What your ASF accreditation already covers
You are not starting from zero.
What the module adds — 18 management system criteria
They concern how your quality management system is structured and governed — not what you do for patients, but how you manage the system that underpins everything you do.
The facility formally documents the internal and external factors that affect its ability to achieve its quality objectives, including whether climate change is a relevant issue.
Key stakeholders — patients, staff, regulators, payers — and their relevant requirements are identified, the facility decides which of those requirements its quality management system will address, and the list is reviewed annually.
The boundaries of the quality management system, including which services and locations are covered, are defined and documented.
The sequence and interaction of key processes is identified, with ownership assigned for each.
A quality policy signed by leadership is communicated to all staff and reviewed at each management review.
Changes to the QMS are planned — objectives, resources, responsibilities and risks assessed — before implementation, including how the change will be communicated, how its effectiveness will be monitored, and how the results will be reviewed.
Critical operational knowledge is identified, protected from loss, applied and shared, and a process exists for acquiring new knowledge where gaps are found.
Required documented information is maintained, including the scope statement, quality policy and quality objectives.
When patient or service requirements change after initial agreement, documentation is updated and relevant staff informed.
New clinical services or programmes follow a defined process covering inputs, outputs, controls and validation before launch.
A register of external providers is maintained and their performance evaluated against defined criteria.
Controls applied to verify the quality of each critical external provider’s output are specified.
Requirements are communicated clearly to external providers before work begins and confirmed understood.
Any output — test result, procedure record, prescription — can be traced to the patient, staff member and date.
A process exists for handling, storing and returning patient property, with notification when anything is lost or damaged.
Changes to service provision are reviewed, controlled and documented, with results retained.
A planned internal audit programme covering all QMS processes runs at least once per year, with documented results and follow-up.
Opportunities for improvement identified through monitoring, audit and management review are acted on systematically.
How the assessment works
The 18 module criteria are assessed as part of your existing annual verification visit — no separate visit, no separate surveyor. The module adds approximately half a day to the visit, focused entirely on your management system documentation and processes.
Evidence follows the same practice-based standard as ASF accreditation: whatever format your facility already uses. A scope document on a single page, a quality policy in the staff handbook, a process map on a whiteboard — these are all acceptable. Nothing needs to be created for the assessment.
- Clause-by-clause compliance map
- QR-verified certificate page on the ASF registry
Formal certification requires engagement with an IAF-accredited certification body.