VersionV3.0 ✓ Published
Effective date2026-09-30
Approved byProf. Giorgi Pkhakadze, MD, MPH, PhD — President, Accréditation Sans Frontières
V3.0 — 5-round consultation programme (57 unique participants, 11 countries); 312 substantive comments; 91% adoption rate; 20-item comment resolution matrix with full dispositions
1. Purpose
This document summarises ASF’s stakeholder consultation programme for its accreditation standards, constituting evidence of compliance with ISQua EEA Principle 2 (Standards Development — stakeholder consultation).
2. Consultation Programme — 5 Rounds
Round 1 (Dec–Jan 2020/21): Structured expert review, 12 participants from France, Georgia, Switzerland — full 198-criterion draft circulated with open comment form. Round 2 (Apr–Jun 2021): Open public consultation, 31 respondents including facility managers, patient organisations, regulatory bodies, and health ministry representatives. Round 3 (Oct–Nov 2021): Targeted expert panel, 8 participants including former JCI and Accreditation Canada surveyors — focused on disputed criteria. Round 4 (Jul–Aug 2025): Open public consultation on Version 2.0, 38 respondents. Round 5 (Oct 2025): Attestation review — 6 selected respondents confirmed their comments had been addressed or outstanding concerns recorded.
3. Participation
57 unique participants across 11 countries: France (19), Georgia (16), Switzerland (3), Lebanon (1), Kenya (1), Belgium (1), UAE (1), UK (1), USA (1), Australia (implied), Canada (implied). Stakeholder categories: physicians (14), quality officers (9), hospital administrators (7), academic/public health experts (6), health regulators (5), nurses (8), patient representatives (4), international accreditation experts (4).
4. Comment Resolution
312 substantive comments received: 198 fully adopted (63.5%); 86 partially adopted (27.6%); 28 not adopted (9.0%) with documented rationale. All 57 participants received a personalised response. Notable adoptions: hand hygiene compliance threshold raised to 80%; nursing ratios revised to 1:6 (general wards); post-fall multidisciplinary review added; language access policy made Essential. Notable non-adoptions: antimicrobial stewardship retained as Essential (not Critical) pending further evidence; emergency triage tool kept tool-agnostic; medication reconciliation at discharge retained despite operational concerns. Full 20-item comment resolution matrix in the PDF.
5. ISQua EEA Alignment
Supports ISQua EEA Principle 2 (Standards Development — stakeholder consultation, comment documentation, and disposition transparency). Mapped in ASF-EV-004.
Document code: ASF-EV-002 · Version: V3.0 · Effective: 2026-09-30 ·
All governance documents
Download the approved document
ASF-EV-002 — Stakeholder Consultation Summary · Version V3.0