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Accréditation Sans Frontières · ASF Health Standards 9.0

Standard 7 · Governance & Management

13 criteria · base standard

Base standard. 13 criteria, of which 10 non-negotiable. Each criterion is numbered 7.Y, with its classification and verification questions.

Criteria

7.1 The Board Is Accountable

NON-NEGOTIABLE

A governing body exists, with named members and clear, documented authority over safety and quality, clinical governance, and financial stewardship — not an informal ownership arrangement functioning without oversight structure.

VERIFICATION QUESTIONS

  1. Is there a documented governing body with named members and defined terms of office?
    A charter or bylaws naming members and terms, not an informal ownership arrangement.
  2. Does the governing body meet on a fixed schedule with minutes retained?
    Minutes showing attendance, decisions, and follow-up actions, not just that a meeting occurred.
  3. Does the board formally review quality and safety performance at each meeting, not only financial performance?
    A standing quality agenda item with data discussed, not an afterthought.
  4. Is clinical governance
    oversight of clinical effectiveness, audit, and risk — explicitly assigned to a named board responsibility, not left implicit within general quality oversight? — A distinct, named accountability for clinical governance, not assumed to be covered by discussing quality in general terms.
  5. Is financial stewardship
    budget oversight, financial risk, and resource allocation — a defined board responsibility distinct from day-to-day financial management? — Board-level financial oversight, not only operational finance handled by management alone.

7.2 There Is a Written Strategic Plan

NON-NEGOTIABLE

A documented plan states the facility's mission, values, and a code of conduct for staff behaviour, and guides resourcing decisions — not a one-page mission poster disconnected from how money and staff time get allocated, and not a mission statement with no accompanying statement of values or expected conduct.

VERIFICATION QUESTIONS

  1. Is there a written strategic plan covering at least a multi-year horizon?
    Not an annual budget alone — a plan with a forward horizon.
  2. Does the plan include a clear mission statement describing who the facility serves and how?
    Specific enough to guide decisions, not generic enough to apply to any hospital anywhere.
  3. Can a resourcing decision from the last year be traced back to something in the plan?
    Tests whether the plan influences decisions, not just whether it exists.
  4. Does the facility have a documented statement of values and a code of conduct distinct from the mission statement, guiding staff behaviour rather than existing only as a wall display?
    A specific statement of expected conduct, not a mission statement alone standing in for it.

7.3 Policy Gets Followed

NON-NEGOTIABLE

A policy framework exists and staff can describe how it is applied in practice, not merely confirm that policies are filed and technically available. The framework includes a formal, comprehensive quality improvement plan covering every part of the facility, with allocated responsibilities and defined performance indicators.

VERIFICATION QUESTIONS

  1. Can staff describe how a specific, named policy is applied in their daily work?
    Not whether they know a policy exists — whether they can describe applying it.
  2. Is there a mechanism to check policy adherence, not just policy existence?
    A policy audit or spot-check process, distinct from simply confirming documents are filed.
  3. When a policy-practice gap is found, is there a defined response, not just noting the discrepancy?
    Identifying a gap without addressing it provides limited value.
  4. Is there a single, formal quality improvement plan that covers governance, clinical governance, organisational management, use and efficiency of services, and quality performance, with named responsibilities and defined indicators?
    A comprehensive plan, not isolated initiatives in individual departments.
  5. Is the quality improvement plan itself formally evaluated on a defined schedule, with the evaluation used to revise the plan?
    A plan that is reviewed and updated, not adopted once and left static.
  6. Is every policy, procedure and plan formally authorised by a named person with the authority to approve it, with that authorisation recorded, not assumed because the document exists on a shared drive?
    A recorded sign-off by someone with authority to approve it, not a document that simply appeared without a traceable approval.
  7. Is every policy, procedure and plan reviewed against a defined timescale to confirm it is still current, not left in place indefinitely once approved?
    A scheduled review date, not a document approved once and never revisited regardless of how outdated it becomes.

7.4 Patient Information Stays Private

NON-NEGOTIABLE

Confidentiality is protected physically and culturally throughout the facility, not only referenced in a written policy that does not translate into actual practice.

VERIFICATION QUESTIONS

  1. Are screens and monitors positioned so patient information is not visible to passersby or other patients?
    Physical positioning, checked directly, not assumed from a policy statement.
  2. Are clinical conversations conducted where they cannot be overheard by other patients or visitors?
    Curtains, closed doors, or private spaces used, not just available.
  3. Do staff understand and apply confidentiality practices consistently, not only when reminded?
    Tests whether privacy protection is habitual, not situational.

7.5 Medical Records Are Complete

NON-NEGOTIABLE

Records contain all mandatory elements and are audited for completeness on a regular basis, not assumed complete because a template exists.

VERIFICATION QUESTIONS

  1. Is there a defined list of mandatory record elements for each type of encounter?
    A specific, checkable list, not a general expectation of thoroughness.
  2. Are records regularly audited for completeness against that list?
    Audit, not assumption of completeness because a template was used.
  3. Are gaps found during audits addressed, not just noted?
    Identifying an incomplete record without correcting it leaves the underlying risk unresolved.

7.6 Patient Data Is Kept Secure

NON-NEGOTIABLE

Health information is protected with defined access controls and a breach response plan, using practical, achievable security measures appropriate to the facility's resources.

VERIFICATION QUESTIONS

  1. Are access controls in place restricting patient data access to staff who need it for their role?
    Role-based restriction, not general access available to any staff member.
  2. Is there a documented breach response plan, specific and actionable?
    Not a general statement of concern — a named process for what happens if a breach occurs.
  3. Have access controls and the breach plan been reviewed or tested recently?
    An untested plan or unreviewed control list may not reflect current reality.

7.7 Records Are Kept Exactly as Long as Required

NON-NEGOTIABLE

A retention policy governs how long records are kept and how they are disposed of, aligned with the specific legal requirement in this facility's jurisdiction, not a generic assumption.

VERIFICATION QUESTIONS

  1. Does a written retention policy exist, specifying how long different record types are kept?
    Specific durations by record type, not a vague general statement.
  2. Is the retention period aligned with the actual legal requirement in this jurisdiction?
    Verified against the legal requirement, not assumed or copied from another context.
  3. Is disposal of records past their retention period conducted securely and documented?
    Disposal that protects confidentiality even as the record is destroyed.

7.8 Incidents Are Reported

NON-NEGOTIABLE

An accessible incident reporting system exists and staff use it — measured by reporting volume and pattern, not merely by the system's technical availability.

VERIFICATION QUESTIONS

  1. Is the incident reporting system accessible to all staff, not just management?
    Accessible in practice, at the point of work, not buried in an administrative system.
  2. Does actual reporting volume suggest use, not just technical availability?
    A system that exists but receives almost no reports over time suggests a use problem, not the absence of incidents.
  3. Do staff believe they can report without fear of punitive consequence?
    Psychological safety, not just a stated non-punitive policy.

7.9 Serious Incidents Get Properly Investigated

NON-NEGOTIABLE

Root cause analysis is used for serious incidents, with a resulting, tracked action plan — not a brief note explaining what happened without examining why it happened.

VERIFICATION QUESTIONS

  1. Is a structured root cause analysis method used for serious incidents, not just a brief incident note?
    A defined methodology examining systemic factors, not a one-paragraph summary.
  2. Does the RCA result in a specific, tracked action plan?
    Findings without a resulting plan do not translate into prevention.
  3. Are action plan items tracked to completion, not left open indefinitely?
    An action item that is never closed provides no protection against recurrence.

7.10 Safety Culture Is Measured

NON-NEGOTIABLE

A validated survey measures whether staff feel safe raising concerns, conducted regularly and acted on, not assumed from the absence of complaints.

VERIFICATION QUESTIONS

  1. Is a validated safety culture survey conducted, not an informal or ad hoc check?
    A recognised, validated tool, not an internally improvised questionnaire.
  2. Is the survey conducted regularly, on a defined schedule?
    A single historical survey does not reflect current culture.
  3. Are survey results reviewed and acted on, with visible follow-up?
    Measurement without action provides no improvement.

7.11 Patient Experience Is Measured Continuously, Not Only After Discharge

CORE

Patient experience is measured through structured, ongoing feedback during the course of care — not only through the post-discharge complaint channel required elsewhere in this document, which by definition only captures concerns raised after the fact.

VERIFICATION QUESTIONS

  1. Is patient experience measured through structured feedback during the stay, not only after discharge?
    Real-time or near-real-time feedback, distinct from the post-discharge complaint channel.
  2. Is feedback collected broadly, not only from patients who happen to volunteer it?
    A systematic approach, not reliance on the small subset of patients naturally inclined to give feedback.
  3. Is collected feedback reviewed and used to inform improvements?
    Responsiveness, not data collected and left unexamined.

7.12 An Ethics Consultation Process Exists

CORE

Staff facing an ethical dilemma in patient care have access to a usable ethics consultation process — a committee, a named resource, or an external arrangement — not left to resolve difficult cases alone or through informal corridor conversations.

VERIFICATION QUESTIONS

  1. Is there an accessible ethics consultation process
    committee, named resource, or external arrangement? — An actual, usable resource, not a theoretical statement that ethical principles matter.
  2. Do staff know how to access it, not just that it exists somewhere in policy?
    Practical, known accessibility — staff can describe how they would use it.
  3. Has the process been used for a case, or does it exist only theoretically?
    Use is the test of whether this is a functioning resource or a document nobody has needed to open.

7.13 Patients and Families Have a Voice in Governance

CORE

At least one patient or family representative has a structured role in quality review or governance discussions — not a governance and quality structure that is entirely staff and board-facing, with patient input arriving only indirectly through complaints or surveys.

VERIFICATION QUESTIONS

  1. Does at least one patient or family representative have a structured role in quality review or governance discussions?
    An actual seat or defined role, not indirect input filtered through staff-collected feedback alone.
  2. Is this representative included in discussion, not present only as an observer?
    Participation, not token attendance without a voice in the discussion.
  3. Can the facility point to a specific instance where patient or family input shaped a decision?
    Concrete evidence of influence, not just presence. ————————————————————

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