Accréditation Sans Frontières
International Accreditation of Healthcare Facilities
Accréditation Sans Frontières
International Accreditation of Healthcare Facilities
The ASF standard covers four quality domains across all three programme tracks. Evidence requirements are calibrated to context. The principle — and the independence of the evaluation — is the same everywhere.
Each domain contains standards. Each standard contains criteria. Each criterion has defined evidence indicators. The structure — and the minimum standards threshold for accreditation award — is the same across all three programme tracks — what adapts is the evidence format and threshold.
Medication safety and reconciliation. Infection prevention and control. Surgical safety (where applicable). Triage and emergency response protocols. Adverse event identification, reporting, and root-cause analysis. Patient identification at every clinical step.
WHO Patient Safety programme · Lancet Global Health · JAMA Surgery
Care pathway adherence by clinical area. Chronic disease management protocols. Maternal and child health standards (where applicable). Diagnostic accuracy and result communication. Referral documentation and follow-up. Outcome measurement and reporting.
BMJ Quality & Safety · Cochrane Reviews · WHO clinical guidelines
Leadership structure and accountability. Staff credentialing and ongoing development. Incident reporting systems. Financial transparency and sustainability. Strategic planning and performance review. Consent processes and patient rights documentation.
ISQua governance principles · OECD health system governance framework
Independent patient council — convened and facilitated by ASF, not the facility. Structured patient feedback at point of care. Public reporting of quality indicators. Complaint management with documented resolution. Community engagement where relevant to the facility’s catchment.
Picker Institute · Patient-Reported Outcomes research · WHO people-centred care
The four domains above are the public narrative. Underneath them sits the full working standard hospitals are actually assessed against — organised into twelve chapters covering everything from governance to patient safety culture. Each standard is a complete two-page unit: a self-assessment form on one side, evidence-based guidance and surveyor instructions on the other. We publish the whole thing openly, in the same spirit as the rest of ASF’s work — no paywall, no request form, no access tier. Anyone accrediting, studying, or simply curious can read exactly what we check for.
Governing body accountability, strategic planning, leadership roles, policy control, ethics, financial oversight, risk management, quality improvement, transparency, and stakeholder engagement.
Patient rights charter, informed consent, confidentiality, identification, complaints, vulnerable patient protections, advance directives, language access, feedback monitoring, and non-discrimination.
Staff credentialing, mandatory induction, staffing levels and skill mix, performance appraisal, continuing professional development, occupational health, workforce planning, staff wellbeing, whistleblowing, and volunteer supervision.
Hand hygiene, PPE, clinical waste, decontamination, IPC programme leadership, HAI surveillance, outbreak response, staff training, patient isolation, antimicrobial stewardship, benchmarking, and patient engagement.
Patient assessment, care planning, medication safety and prescribing, clinical documentation, handover, high-risk patient monitoring, diagnostic results management, rehabilitation, discharge planning, and chronic disease management.
WHO Surgical Safety Checklist, anaesthesia safety, surgical site infection prevention, informed consent for surgery, instrument counts, theatre environment, blood products, post-operative care, outcome monitoring, and minimally invasive procedure safety.
Emergency triage, resuscitation readiness, mass casualty and disaster response, critical care admission criteria, sepsis management, deteriorating patient recognition, trauma protocols, mental health emergencies, paediatric protocols, and post-emergency debriefing.
Laboratory quality management, critical value reporting, specimen collection and labelling, equipment calibration, external quality assurance, point-of-care testing, radiation safety, imaging turnaround, pathology turnaround, and digital imaging/PACS.
Medication storage and security, high-alert medications, medication reconciliation, dispensing verification, controlled drugs, adverse drug event reporting, cold chain and vaccines, medication error review, clinical pharmacy review, and formulary management.
Safe water supply, fire safety and evacuation, medical equipment maintenance, electrical safety and backup power, sanitation and hygiene, security and access control, building inspection, HVAC, environmental sustainability, and decommissioning.
Medical record completeness, data confidentiality and security, record retention, clinical coding, data quality assurance, EHR governance, national health data reporting, clinical audit, informatics strategy, and interoperability.
Incident reporting, root cause analysis, patient safety culture measurement, clinical audit programme, near-miss reporting, mortality and morbidity review, safety walkrounds, safety huddles, external accreditation and peer review, and benchmarking.
Standards marked CORE within each chapter are non-negotiable minimums. Guided e-learning for every standard is available at academy.gmj.ge.
A hospital in a post-transition health system and a clinic in a humanitarian setting are assessed against the same four domains and the same criteria. What adapts is what counts as evidence — reflecting what is genuinely achievable in each context without lowering the substantive standard.
ASF standards are developed through a systematic process grounded in operational experience. The baseline survey is the first formal measurement of a facility against these standards — drafted, tested in live accreditation environments, revised based on what surveyors observe and what facilities can genuinely achieve, and then formalised. This is the reverse of the standard industry process, where standards are written in committee and then applied.
Evidence is drawn from peer-reviewed literature (WHO, Lancet, BMJ, JAMA), ISQua publications, and eight years of operational data from 50+ accredited facilities. The evidence base is reviewed annually and updated on a defined cycle.
WHO does not endorse any single accreditation body \u2014 a deliberate, stated position \u2014 but WHO does operate its own transparent, peer-reviewed quality assurance framework: the Emergency Medical Team Classification, with published minimum standards, external peer review, and a public classification list of 55 teams as of 2025. ASF’s own self-assess-then-verify model, and its published Means of Verification for every criterion, follows that same precedent. The framework also serves UN Sustainable Development Goal 3.8 \u2014 universal access to quality, safe, and effective essential health services \u2014 directly.
Standards are published through the Georgian Medical Journal (Scopus-indexed, DOI-assigned, open access) — making ASF the only accreditation body whose standards framework is citable academic output.
ASF is currently preparing its standards for submission to the ISQua External Evaluation Association (ISQua EEA) — the body that independently evaluates whether an accreditation organisation’s standards meet internationally recognised principles for healthcare quality.
ISQua EEA accreditation is held by only a small number of accreditation organisations worldwide, including several of the world’s most established international accreditors. It is the mark that an accreditor’s standards can be independently trusted.
ASF accreditation is not a binary pass or fail, but it is not a maze either. Every standard is scored Green, Yellow, or Red — Green means fully in place, Yellow means genuinely in progress, Red means not yet started. A facility’s level is a direct, computable result of those scores, not a judgement call. If you can see your own Green/Yellow/Red scores, you already know your level before we tell you.
The facility is actively working with ASF and has met every non-negotiable requirement — the small set of things that must simply be true regardless of anything else, across governance, safety, and every department it has declared. This is a real, public milestone in its own right, not a lesser version of accreditation.
Every criterion the facility is assessed against — institutional and every department it declared — is Green. Not just the non-negotiables: everything. This is the public credential, verified on site, and listed on the accredited facilities register.
Status is checked at each annual survey. A facility can hold ASF Registered while working toward full accreditation \u2014 there is no minimum time required at Registered before progressing, only the actual completion of every remaining Green. Accredited status is publicly listed on the accredited facilities register. A facility that no longer meets its non-negotiables at annual survey has its status reviewed and may be placed on a monitored improvement plan rather than losing accreditation outright.
We are happy to discuss the standards framework in detail — for facilities considering accreditation or for researchers and policymakers.
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