VersionV4.0 ✓ Published
Effective date2026-09-30
Approved byProf. Giorgi Pkhakadze, MD, MPH, PhD — President, Accréditation Sans Frontières
Applies toAll ASF personnel, surveyors, Standards Development Committee members, Accreditation Decision Committee members, and any other persons exercising authority in ASF accreditation processes
Related documentsASF-GOV-001 · ASF-GOV-002 · ASF-GOV-004 · ASF-GOV-005 · ASF-OPS-001 · ASF-OPS-002
SupersedesASF-GOV-003 V2.0 (2026-09-30)
Next reviewSeptember 2031, or earlier on trigger
Version History
| Version | Date | Nature of change | Approved by |
|---|---|---|---|
| V0.1 | 2024-11-15 | Initial draft | — |
| V1.0 | 2025-01-20 | First published version | Prof. G. Pkhakadze, ASF President |
| V2.0 | 2025-09-01 | Five-threat ISO 17021-1 taxonomy added; Declaration of Impartiality form (Annex A) added | Accreditation Decision Committee |
| V3.0 | 2026-05-14 | 36-month consultancy exclusion and 24-month post-relationship bar formalised | Prof. G. Pkhakadze, ASF President |
| V4.0 | 2026-09-30 | Final pre-submission revision; per-role requirements table expanded; approved for ISQua EEA package | Prof. G. Pkhakadze, ASF President |
1. Purpose
1.1Impartiality is the foundation of ASF’s accreditation programme. The credibility of the ASF accreditation mark depends entirely on assessments being objective, consistent, and free from commercial or other undue influence.
1.2This policy establishes ASF’s requirements for identifying, declaring, managing, and, where necessary, eliminating threats to impartiality across all accreditation activities: standards development, surveyor selection and assessment conduct, accreditation decision-making, appeals, and post-accreditation monitoring.
1.3This policy applies to: (a) the ASF President; (b) all Standards Development Committee (SDC) members; (c) all Accreditation Decision Committee (ADC) members; (d) all ASF surveyors; (e) any external expert or consultant engaged by ASF; and (f) any ASF personnel with access to applicant information. Non-compliance may result in the consequences set out in Section 9.
2. Definitions
| Term | Definition |
|---|---|
| Impartiality | Presence of objectivity; freedom from actual, perceived, or potential bias or conflict of interest. |
| Conflict of interest | A situation in which a person has a financial, professional, personal, or institutional interest that could compromise their independent judgement. |
| Threat to impartiality | Any circumstance or interest that may undermine objectivity, even when actual bias does not exist. ASF identifies five threat categories (Section 4). |
| Consultancy/advisory threat | A serious threat arising from the provision of pre-accreditation preparation services to an applicant by a person who also participates in that organisation’s assessment or decision. |
| Declaration | A written, signed statement disclosing any potential or actual conflict of interest in relation to a specific accreditation activity. |
3. Core Principle — Separation of Assessment from Consultancy
3.1ASF does not provide consultancy, advisory, or preparation services to healthcare facilities that seek or hold ASF accreditation. The provision of such services by any person in an assessor or decision-making role is prohibited.
3.2A person who has provided consultancy, pre-accreditation gap analysis, or advisory services to a facility within the 36 months immediately prior to a survey shall not participate in that survey, nor in the accreditation decision, nor in any appeal arising from it.
3.3A person currently providing or committed to provide future advisory services shall not participate in any assessment of that facility until such relationship is terminated and a minimum of 24 months have elapsed. This applies regardless of whether the consultancy was remunerated.
4. Identifying Threats to Impartiality
4.1ASF recognises five threat categories (following ISO/IEC 17021-1:2015 taxonomy):
| Threat | Definition | Example in healthcare accreditation |
|---|---|---|
| Self-interest | Financial or other personal benefit linked to the accreditation outcome. | Surveyor owns shares in the assessed facility. |
| Self-review | Assessing one’s own prior work. | Surveyor auditing a QMS they designed. |
| Familiarity | Long-standing close relationship reducing professional scepticism. | Surveyor assessing a facility where they previously worked. |
| Advocacy | Acting as advocate or opponent for the assessed organisation. | Surveyor who publicly endorsed the organisation’s approach. |
| Consultancy/advisory | Provision of pre-accreditation preparation services. | Surveyor who conducted a gap analysis for the facility within the past 36 months. |
4.2ASF applies an objective test: would a reasonable and informed third party conclude that impartiality was compromised? Where this test cannot be answered with confidence, the threat is treated as material and the person is excluded.
5. Per-Role Impartiality Requirements
5.1 Surveyors
5.1.1Before each survey assignment, every surveyor completes a written Declaration of Impartiality (Annex A) covering all five threat categories.
5.1.2A surveyor shall not be assigned where: (a) they provided consultancy/advisory services within the past 36 months; (b) they are employed by or have a current financial relationship with the facility; (c) they have a close personal relationship with the facility’s senior leadership; (d) they led or participated in a survey of this facility within the past 12 months (waivable by ADC Chair with documented rationale); or (e) any other material threat applies.
5.1.3Surveyors who discover a potential conflict after assignment must notify ASF immediately for reassignment or documented mitigation.
5.2 Accreditation Decision Committee Members
Before each ADC session, each member reviews the facility list and declares any conflict in writing. A member with a conflict for a specific decision withdraws from deliberation and vote and is not counted toward quorum for that item. All decisions record members present, declared conflicts, and vote count.
5.3 Standards Development Committee Members
SDC members are subject to the requirements in ASF-GOV-002, §6. In addition to per-meeting declarations, they declare any change in circumstances — new employment, advisory relationships, or relevant publications — immediately when the change occurs.
5.4 Expert Reviewers and External Consultants
All external experts complete a Declaration of Impartiality before commencing their engagement. Selection criteria explicitly assess potential conflicts before engagement.
6. Declaration Procedure
6.1Declarations use the standard ASF Declaration of Impartiality form (Annex A). The form is signed, dated, and submitted before the person participates. Oral declarations are not accepted.
6.2Declarations are retained as controlled records for a minimum of five years.
6.3Where a person declares a potential conflict: (a) it is reviewed by the relevant Chair; (b) the Chair determines whether it constitutes a material threat using the objective test in 4.2; (c) if material, the person is excluded; (d) if not material, the determination and rationale are documented; (e) where the conflict involves the ASF President, determination is made by the SDC Chair or an independent external adviser.
6.4Standing annual declarations (for SDC and ADC members) do not substitute for activity-specific declarations.
7. Organisational Impartiality Safeguards
ASF maintains the following structural safeguards: (a) Separation of assessment from decision-making — surveyors present findings but withdraw before ADC deliberation and vote; (b) Separation of standards development from operational accreditation — the SDC approves standards but holds no authority over individual decisions; (c) Independent ADC membership — at least one ADC member independent of operational management; (d) No outcome-linked compensation — surveyor fees are fixed and no compensation is linked to accreditation outcomes; (e) Transparent applicant disclosure — applicants are invited to declare known relationships with ASF personnel at the point of application.
8. Impartiality Register
ASF maintains a confidential Impartiality Register recording all declarations by surveyors, committee members, and external experts: name, activity, date, and whether a conflict was declared and its resolution. The register is reviewed annually by the ASF President and is available for inspection by ISQua EEA assessors.
9. Consequences of Breach
9.1Failure to comply constitutes a serious breach. Consequences may include: (a) removal from the current assignment; (b) temporary suspension pending investigation; (c) permanent removal from the surveyor register or committee; (d) review and potential invalidation of any affected accreditation decision; (e) notification to the affected facility.
9.3A person found to have knowingly failed to declare a material conflict is permanently removed from all ASF governance and assessment roles, regardless of whether the conflict affected the outcome.
9.4Decisions under this section may be appealed under ASF-GOV-005 (Complaints and Appeals Procedure).
10. ISQua EEA Alignment
This policy meets the requirements of ISQua EEA Principle 4 (Independence) and ISO/IEC 17021-1:2015, clause 5.2. The ASF ISQua EEA Crosswalk (ASF-EV-004) maps these provisions to the applicable EEA criteria.
11. References
| [1] | ISQua IAP. Principles for Standards. 6th Ed. ISQua EEA, Dublin, 2023. |
| [2] | ISO/IEC 17021-1:2015 — Conformity Assessment: Requirements for Bodies Providing Audit and Certification of Management Systems. ISO, Geneva, 2015. |
| [3] | ISO/IEC 17011:2017 — Conformity Assessment: Requirements for Accreditation Bodies. ISO, Geneva, 2017. |
| [4] | ISO/IEC 17065:2012 — Conformity Assessment: Requirements for Bodies Certifying Products, Processes and Services. ISO, Geneva, 2012. |
| [5] | Shaw CD et al. Profiling health-care accreditation organisations. Int J Qual Health Care. 2013;25(3):222–231. |
| [6] | Greenfield D, Braithwaite J. Health sector accreditation research: a systematic review. Int J Qual Health Care. 2008;20(3):172–183. |
| [7] | IAF Mandatory Document MD 6:2014 — Application of ISO/IEC 17021-1 for Environmental Management Systems. |
| [8] | OECD. Managing Conflict of Interest in the Public Service. OECD Publishing, Paris, 2003. |
| [9] | Council of Europe. CM/Rec(2010)15 on the Role of Ombudsman Institutions in Promoting Impartiality. Strasbourg, 2010. |
| [10] | HQACI. Impartiality Policy. ISQua EEA Accredited Document, 2026. |
| [11] | JCI Accreditation Standards for Hospitals. 7th Ed. JCI, Oak Brook, 2020. |
| [12] | EA-7/05 M:2018 — EA Guidance on ISO/IEC 17021-1 for Medical Device Quality Management Systems. |
Annex A — Declaration of Impartiality Form
The Declaration of Impartiality form (ASF-GOV-003 Annex A) must be completed and signed by every ASF surveyor before commencing each accreditation survey. The completed form is retained by the ASF QMS Coordinator as a record of impartiality management for the survey. The form includes six conflict-of-interest screening questions, a confidentiality undertaking, and a formal declaration.
Document code: ASF-GOV-003 · Version: V3.0 · Effective: 2026-09-30 · Next review: September 2031 ·
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ASF-GOV-003 — Impartiality Policy · Version V4.0