References

1. Joint Commission. Accreditation Decision Categories: Accreditation, Accreditation with Follow-up Survey, Preliminary Denial of Accreditation, Denial of Accreditation. Oakbrook Terrace (IL): The Joint Commission; 2026.

Annex A — Self-Assessment Submission Checklist

Annex B — Sample Survey Agenda

Annex C — Accreditation Decision Notification Template

Index

Foreword

This guide is written for one reader specifically: the organization considering, or already pursuing, ASF accreditation. Every other ASF publication — the seven standards, How ASF Develops and Revises Standards, the ASF Surveyor Training Standard — is written either to state a requirement or to govern how ASF itself operates. This one is different. It answers the question an administrator, a medical director, or a quality lead actually asks before applying: what is this process going to look like for us?

This guide does not replace reading the specific ASF standard your organization will be assessed against — that document remains the actual requirement. What this guide provides is the journey around it: how to apply, what a self-assessment submission looks like, what happens during an on-site survey, how a decision is reached and communicated, what happens after accreditation is granted, and what re-accreditation involves.

1. Before You Apply

1.1 Which Standard Applies to Your Organization

ASF currently publishes seven organizational standards, each governing a distinct type of healthcare setting: Hospital, Ambulatory Clinic, Long-Term Care, Primary Health Clinic, Fitness & Wellness, Telemedicine, and Home Care. Your organization applies against the standard matching the services it actually provides — not the standard it aspires to, or the one a comparable organization elsewhere holds. Where an organization provides services spanning more than one standard — a hospital operating an on-site long-term care unit, for instance — it may pursue accreditation against more than one standard concurrently, with a coordinated, not duplicated, survey process.

1.2 What Accreditation Actually Certifies

ASF accreditation certifies that your organization was independently assessed, by trained and certified ASF surveyors, against a specific published standard, on a specific date, and met that standard's requirements at the level of compliance recorded in your accreditation decision. It does not certify that your organization will always meet that standard going forward without ongoing effort — accreditation is a verified snapshot, maintained through the ongoing compliance expectations described in Section 5, not a permanent guarantee.

Consistent with the same principle that governs ASF's own standards development, accreditation is not a credential your organization purchases; it is a status your organization earns through demonstrated, evidenced compliance, verified by people who were themselves trained and certified specifically to make that judgment.

1.3 Before You Submit an Application

Organizations considering ASF accreditation are strongly encouraged to obtain and read the full text of the applicable standard before applying — every ASF standard is published in full and freely available, consistent with ASF's founding transparency principle. There is no benefit to your organization in applying before understanding what you are actually being assessed against.

• Obtain and review the specific ASF standard applicable to your organization in full
• Identify, internally, which requirements you are confident you already meet, and which will require genuine work before a survey
• Confirm your organization's legal and operational eligibility — ASF accreditation applies to an operating organization providing the services the standard governs, not a facility still under construction or a service not yet operational

2. Application and Self-Assessment

2.1 Submitting an Application

Your organization submits a formal application to ASF, specifying the standard(s) applied against, your organization's legal name and registered location, the scope of services covered, and a designated point of contact for the accreditation process. ASF confirms receipt and eligibility within a defined period, consistent with the transparency and responsiveness principles governing ASF's own internal processes.

2.2 The Self-Assessment

Before any survey is scheduled, your organization completes a structured self-assessment against every requirement in the applicable standard — the same self-assessment-first discipline both ISQua EEA and Accreditation Canada apply before any external survey takes place. This is not a formality: a genuine, honest self-assessment is what allows both your organization and ASF to identify, before a surveyor ever visits, where real preparation is still needed.

For each requirement in the standard, your self-assessment states whether your organization is compliant, partially compliant, or not yet compliant, with supporting evidence referenced for each answer — a policy document, a training record, an observed process — not merely a compliance claim without support.

2.3 What a Complete Submission Includes

• A completed self-assessment covering every requirement in the applicable standard
• Supporting evidence referenced for each self-assessment response
• Basic organizational information: services provided, staffing structure, and physical or virtual site details relevant to the standard
• Confirmation of the designated point of contact for survey scheduling

2.4 What Happens After Submission

ASF reviews the completed self-assessment for completeness before scheduling a survey — not for compliance itself, which remains the surveyor's independent judgment during the on-site survey described in Section 3. Where a self-assessment is materially incomplete, ASF returns it for completion before scheduling proceeds, rather than scheduling a survey against an assessment nobody can actually use.

3. The On-Site Survey

3.1 The Survey Team

Every ASF survey is conducted by surveyors certified under the ASF Surveyor Training Standard — individuals who have themselves met a defined eligibility bar, completed structured training, passed an observed competency assessment, and remain in active certified status. Your survey team size and composition is determined by the scope and complexity of your organization, not fixed regardless of context: a small primary health clinic may be surveyed by a single certified surveyor; a multi-department hospital survey typically involves a small team, each surveyor assigned specific sections of the standard matching their own professional background.

Your designated point of contact receives the names and professional backgrounds of the assigned survey team in advance of the survey date, consistent with the transparency principle governing ASF's own operations.

3.2 Survey Duration

Survey duration is proportionate to your organization's size and the standard applied — typically two to five days on site, informed by the same proportionate range comparable international accreditation bodies apply. A small ambulatory clinic survey may be completed in a shorter period than a full-service hospital survey covering multiple departments and shifts.

3.3 What Surveyors Actually Do

An ASF survey draws on three distinct methods, not one:

• Document review — verifying that policies, procedures, training records, and other documented evidence referenced in your self-assessment genuinely exist and say what your self-assessment claimed they say
• Direct observation — observing actual practice as it happens, not only as it is described, consistent with the same observed-performance principle the ASF Surveyor Training Standard itself applies to certifying surveyors
• Structured interviews — with leadership, staff, and, where the applicable standard calls for it, patients, residents, or service users, to understand how a policy actually functions in practice, not only how it reads on paper

3.4 Preparing for a Survey Without Staging One

The single most common mistake an organization makes preparing for a survey is treating it as a performance to stage rather than a genuine practice to demonstrate. Surveyors are specifically trained to distinguish a process that exists because it was built for daily use from one assembled shortly before a survey date.

• Ensure staff at every level understand the standard as it applies to their own actual work, not only that a survey is happening
• Have genuine, current documentation available — not documentation freshly created to match the standard's wording
• Address self-assessment gaps identified in Section 2 with real operational change, not with new paperwork describing a change that has not actually happened

4. The Accreditation Decision

4.1 Possible Outcomes

Following the survey, ASF's decision falls into one of four categories, consistent with the same confirm/amend-equivalent/revise-equivalent/withdraw-equivalent logic that governs how ASF reviews its own standards, and consistent with the real, comparable outcome categories established international accreditors such as Joint Commission use, rather than a simplified binary pass/fail model [1]:

• Full accreditation — your organization met the applicable standard's requirements at the level of compliance recorded in the survey findings
• Conditional accreditation — your organization met the substantial majority of requirements, with specific, time-bound conditions attached that must be addressed and evidenced within a defined period
• Deferred decision — the survey identified gaps significant enough that a decision cannot yet be made responsibly; a follow-up survey or additional evidence is required before a decision is issued
• Accreditation declined — your organization did not meet the applicable standard at a level sufficient for any of the above outcomes

4.2 How Findings Are Communicated

Your organization receives a written survey report identifying, requirement by requirement, where compliance was confirmed, where conditions apply, and the specific evidence underlying each finding — not a bare pass/fail statement. This is deliberate: a report that only states the outcome, without the evidence behind it, gives your organization nothing to act on, whatever the decision.

Where conditions are attached, the report specifies exactly what evidence would resolve each condition and the deadline by which it must be submitted.

4.3 If You Disagree With the Decision

Your organization may appeal a survey decision. The appeal follows the same grounds and independent-review structure ASF applies to appeals within its own governance under Section 14 of How ASF Develops and Revises Standards, adapted here for an external applicant:

1. Grounds for appeal. An appeal may be filed on the grounds that the survey process did not follow the procedures described in Section 3 of this guide, that evidence your organization submitted was not genuinely considered, or that a finding materially departs from the evidence the surveyors actually gathered.

2. Submission. Appeals are submitted in writing within thirty days of receiving the survey report, specifying the grounds above and the specific finding being contested.

3. Independent review. The appeal is reviewed by Council members who were not involved in the original survey decision — the same impartiality requirement that governs every appeal ASF handles, whether the appellant is an external organization or a member of ASF's own Council.

4. Decision and record. The reviewing panel's decision, and its reasoning, is documented and provided to your organization in writing. Where an appeal is upheld, the specific finding is reconsidered; it does not require your organization to undergo an entirely new survey unless the appeal's grounds specifically require it.

5. After Accreditation

5.1 Ongoing Compliance

Accreditation reflects your organization's compliance as verified on the date of survey — it is maintained, not simply held, through the accreditation cycle that follows. Your organization is expected to continue operating consistent with the standard, not to revert to pre-survey practice once the survey team has left.

Where a conditional accreditation was issued, your organization submits the evidence resolving each condition by the deadline specified in your decision report. Failure to resolve a condition by its deadline is addressed under the same accountable process that governs the original decision, not left unresolved indefinitely.

5.2 Serious Incidents at an Accredited Organization

ASF accreditation does not mean a serious adverse event will never occur at your organization — no accreditation status, from any body, can guarantee that. What matters is how such an event is identified, investigated, and responded to. ASF maintains a separate policy specifically governing serious incidents at accredited organizations, addressing what must be reported, how it is reviewed, and how it relates to your organization's accreditation status. That policy is referenced here and published as its own document; it is deliberately not condensed into this guide, because it deserves the same full, standalone treatment as any other ASF standard.

5.3 Public Complaints About Your Organization

Patients, residents, families, and members of the public have a direct channel to raise a concern with ASF about your organization's compliance with the standard it holds — independent of whether your organization is aware of or agrees with that concern. This channel is governed by the ASF Public Complaints & Feedback Policy, published as its own document. Where such a complaint is received, your organization will be asked to respond within a defined period, consistent with the same accountable, evidence-based process governing every other ASF decision about your organization.

5.4 Your Public Accreditation Status

Your organization's accreditation status — whether currently accredited, conditional, or otherwise — is publicly visible and independently verifiable, governed by the ASF Public Accreditation Registry Policy. This is not a marketing decision ASF makes on your organization's behalf; it is a standing commitment that anyone can confirm an ASF accreditation claim is genuine, without needing to take your organization's word for it or contact ASF directly.

6. Re-Accreditation and the Next Cycle

6.1 The Three-Year Cycle

ASF accreditation is granted for a three-year cycle, aligned with the same three-year revision cycle that governs ASF's own published standards under How ASF Develops and Revises Standards. This is deliberate: your organization's re-accreditation naturally falls close to when the standard itself was most recently reviewed, so your next survey is always conducted against a genuinely current standard, not one already several years out of date.

6.2 Preparing for Re-Accreditation

ASF contacts your organization's designated point of contact in advance of your accreditation's expiry to begin the re-accreditation process — including a new self-assessment against the current version of the applicable standard, which may itself have been revised since your last survey. Re-accreditation is not an abbreviated repeat of your original survey; it is conducted with the same rigor, because a standard's requirements do not become less important to verify simply because your organization was compliant three years earlier.

6.3 If Your Organization's Circumstances Change Mid-Cycle

Where your organization's services, scope, or physical or virtual operating context change materially during an accreditation cycle — opening a new department, changing ownership, or a comparable material change — your organization notifies ASF, and ASF determines whether an interim review is warranted before your next scheduled re-accreditation. Accreditation reflects the organization ASF actually assessed; it does not automatically extend to an organization that has since materially changed.

Annex A — Self-Assessment Submission Checklist

• Every requirement in the applicable ASF standard has a stated compliance response: compliant, partially compliant, or not yet compliant
• Every response is supported by referenced evidence — a named policy, record, or observed process, not an unsupported assertion
• Basic organizational information is complete: services provided, staffing structure, and relevant site details
• A designated point of contact is named, with direct contact details for survey scheduling
• Gaps identified as “not yet compliant” include a realistic statement of what work is underway to address them, not only an acknowledgment that a gap exists

Annex B — Sample Survey Agenda

Day 1

• Opening meeting with organizational leadership
• Document review: governance, policy, and organizational records
• Facility or service orientation walk-through

Day 2

• Direct observation of service delivery during normal operating hours
• Structured interviews with staff across relevant departments or functions
• Continued document review, focused on gaps identified in the self-assessment

Day 3 (where applicable, for larger or multi-department organizations)

• Structured interviews with patients, residents, or service users, where the applicable standard calls for it
• Survey team internal review of findings

Closing

• Closing meeting with organizational leadership: preliminary findings shared verbally; the full written report follows separately, per Section 4.2

Annex C — Accreditation Decision Notification Template

Organization name: ___________________________________________________

Standard(s) surveyed against: ___________________________________________

Survey date(s): _______________________________________________________

Survey team: ___________________________________________________________

Decision

• ☐ Full accreditation   ☐ Conditional accreditation   ☐ Deferred decision   ☐ Accreditation declined

Findings by Requirement

[For each requirement in the applicable standard: finding, supporting evidence considered, and, where applicable, condition and deadline.]

Appeal Rights

This decision may be appealed within thirty days of receipt, per Section 4.3 of this guide.

Decision issued by: _____________________ Date: _____________________

This guide describes the accreditation process ASF applies to every organization, in every country, against every published ASF standard — the same process, regardless of where your organization operates.

Index

Accreditation Decision Outcomes, Section 4.1

Application and Self-Assessment, Section 2

Appeal Process, Section 4.3

On-Site Survey, Section 3

Ongoing Compliance, Section 5.1

Public Accreditation Status, Section 5.4

Public Complaints, Section 5.3

Re-Accreditation Cycle, Section 6

Serious Incidents, Section 5.2