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Accréditation Sans Frontières

International Accreditation of Healthcare Facilities

ASF Institutional Policy Manual · Aligned with PHIG, September 2026

Part of the ASF policy framework, aligned with the equivalent PHIG policy. To raise a concern: see the ASF Complaints and Reporting Channel.

Every ethics or security incident is logged within 24 hours, assessed within 3 working days and closed with a written outcome. Owner: Ethics and Compliance Officer (Irakli Pshinashvili); security incidents are logged by the Security Focal Point (Tamar Talakvadze).

Incident categories

Category Examples Lead
Financial crime Fraud, bribery, money laundering, sanctions breach Ethics and Compliance Officer
Safeguarding Sexual exploitation, abuse, harassment, child abuse, trafficking Safeguarding and People Lead
Misconduct Conflict of interest, discrimination, bullying, breach of the Code Ethics and Compliance Officer
Research and publishing Fabrication, falsification, plagiarism, unethical research Research Integrity Officer
Data Personal data breach, loss of devices, unauthorised access Data Protection Officer
Safety and security Accident, assault, theft, detention, threat, travel incident Security Focal Point with Head of Administration

Process

Every credible allegation is investigated; unfounded ones are closed with written reasons.

Investigation standards

  1. Independence: the investigator has no conflict and is not in the reporting line of the subject. Allegations against the Head of Administration or a focal point are overseen by the Chair; complex cases may use an external investigator.
  2. Terms of reference set scope, timeline and who is informed.
  3. Fairness: the subject is told of the allegation and may respond before any finding. Findings are based on the balance of probabilities.
  4. Survivor-centred for safeguarding cases: the survivor’s safety and consent guide each step (Policy 8).
  5. Evidence is kept securely; interviews are recorded in writing and signed.
  6. Timeline: investigations normally conclude within 60 days; delays are explained to the reporter and donor.

Outcomes

Disciplinary action, recovery of funds, contract termination, referral to authorities, control improvements and lessons learned. The Board receives an anonymised incident summary every quarter.

Incident register

The Ethics and Compliance Officer keeps a confidential register of every incident, decision and donor notification, retained for at least seven years.

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