VersionV3.0 ✓ Published
Effective date2026-09-30
Approved byProf. Giorgi Pkhakadze, MD, MPH, PhD — President, Accréditation Sans Frontières
Applies toAll ASF accreditation agreements — new applications, active accreditations, and renewal processes
Related documentsASF-OPS-001 · ASF-OPS-002 · ASF-OPS-005 · ASF-OPS-006 · ASF-GOV-005
SupersedesASF-OPS-003 V2.0 (2026-11-24)
Next reviewSeptember 2031, or earlier on trigger
Version History
| Version | Date | Nature of change | Approved by |
|---|---|---|---|
| V0.1 | 2024-12-10 | Initial draft | — |
| V1.0 | 2025-02-01 | First published version | Prof. G. Pkhakadze, ASF President |
| V2.0 | 2025-10-05 | 8-row cycle timeline; 12-month renewal notice formalised | Accreditation Decision Committee |
| V3.0 | 2026-09-30 | 3-type in-cycle monitoring; 3 exceptional extension grounds; approved for ISQua EEA package | Prof. G. Pkhakadze, ASF President |
1. Purpose
This policy defines the structure, duration, and sequencing of the accreditation cycle for all ASF accreditation programmes — from initial survey through to renewal or lapse. It sets out the obligations of both the facility and ASF at each stage, and the monitoring activities ASF conducts during the accreditation period.
2. Accreditation Cycle Duration
2.1Full Accreditation: 3 years from survey date. Certificate specifies start and expiry dates.
2.2Conditional Accreditation: 12 months with mandatory 6-month mid-term review. Maximum one 12-month extension where significant progress demonstrated.
2.3Recognition Award: 12 months, non-renewable. Facility must achieve Conditional or full Accreditation on next survey.
2.5An extension of up to 6 months may be granted only for: (a) significant force majeure (natural disaster, armed conflict, public health emergency); (b) publication of a new ASF standard edition requiring a reasonable preparation period; or (c) surveyor unavailability on ASF’s side. Extensions are approved in writing by the President and reflected in the public registry.
3. Accreditation Cycle Timeline
| Timepoint | Activity | Documentation required |
|---|---|---|
| Survey date | Full accreditation survey conducted | Complete survey report submitted within 10 working days of survey close |
| + 30 calendar days | ADC session held; decision issued | ADC session record; decision letter with compliance percentages |
| + 30–60 days post-decision | CAP submitted by facility (where required) | CAP covering each nonconformance with root cause, action, owner, target date, completion evidence |
| + 6 months (Conditional only) | Mid-term review — ASF assesses CAP progress | Facility CAP progress submission; ASF mid-term review finding |
| + 12 months (Conditional / Recognition) | End-of-conditional-period survey or review | New survey report; ADC decision; updated certificate or further action |
| Year 2 (full Accreditation) | Annual declaration of continued compliance submitted | Signed annual declaration; updated contact and ownership details |
| 12 months before expiry | ASF issues renewal notice; facility confirms intention | Renewal notice letter; confirmed survey booking within 30 days |
| Expiry date | Accreditation period ends | New certificate issued, or lapse notice |
4. Survey Planning and Scheduling
4.2For renewal surveys, ASF issues a formal renewal notice no later than 12 months before the expiry date. The notice confirms the expiry date, invites renewal confirmation, and proposes a 90-day survey window targeting approximately 60 days before expiry.
4.3The facility must confirm its intention to renew within 30 calendar days of the renewal notice. No response is treated as notification of intention not to renew.
4.4For new applications, the target from receipt of a complete application to survey date is 90 calendar days, subject to surveyor availability.
4.5Surveys are conducted on-site. Remote or documentary-only surveys are not accepted as the basis for an accreditation decision.
5. Monitoring During the Accreditation Period
5.1.1 Annual Declaration of Continued Compliance
In year 2 of a 3-year cycle, the accredited facility submits a signed annual declaration confirming: (a) the facility continues to operate within the scope of its accreditation; (b) no material changes affect compliance; and (c) all obligations under ASF-OPS-005 are being met. Signed by the CEO or equivalent.
5.1.2 Significant Change Notification
Accredited facilities notify ASF within 30 calendar days of any significant change, including:
- (a) Change in ownership or legal entity
- (b) Addition or removal of a major clinical service line within accreditation scope
- (c) Significant physical expansion or relocation
- (d) Regulatory action (licence suspension, enforcement notice, patient safety directive)
- (e) Sentinel event investigation finding implicating Critical criteria
- (f) Major staffing change affecting accreditation criteria compliance
ASF assesses whether the change: (a) has no material effect; (b) requires documentary review or targeted visit; or (c) warrants suspension under ASF-OPS-001, §4.7.
5.1.3 Reactive Monitoring
ASF may initiate a reactive monitoring review in response to a substantiated complaint, an adverse media report or regulatory finding, or third-party information raising a compliance concern. Reactive monitoring is proportionate — ranging from a written information request to an unannounced on-site visit in exceptional circumstances.
6. Lapse of Accreditation
6.1Accreditation lapses automatically on the expiry date if a new certificate has not been issued. A lapse occurs where the facility does not confirm renewal intention in time, the renewal survey is not completed before expiry without an extension, or the renewal survey results in Non-Accreditation.
6.2A lapsed facility must immediately cease use of the ASF accreditation mark. The public registry is updated within 5 working days.
6.3Reapplication: no minimum waiting period for administrative lapse; 12-month restriction applies for lapse following Non-Accreditation (per ASF-OPS-001, §4.6.3).
7. Relationship to Other ASF Policies
| Policy | Aspect of the cycle governed |
|---|---|
| ASF-OPS-001 | Decision types, thresholds, CAP requirements, and suspension/withdrawal from the cycle |
| ASF-OPS-002 | Survey team composition and surveyor qualifications |
| ASF-OPS-005 | Specific obligations of the accredited organisation during the accreditation period |
| ASF-OPS-006 | Eligibility criteria for new applications entering the cycle |
| ASF-OPS-007 | Language requirements during surveys within the cycle |
| ASF-OPS-008 | Financial arrangements for surveys within the cycle |
| ASF-GOV-005 | Redress options available at any point in the cycle |
8. ISQua EEA Alignment
This policy addresses ISQua EEA Principle 9 (Accreditation Cycle): defined cycle with regular re-assessment intervals; systematic in-cycle monitoring; and defined procedures for lapse, suspension, and withdrawal. The ASF ISQua EEA Crosswalk (ASF-EV-004) maps these provisions to the applicable EEA criteria.
9. References
| [1] | ISQua IAP. Principles for Standards. 6th Ed. ISQua EEA, Dublin, 2023. |
| [2] | JCI Accreditation Standards for Hospitals. 7th Ed. JCI, Oak Brook, 2020. |
| [3] | Accreditation Canada. Qmentum: Survey and Cycle Management Framework. Ottawa, 2022. |
| [4] | ACHS. EQuIP National Accreditation Cycle and Monitoring Policy. Sydney, 2018. |
| [5] | ISO/IEC 17021-1:2015 — Conformity Assessment. §9.6 Maintaining, Extending, Suspending, and Withdrawing Certification. ISO, Geneva, 2015. |
| [6] | ISO/IEC 17011:2017 — Conformity Assessment: Requirements for Accreditation Bodies. §6.5. ISO, Geneva, 2017. |
| [7] | Greenfield D, Braithwaite J. Health sector accreditation research: a systematic review. Int J Qual Health Care. 2008;20(3):172–183. |
| [8] | Brubakk K et al. A systematic review of hospital accreditation. BMC Health Serv Res. 2015;15:280. |
| [9] | Flodgren G et al. External inspection of compliance with standards for improved healthcare outcomes. Cochrane Database Syst Rev. 2016;12:CD008992. |
| [10] | HQACI. Accreditation Cycle Policy. ISQua EEA Accredited Document, 2026. |
| [11] | Shaw CD et al. Profiling health-care accreditation organisations. Int J Qual Health Care. 2013;25(3):222–231. |
| [12] | WHO. Standards for Improving Quality of Maternal and Newborn Care in Health Facilities. Geneva, 2016. |
Document code: ASF-OPS-003 · Version: V3.0 · Effective: 2026-09-30 · Next review: September 2031 ·
All governance documents
Download the approved document
ASF-OPS-003 — Accreditation Cycle Policy · Version V3.0