumanitarian settings: MinimumTransition and fragile: MustStandard: Must
For an organisation operating multiple sites, explicit, documented governance defines which decisions belong to central or corporate leadership and which belong to site-level leadership, with no ambiguity about who holds authority for a given decision.
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.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Chief executive (ISCO 1120) | Approves the decision rights table | Must |
| Manager (ISCO 1342) | Keeps the table and shares it with each site lead | Must |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NET-FRM-001 · Decision rights table | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
| NET-POL-001 · Decision rights between central and site leadership | Chief executive (ISCO 1120) | Governing body members | N/A | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Governance and Management (H-07) | Chief executive; Manager |
References
- Pan American Health Organization (2020). Framework for the Response of Integrated Health Service Delivery Networks to COVID-19. Used for: network governance and response across integrated health service delivery networks (COVID-era). https://news.gmj.ge/guideline/framework-for-the-response-of-integrated-health-service-delivery-networks-to-covid-19/
23.2Incident Learning Is Shared Across Sites, Not SiloedHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
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.
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.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Logs serious incidents and shares lessons | Medium |
| Secretary (ISCO 3344) | Keeps the incident learning log | Medium |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NET-REG-001 · Incident learning log | Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Incident Reporting, Just Culture and Open Disclosure (T-09) | Manager; Nurse |
References
- World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Used for: incident reporting, learning systems and quality across all settings. https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/
23.3Clinical Policy Is Standardised Across Sites, With Any Local Variation Explicitly JustifiedHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
Core clinical policies are standardised across every site in the network, with any permitted local variation explicitly documented and specifically justified, not silent or unexplained drift between sites.
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.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Owns the network list of core policies | Medium |
| Specialist physician (ISCO 2212) | Justifies and signs each local variation | Medium |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NET-REG-002 · Register of justified local variations | Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
| NET-POL-002 · Standard clinical policy and local variation | Chief executive (ISCO 1120) | Governing body members | N/A | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Governance and Management (H-07) | Chief executive; Manager |
References
- World Health Organization (2019). Surgical Care at the District Hospital. Used for: standard policy and quality in first-referral sites. https://news.gmj.ge/guideline/surgical-care-at-the-district-hospital/
- World Health Organization (2017). Medication Without Harm: Global Patient Safety Challenge on Medication Safety. Used for: policy, standards and reporting of medication safety across health care settings. https://news.gmj.ge/guideline/medication-without-harm-global-patient-safety-challenge-on-medication-safety/
23.4Credentialing and Privileging Are Centrally Verified and Consistently RecognisedHumanitarian settings: MustTransition and fragile: MustStandard: Must
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 practice without current credentials confirmed for that 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.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Runs the central credentialing check | Must |
| Secretary (ISCO 3344) | Keeps the verified clinician register | Must |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NET-REG-003 · Verified clinician and site recognition register | Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
| NET-POL-003 · Central credentialing and privileging | Chief executive (ISCO 1120) | Governing body members | N/A | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Credentialing, Competence and the Training Matrix (T-14) | Manager; Secretary |
References
In process of development. Will be available soon.
23.5Central Resource and Staffing Decisions Are Evaluated for Site-Level Patient Safety ImpactHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
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.
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.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Chief executive (ISCO 1120) | Makes the central decision | Medium |
| Manager (ISCO 1342) | Completes the safety impact evaluation | Medium |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NET-FRM-002 · Central decision safety impact evaluation | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Governance and Management (H-07) | Chief executive; Manager |
References
- World Health Organization (2017). Hospital Safety Index: Guide for Evaluators, second edition. Used for: evaluating hospital safety before a central decision takes effect. https://news.gmj.ge/guideline/hospital-safety-index-guide-for-evaluators-2nd-ed/
23.6Site-Level Quality Data Is Reviewed by Central GovernanceHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
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.
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.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Chief executive (ISCO 1120) | Reviews site metrics each quarter | Medium |
| Manager (ISCO 1342) | Records actions and follow-up | Medium |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NET-REG-004 · Central quality review register | Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Governance and Management (H-07) | Chief executive; Manager |
References
- World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Used for: incident reporting, learning systems and quality across all settings. https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/
Who is responsible for Standard 23
Each criterion names the positions responsible for it. Every position links to its own terms of reference.
| Criterion | Responsible | Supports |
|---|---|---|
| 23.1 Governance Structure Defines Authority Between Central and Site-Level Leadership | Board of directors Chief executive officer (CEO) |
Chief operating officer (COO) |
| 23.2 Incident Learning Is Shared Across Sites, Not Siloed | Patient safety officer Chief quality and safety officer |
Incident reporting coordinator |
| 23.3 Clinical Policy Is | Clinical governance lead Chief medical officer (CMO) |
Chief quality and safety officer |
| 23.4 Credentialing and Privileging Are Centrally Verified and Consistently Recognised | Competency assessor Chief human resources officer |
Training and education manager |
| 23.5 Central Resource and Staffing Decisions Are Evaluated for Site-Level Patient Safety Impact | Chief financial officer (CFO) Chief operating officer (COO) |
Chief quality and safety officer |
| 23.6 Site-Level Quality Data Is Reviewed by Central Governance | Chief quality and safety officer Quality manager |
Clinical audit officer |
Role details: reporting, supervision and training
Training shown is the general recommendation. Role-specific training is set in the next improvement round.
Questions and answers
The criterion text is the authority. These answers summarise it.
Who does Standard 18 apply to?
An organisation operating more than one site under one governance structure.
What do the colours mean for this standard?
Red (Must) is required. Green (Medium) is recommended. Yellow (Minimum) is the lowest acceptable level in humanitarian settings. Standard setting is Must on every criterion.
Why is 23.4 red in humanitarian settings?
A clinician who practises at a site without verified credentials can harm patients directly, so central verification is required everywhere.
Does every serious incident have to be shared with other sites?
Yes. Under 23.2 each serious incident triggers a review and is shared with every other site under the same governance structure.
Can a central decision on staffing take effect before its safety impact is checked?
No. Under 23.5 the safety impact at each affected site is evaluated and any impact is mitigated before the decision is finalised.
Do I have to use the documents on this page?
No. The policies, forms and registers are drafts to help you. Adapt them to your organisation, write your own, or upload your own. What the assessor checks is that the criterion is met and that you can show how.
What does In process of development mean?
That part of the standard is still being prepared. It may be a document, a course, a reference or a role table. It will be added in a later version.
Guidelines for this standard
3 guideline(s) are held in the GMJ Guidelines Library and listed here. Each link opens the full guideline on news.gmj.ge. The complete library, grouped by standard, is at Guidelines.
- Organization of the network of curative services (Management of a cholera epidemic) — MSF Management of a cholera epidemic (Médecins Sans Frontières)
- Framework for the Response of Integrated Health Service Delivery Networks to COVID-19 (Pan American Health Organization)
- Evaluating the impact of the human papillomavirus vaccine in Latin America and the Caribbean (Pan American Health Organization)
Also relevant to this standard:
- National Guidance on Learning from Deaths (NHS England)
- Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care (World Health Organization)