VersionV3.0 ✓ Published
Effective date2026-09-30
Approved byProf. Giorgi Pkhakadze, MD, MPH, PhD — President, Accréditation Sans Frontières
Applies toAll organisations granted ASF Accreditation or Conditional Accreditation, from the date of the decision until expiry, lapse, suspension, or withdrawal
Related documentsASF-OPS-001 · ASF-OPS-003 · ASF-OPS-004 · ASF-GOV-003 · ASF-GOV-004 · ASF-GOV-005
SupersedesASF-OPS-005 V2.0 (2026-09-30)
Next reviewSeptember 2031, or earlier on trigger
Version History
| Version | Date | Nature of change | Approved by |
|---|---|---|---|
| V0.1 | 2025-01-05 | Initial draft | — |
| V1.0 | 2025-03-01 | First published version | Accreditation Decision Committee |
| V2.0 | 2025-12-10 | 8-row obligations summary; 8 significant change triggers formalised | Accreditation Decision Committee |
| V3.0 | 2026-09-30 | 15-WD documentary review deadline; 60-day board reporting; 3-tier non-compliance response; approved for ISQua EEA package | Prof. G. Pkhakadze, ASF President |
1. Purpose
Accreditation is not a one-time event. It represents an ongoing commitment to maintain the standards against which the facility was assessed, to cooperate with ASF’s in-cycle monitoring, and to disclose any changes affecting accreditation status. These obligations are conditions of accreditation. Non-compliance may result in suspension or withdrawal under ASF-OPS-001, §4.7.
2. Obligations Summary
| Obligation | Timeframe / trigger | Consequence of non-compliance |
|---|---|---|
| Submit CAP | 30 days (Conditional/Recognition Award); 60 days (full Accreditation with Significant nonconformances) | Failure may trigger suspension |
| Submit CAP progress report | At 6-month mid-term review (Conditional only) | Failure: suspension considered |
| Annual declaration of continued compliance | Year 2 of 3-year cycle — signed by CEO | Failure: recorded as non-compliance; follow-up required |
| Notify ASF of significant changes | Within 30 calendar days of the change | Failure: may be treated as misrepresentation; suspension considered |
| Cooperate with monitoring reviews | Documentary review: 15 working days; on-site visit: agreed date | Non-cooperation: suspension considered |
| Comply with accreditation mark requirements | Throughout accreditation period (ASF-OPS-004) | Mark misuse: formal notice, escalation, legal action |
| Confirm renewal intention | Within 30 days of 12-month renewal notice | No response: treated as intention not to renew; lapse notice prepared |
| Remove mark on lapse/suspension/withdrawal | 14 days (lapse); 5 working days (suspension or withdrawal) | Breach of licence; enforcement under ASF-OPS-004, §7 |
3. Corrective Action Plan
A valid CAP addresses every nonconformance in the survey report. For each nonconformance: (a) criterion reference and description; (b) root cause analysis; (c) specific corrective action with sufficient precision; (d) responsible person; (e) target completion date; (f) completion evidence for review. ASF acknowledges within 5 working days and checks completeness within 15 working days. Incomplete CAPs are returned with specific feedback. Failure to submit by the deadline may trigger suspension.
4. Continued Compliance
The accredited organisation maintains compliance throughout the period — not only at survey time. In year 2 of a three-year cycle, a signed annual declaration is submitted by the CEO confirming: (a) operation within accreditation scope; (b) no undisclosed material changes; and (c) all post-accreditation obligations being met.
5. Significant Change Notification
Notify ASF within 30 calendar days of: (a) change in ownership or legal entity; (b) addition of a major clinical service within scope; (c) removal of a clinical service that was in scope at survey; (d) significant physical expansion or relocation; (e) regulatory action — licence suspension, enforcement notice, patient safety directive, or formal investigation; (f) sentinel event finding implicating Critical criteria; (g) material change in medical or nursing staffing; (h) change in information management systems forming a material part of assessed compliance. ASF notifies its assessment within 15 working days. Failure to notify may constitute material misrepresentation.
6. Cooperation with Monitoring
Documentary reviews: documents provided within 15 working days. Mid-term review submissions: on the specified date. Surveillance visits: staff made available; access provided to all areas in scope. Where cooperation is not possible in time due to exceptional circumstances, written notice to ASF before the deadline with an alternative date within 15 calendar days. Non-cooperation may result in suspension.
7. Quality Improvement
The accredited organisation: implements CAP actions within committed dates; maintains an internal quality improvement programme addressing nonconformances; monitors corrective action effectiveness through internal audit; and shares the survey report with the leadership body within 60 days of the accreditation decision notification.
8. Non-Compliance — Graduated Response
(a) Minor or first-instance — written reminder with revised deadline; recorded in accreditation record. (b) Repeated or material — formal written notice; placed before ADC; suspension considered. (c) Serious — including undisclosed significant change, material misrepresentation, or persistent non-cooperation — suspension issued immediately; withdrawal considered. Suspension and withdrawal may be appealed under ASF-GOV-005 within 30 calendar days.
Document code: ASF-OPS-005 · Version: V3.0 · Effective: 2026-09-30 · Next review: September 2031 ·
All governance documents
Download the approved document
ASF-OPS-005 — Post-Accreditation Obligations · Version V3.0