How ASF Standards Are Developed
The people who write ASF standards do not make accreditation decisions. This page documents the full governance architecture: who sits on the Council, how the firewall is enforced structurally, the six-step development process (including mandatory equity review), the conflict-of-interest register, the appeals procedure, and how ASF’s methodology aligns with ISQua EEA, Accreditation Canada, JCI, ACHS, and HAS requirements.
The ASF International Standards Council
The ASF International Standards Council is the standing body responsible for every standard ASF publishes. It was established in Paris in 2020 under loi 1901, Article 8 of ASF’s statutes. The Council is operationally and legally separate from ASF’s accreditation function. Its mandate is to develop, review and retire standards only — never to assess, certify or accredit any facility.
Minimum 7 members. Required seats: at least one clinician, one quality scientist, one public health specialist, one health economist, one research methodologist, and one mandatory patient/lay representative (lived-experience seat). Minimum two countries on every Revision Panel.
Fixed three-year terms, renewable once. A member who has served two consecutive terms must wait three years before reappointment. Appointments and reappointments are recorded in the Annual Activity Report.
Quorum: two-thirds of serving members. Decisions by simple majority of members present; Chair has a casting vote. Standards approval and retirement require a two-thirds majority. Recused members are excluded from the count.
Current Council Members
Appointments effective September 2026. Roster updated when any appointment changes. Declarations reviewed annually and at every new revision opening.
Corrections: info@accreditation.ge. Roster last reviewed: September 2026.
The Firewall: Standard-Writing and Accreditation Are Structurally Separate
“Council members do not conduct facility or programme assessments. A separate ASF function carries out that work. This separation exists specifically to prevent the body that writes a requirement from also being the body that decides, for its own convenience, whether that requirement has been met.”
This separation is structural, not delegated. It is embedded in three places that cannot be overridden by a single decision:
Article 8 of ASF’s founding statutes, registered in Paris in 2020, establishes the International Standards Council as a body distinct from the Board of Directors and from the operational accreditation function. No individual may hold a role in more than one pillar simultaneously.
Section 2.4 of ASF-MAN-001-v4 states the formal prohibition: a Council or Revision Panel member may not be appointed as a surveyor, and a certified surveyor may not be appointed to the Council. There is no exception clause.
ASF-SURV-STD-v2 Domain A repeats the prohibition from the opposite direction: a candidate surveyor who holds or seeks a Council role is ineligible for surveyor certification.
- Writes, reviews, revises and retires all published standards
- Sets the criteria and the evidence base
- Never visits a facility
- Never makes an accreditation decision
- Never employs or appoints surveyors
- Reports through the Annual Activity Report, not through the accreditation function
- Certified surveyors conduct on-site and document assessments
- An independent review panel makes the accreditation decision
- Neither group writes, reviews or revises any standard
- Neither group may propose a criterion change outside the formal revision procedure
- Surveyor feedback on criteria is channelled through the formal revision proposal process, not through the accreditation function
Conflict-of-Interest Policy and Public Register
ASF’s COI policy is grounded in the Guidelines International Network (GIN) Principles for Disclosure of Interests and Management of Conflicts and in WHO’s declaration and severity-review practice. A conflict of interest is any financial, professional, or personal interest that might reasonably lead an independent observer to question whether a member’s judgment on a specific revision is influenced by something other than the evidence.
- Employment or consulting fees from any facility that could be affected by the standard under revision
- Equity or financial interest in any relevant commercial entity
- Authorship of a clinical guideline that the standard relies on or conflicts with
- Prior public positions or publications on the specific clinical question
- Personal or family relationships with any party with a material interest
- Severity grading: none / advisory-only / recusal / removal
- Chair makes the grading decision; conflicts about the Chair’s own interests are decided by the full Council
- Recused member may not vote, draft or receive confidential working documents on that revision
- All severity decisions are recorded in the revision file and disclosed in the published standard’s document history
All current Council member conflict-of-interest declarations are on file. The declarations in the Council roster above (Section 01) reflect each member’s current disclosure. The full signed declarations are filed and available on request to any person with a legitimate interest — contact info@accreditation.ge with subject “COI Register Request”.
When a revision is opened, an updated declaration is obtained from every Panel member before the first meeting. Any material conflict identified during a revision is recorded in the published standard’s version history.
The Five-Stage Development Process
Every ASF standard — new or revised — passes through five mandatory stages. No stage may be skipped. Every stage produces at least one document that is filed, version-controlled, and available for external audit. This is a requirement of ASF-MAN-001-v4 Part V: every procedure is backed by an actual document, not only a described intention.
Evidence Review — GRADE Framework
The Revision Panel maps peer-reviewed literature, WHO guidelines, JCI standards and Accreditation Canada practice against the scope of the standard. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework is used to rate evidence certainty across four levels: High, Moderate, Low, Very Low. Gaps — areas where evidence is absent or contested — are identified and recorded. The evidence map is published alongside the standard as the References & Evidence Base document.
Drafting — Four-Element Criterion Format
The Panel drafts each criterion in the standard four-element format: (a) the requirement statement, (b) the self-assessment question, (c) the guidance note explaining intent and what good/failure looks like, and (d) the means of verification — what an assessor will independently check. Each criterion is tagged for applicability across the four facility categories (Crisis/CR, Transitional/TR, Small/SM, Standard/ST). Updated COI declarations are collected from every Panel member before any draft is circulated.
Equity Review — Mandatory Eight-Question Checklist
Before any draft proceeds to public consultation, the Revision Panel completes the mandatory equity review checklist (ASF-EDI-001-v1, Section 8). The checklist asks whether each criterion creates disparate impacts by gender, disability, language, migration status, socioeconomic status, age, race and culture, or resource level. A yes to any question requires a documented response — criterion amendment, guidance note clarification, or recorded justification. The completed checklist is filed in the revision file and summarised in the Annual Activity Report. No draft may proceed to Stage 3 without a signed, completed equity review.
Public Consultation — Minimum 45 Days
Every draft is published in full for a minimum 45-day open comment period — announced publicly, with no registration requirement. Any person or organisation — a clinician, a patient, a researcher, a regulator — may submit evidence, a challenge, or a proposed alternative on any criterion. All comments are logged, individually numbered, and responded to in writing. Each response states: accepted and incorporated; accepted and modified; deferred to next revision cycle with reasons; or rejected with reasons. The comment log and response register are published alongside the final standard.
Pilot — Minimum Three Facilities, Two Countries
The finalised post-consultation draft is tested in a minimum of three facilities across at least two different countries before publication. Pilot sites are selected to represent at least two facility categories. Pilot findings — including criteria found to be ambiguous, impractical, or inconsistently interpreted — are reviewed by the full Panel. Each finding results in: criterion accepted; criterion amended; or criterion referred back for evidence review. The pilot report is retained in the revision file.
Publication, Version Control & Registration
Published in full, free of charge, in English and Georgian. Every published standard carries: document code, version number, publication date, revision history, and the names of the Revision Panel members. The PDF is the controlled version; the online reading version is maintained in parallel. Every published standard is entered in the Public Standards Register. The standard enters a three-year revision cycle from the publication date.
The Three-Year Revision Cycle & Annual Activity Report
Every published standard is formally reviewed within three years of its publication date. At scheduled review the Council must reach one of three decisions: Reaffirm (no substantive change), Revise (amend or replace one or more criteria), or Retire (withdraw the standard from active use with a published retirement notice).
A standard that cannot be reaffirmed or amended and is no longer fit for purpose is retired, not left in indefinite use. The retirement notice states the reason and, where applicable, the successor standard.
Between scheduled reviews, any person may submit a revision proposal with supporting evidence. The Council is required to respond in writing within 60 days: accept for immediate revision; defer to next scheduled review with reasons; or reject with reasons. A sentinel event — a patient-safety incident directly connected to a criterion — triggers an unscheduled review within 30 days.
ASF publishes an Annual Activity Report covering all standards activity in the preceding calendar year. The report states: (a) which standards were in the revision cycle; (b) how many revision proposals were received and their outcomes; (c) how many COI declarations were filed and how many triggered recusal; (d) the composition of each active Revision Panel; and (e) any standards retired or newly registered. The Annual Activity Report is published each year on or before 31 March for the preceding year.
The 2025 Annual Activity Report will be published by 31 March 2026. The 2026 report (covering January–December 2026) will be published by 31 March 2027.
Appeals Against Standards Decisions
Any person or organisation may appeal a Council decision on a standard — its content, the rejection of a revision proposal, or the retirement of a standard — through the following procedure. This procedure is distinct from the accreditation appeals process, which covers decisions on individual facility accreditation status.
Public Standards Register
Every ASF standard has a unique document code. The register below shows every published standard, its current version, publication date, and next scheduled review. This register is updated on every publication or retirement event.
International Framework Alignment
The table below maps each element of ASF’s standards development process against the published requirements and practices of the five reference bodies. The ASF methodology was designed from the outset to meet or exceed these requirements. ASF intends to submit to ISQua EEA external evaluation when the minimum operational criteria are met.
✓ Met · ⚠ In progress or partial · ✗ Not met · N/S Not specified. * Hover for note. JCI = Joint Commission International; AC = Accreditation Canada (HSO); ACHS = Australian Council on Healthcare Standards; HAS = Haute Autorité de Santé (France); ISQua EEA = International Society for Quality in Health Care External Evaluation Association.
Propose a Revision or Submit Evidence
If you have peer-reviewed evidence that a criterion is wrong, missing, or working against patient safety, the Council wants to hear it. This procedure is also how surveyors and accredited facilities may formally flag criteria they find ambiguous or inconsistent in the field.
- The standard document code and criterion number (e.g. ASF-HOSP-STD-v3, Criterion H-2.3)
- The evidence: citation(s) including source, year, and GRADE certainty level if applicable
- The proposed change: specific replacement text, deletion, or new criterion
- Your name and contact (or state if submitting anonymously — anonymous submissions cannot receive a written response)
There is no fee. The Council will respond in writing within 60 days of receipt.
