Accréditation Sans Frontières · ASF Health Standards 9.0
Standard 15 · Enterprise & Multi-Site Governance
6 criteria · base standard
Base standard. 6 criteria, of which 2 non-negotiable. Each criterion is numbered 15.Y, with its classification and verification questions.
Criteria
- 15.1 Governance Structure Defines Authority Between Central and Site-Level Leadership (NON-NEGOTIABLE)
- 15.2 Incident Learning Is Shared Across Sites, Not Siloed (CORE)
- 15.3 Clinical Policy Is Standardised Across Sites, With Any Local Variation Explicitly Justified (CORE)
- 15.4 Credentialing and Privileging Are Centrally Verified and Consistently Recognised (NON-NEGOTIABLE)
- 15.5 Central Resource and Staffing Decisions Are Evaluated for Site-Level Patient Safety Impact (CORE)
- 15.6 Site-Level Quality Data Is Reviewed by Central Governance (STANDARD)
15.1 Governance Structure Defines Authority Between Central and Site-Level Leadership
NON-NEGOTIABLE
For an organisation operating multiple sites, explicit, documented governance defines which decisions belong to central/corporate leadership and which belong to site-level leadership, with no ambiguity about who holds authority for a given decision — not an informal or assumed division that leaves gaps when a decision needs to be made.
VERIFICATION QUESTIONS
- Is the division of authority between central and site-level leadership explicitly documented, not assumed or informal?
A written, specific division, not an unwritten understanding that can be interpreted differently by different people. - Can site leadership clearly identify who holds authority for a specific type of decision when asked?
A test of whether the documented structure translates into practical clarity for the people who need it. - Is there a defined escalation path when a decision's ownership is unclear?
Even a well-documented structure can encounter an edge case; a defined path for resolving ambiguity matters.
15.2 Incident Learning Is Shared Across Sites, Not Siloed
CORE
A serious incident identified at one site triggers a review and dissemination process reaching every other site under the same governance structure, with lessons learned reaching relevant staff elsewhere in the network — not confined to the originating site as though it carries no relevance to the rest of the organisation.
VERIFICATION QUESTIONS
- Is there a defined process for a serious incident at one site to reach other sites in the network?
A functioning cross-site process, not an assumption that lessons will somehow travel informally. - Do staff at other sites receive and register relevant incident learning, not merely have it technically distributed?
Receipt and understanding, not just an email sent with no confirmation it was read or absorbed. - Does a pattern across multiple sites' incidents get identified and addressed at the network level?
A pattern invisible at any single site may only become visible when incidents are aggregated across the network.
15.3 Clinical Policy Is Standardised Across Sites, With Any Local Variation Explicitly Justified
CORE
Core clinical policies are standardised across every site in the network, with any permitted local variation explicitly documented and specifically justified — not silent, unexplained drift between sites that leaves patients receiving different standards of care depending on which site they visit.
VERIFICATION QUESTIONS
- Are core clinical policies standardised across sites, not left to independently drift at each location?
A shared baseline, not each site quietly developing its own version over time. - Is any permitted local variation explicitly documented and specifically justified, not simply tolerated without explanation?
A documented reason for variation, not an unexplained gap between what is written and what is practised at a given site. - Is there a periodic process for checking that sites still follow the standardised policy, not assumed to remain aligned indefinitely?
Standardisation can erode over time without active checking.
15.4 Credentialing and Privileging Are Centrally Verified and Consistently Recognised
NON-NEGOTIABLE
A clinician's credentials and clinical privileges are verified through a single, central process and consistently recognised across every site where that clinician practises, with no site allowing a clinician to practise without their current credentials and privileges being confirmed for that specific site.
VERIFICATION QUESTIONS
- Is credentialing verification centralised, not independently and inconsistently repeated or skipped at each site?
A single, reliable verification process, not a patchwork where sites verify differently or not at all. - Does every site confirm a clinician's current privileges before they practise there, not assume central verification covers every site automatically?
A specific, site-level confirmation step, even within a centralised system, closes a potential gap. - Is there a reliable process for a privilege change or suspension at one site to propagate to all sites where that clinician practises?
A suspension that does not reach every site where the clinician practises creates a serious gap.
15.5 Central Resource and Staffing Decisions Are Evaluated for Site-Level Patient Safety Impact
CORE
A central decision affecting staffing, equipment, or resource allocation at a specific site is evaluated for its patient safety impact at that site before being finalised, with a documented process for that evaluation — not a purely network-level financial or operational decision made without consideration of site-level patient safety consequences.
VERIFICATION QUESTIONS
- Is there a documented process for evaluating patient safety impact before a central resource decision affecting a specific site is finalised?
An evaluation step, not a decision made purely on network-level financial or operational grounds. - Does site-level clinical leadership have a voice in that evaluation, not merely informed after the decision is already made?
Input before the decision, not notification after the fact. - Is there a mechanism for a site to flag a safety concern about a central resource decision and have it reconsidered?
A functioning escalation path, not a theoretical right with no actual avenue for reconsideration.
15.6 Site-Level Quality Data Is Reviewed by Central Governance
STANDARD
Quality and safety metrics reported upward from each site are reviewed by central governance, with follow-through action when a metric indicates a problem — not merely collected and filed as a reporting formality with no actual review or consequence.
VERIFICATION QUESTIONS
- Is site-level quality data reviewed by central governance, not simply collected and archived?
A review process, not data flowing upward into a repository nobody examines. - Does a concerning metric from a specific site trigger a follow-through action, not go unaddressed?
Detection without a response provides limited protective value for patients at that site. - Can central governance identify, when asked, a specific recent example of acting on site-level quality data?
A concrete, recent example suggests ongoing practice rather than a theoretical process. ————————————————————