Foreword

1. Parties and Term

2. The Facility Commits To

3. The Secretariat Commits To

4. Channels

4.1 QR code

4.2 Hotline

4.3 Online form and email

4.4 Social media

4.5 Paper

5. Data Sharing and Protection

5.1 Roles

5.2 What is shared

5.3 Lawful basis

5.4 Security and retention

6. Publication

7. Fees

8. Law and Disputes

Annex A — QR Code Placement

Annex B — Liaison Role Description

Annex C — Local-Law Annex (template)

Annex D — Signature Form

References

Index

Foreword

A council costs a facility almost nothing in money and a great deal in honesty. This agreement sets out exactly what the facility commits to — a named liaison, open recruitment, an answer to every verified concern, action on the log, and never seeking the identity of an anonymous complainant — and what it receives in return. It also settles the practical things: where the QR codes go, who answers the hotline, how data moves between the facility and the secretariat, and which law governs.

1. Parties and Term

Between the facility named in Annex D ("the facility") and the secretariat organization named in Annex D ("the secretariat"). The agreement runs for twelve months from signature and renews for successive twelve-month periods unless either party gives three months' written notice. Either party may end it on thirty days' notice for a material breach not remedied within that period.

2. The Facility Commits To

A named liaison — usually the head of quality and/or the head of reception or administration — with authority to act on what the council raises, and a deputy.

Open, continuous recruitment of council members through its website, social media, and a notice at the entrance or patient corner, using the ASF templates (ASF-PV-RECRUIT-001), and never hand-picking members.

Channels in place — QR codes displayed in every ward, at reception and on discharge papers; the hotline number and the online form on its website and on the notice; paper forms in the patient corner collected by the secretariat, not the facility.

Verification within five working days of receiving the draft monthly report: clarify, correct facts, state what has been done. The facility may add; it may not subtract.

Attendance of at least one representative at every monthly meeting, and of a clinical lead when a clinical theme is on the agenda.

Action on the log — every action accepted at a meeting is completed by its date or a revised date is given at the next meeting with the reason.

An answer to every verified concern so that the secretariat can close the loop with the patient within five working days of the meeting.

Never to seek the identity of a complainant who asked for anonymity, and never to disadvantage a patient, family member or council member in their care, employment or otherwise for anything raised through Patient Voice.

A meeting room, monthly, for ninety minutes, and reasonable transport costs for members where the council so agrees.

To display the ASF Patient Charter (seven rights) in reception and on its website.

3. The Secretariat Commits To

Everything in the Secretariat Impartiality Undertaking (ASF-PV-SECRETARIAT-001).

The seven-step monthly cycle in the Terms of Reference (ASF-PV-TOR-001), to its timelines.

The monthly report, the action log, the council record and the annual summary, in the toolkit formats.

The education session at every meeting, and induction for new members.

Training for the liaison and, on request, for reception and ward staff on receiving concerns.

Same-day escalation to the facility's director of any matter coded severity 4 (immediate danger).

4. Channels

4.1 QR code

The secretariat supplies the QR design (Annex A). The facility prints and displays it at the sizes and locations in Annex A. The code opens the Patient Voice form on the secretariat's site; nothing is routed through the facility.

4.2 Hotline

The number is the secretariat's. Hours, languages and voicemail handling are stated in Annex D. Calls are answered by the secretariat, a case number is given on the call, and the caller is told when to expect a written acknowledgement.

4.3 Online form and email

The Patient Voice form on the secretariat's site, with case tracking; and the secretariat's email address. The facility links to both from its website.

4.4 Social media

A public post or message in which the facility is tagged and a concern is expressed is registered as a case. The secretariat replies publicly once, briefly, to move the conversation into a case, and thereafter privately. The facility does not reply to the substance publicly.

4.5 Paper

A locked box in the patient corner, key held by the secretariat, emptied weekly by the secretariat.

5. Data Sharing and Protection

5.1 Roles

For council feedback data, the secretariat is the controller: it collects, holds and decides how the data is used. The facility is a recipient of the verified report. For its own patient records, the facility remains the controller and shares nothing from them with the secretariat except what is needed to verify a case, with identifiers removed where possible.

5.2 What is shared

5.3 Lawful basis

Consent of the patient (who chooses the channel and whether to be identified) and the legitimate interest of both parties in improving the quality and safety of care, balanced against the patient's rights by the anonymity option and the minimal sharing above. Health data within a case is processed for the purposes of quality assurance under Article 9(2)(h)/(i) GDPR or the local equivalent named in Annex C.

5.4 Security and retention

Reports are shared as password-protected PDF or via the secretariat's portal, never over WhatsApp. Case files are deleted three years after closure; council records and annual summaries are kept permanently, anonymised. Breaches are notified to the other party within 24 hours and to the supervisory authority within 72 hours where required.

6. Publication

The facility consents to publication of the council record (anonymised) and the annual summary on the secretariat's site and, where the facility has one, on its ASF profile. The facility may reproduce both. Neither party publishes an individual case. The facility may state publicly that it hosts a Patient Voice Council and may display the Patient Voice mark for the term of this agreement.

7. Fees

Where the secretariat is Accréditation Sans Frontières, the fee is the Patient Voice Package as published in ASF Local Advisory Services (ASF-LAS-001) — €120 per month at the date of this edition — or nil where Patient Voice is included in ASF membership (services 5–6). No fee is linked to any outcome. Where another organization is secretariat, the fee, if any, is stated in Annex D and may not be linked to any outcome.

8. Law and Disputes

French law, with the local-law annex (Annex C) governing the clauses it names. Disputes go first to the two liaisons, then to the ASF Public Complaints and Feedback Policy, and only then to the courts of Paris or the local forum named in Annex C.

Annex A — QR Code Placement

Annex B — Liaison Role Description

Receives the draft report on the first working day of the month; returns it verified within five working days

Attends every council meeting; brings the clinical lead when needed

Owns the action log on the facility side; reports status before each meeting

Ensures QR codes, notices and the Patient Charter stay displayed

Never asks who complained; never lets anyone else ask

Time: about four hours a month

Annex C — Local-Law Annex (template)

Complete for each country in which a council operates. The clauses named here are governed by the local law stated; all other clauses remain under French law.

Georgia — completed example

Annex D — Signature Form

Facility — legal name, address, registration number: __________________________________________________

Facility liaison — name, role, phone, email: __________________________________________________

Deputy liaison: __________________________________________________

Secretariat organization: __________________________________________________

Named secretariat and deputy: __________________________________________________

Hotline number, hours, languages: __________________________________________________

Fee (or "included in membership" / "nil"): __________________________________________________

Local-law annex attached (country): __________________________________________________

Start date: __________________________________________________

Signed for the facility and for the secretariat

References

1. Regulation (EU) 2016/679 (GDPR), Articles 6, 9, 28, 33.
2. Accréditation Sans Frontières. Data Protection Policy, ASF-DATAPROTECT-001-v1. Paris: ASF; 2026.
3. Accréditation Sans Frontières. IT and Data Security Policy, ASF-SECURITY-001-v2. Paris: ASF; 2026.
4. Accréditation Sans Frontières. Local Advisory Services, ASF-LAS-001-v1. Paris: ASF; 2026.
5. Accréditation Sans Frontières. Sentinel Event Policy, ASF-SEP-001-v1. Paris: ASF; 2026.
6. Law of Georgia on Personal Data Protection, 2023.

Index

Anonymity, 2 (8)

Data sharing, 5

Fees, 7

Hotline, 4.2

Liaison, 2 (1), Annex B

Local-law annex, Annex C

Publication, 6

QR code, 4.1, Annex A

Social media, 4.4

Term, 1