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International Accreditation of Healthcare Facilities

ASF Governance & Policy Manual · ASF-POL-52

Quality Improvement and Organisational Evaluation

Part of the ASF Governance & Policy Manual. Verified against ISQua EEA Guidelines and Standards for External Evaluation Organisations, 5th Edition v1.1, March 2022.

This policy governs how ASF improves itself as an organisation — distinct from ASF-POL-17 (risk) and the standards revision cycle (which improves the standards themselves). Owner: ASF Secretariat, reporting to the International Standards Council.

Quality improvement framework

A designated Secretariat role coordinates quality improvement across ASF’s own operations. A quality improvement plan identifies, records, and analyses improvement opportunities — drawn from the Field Testing Record, Monitor/Coordinator feedback (Domain G5 of ASF-MON-STD-v1), complaints data (ASF-POL-21), and governance effectiveness review below — with actions, timelines, and responsibilities, implemented and monitored.

Key performance indicators

ASF tracks and reports to the Council at least twice yearly: facility assessment cycle completion rates, Coordinator/Monitor/Surveyor certification and renewal rates, complaint volumes and resolution times, and field-testing outcomes — the same indicators the Field Testing Record already makes public.

Governance effectiveness

The effectiveness of ASF’s governance — including the Chief Executive’s performance (ASF-POL-50) — is evaluated annually against defined indicators, with results used to improve governance arrangements.

Accreditation process evaluation

The accreditation process and its outcomes — facility satisfaction, appeal outcomes, documentation audits — are evaluated annually, with improvements made and documented.

Client relationship review

Relationships with facilities, and the support ASF offers them, are reviewed regularly against feedback collected through the continuous-engagement cycle, with improvements — to policies, materials, or process — made and documented.

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