Standards › ASF Health Standards V11 › Standard 18
Standard 18 (Multi-Site Governance), PDF
ASF-HS11-S18 · Revision 01 · 1 November 2026 · 24 pages, A4. The same criteria as this page, for printing and assessors.
Where this standard applies
Standard 18 applies to organisations that run more than one site under shared governance. It is optional for every facility type, and each criterion applies to the facility types that adopt it. The table shows each criterion and where it applies.
| Criterion | Hospital | Ambulatory clinic | Primary health clinic | Long-term care | Telemedicine | Home care | Fitness and wellness | Dental clinic | Aesthetic and procedure clinic |
|---|---|---|---|---|---|---|---|---|---|
| 18.1 Governance Structure Defines Authority Between Central and Site-Level Leadership | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| 18.2 Incident Learning Is Shared Across Sites, Not Siloed | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| 18.3 Clinical Policy Is Standardised Across Sites, With Any Local Variation Explicitly Justified | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| 18.4 Credentialing and Privileging Are Centrally Verified and Consistently Recognised | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| 18.5 Central Resource and Staffing Decisions Are Evaluated for Site-Level Patient Safety Impact | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
| 18.6 Site-Level Quality Data Is Reviewed by Central Governance | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes |
Multi-Site Governance
It covers the split of decision rights between central and site leadership, incident learning shared across sites, standard clinical policy with justified local variation, central credentialing and privileging, the safety impact of central decisions, and central review of site quality data.
Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.
Training colours: red means essential, green recommended, yellow optional. Each course shows its level for each setting: humanitarian, transition and fragile, and standard.
18.1
Governance Structure Defines Authority Between Central and Site-Level Leadership
Humanitarian settings: MinimumTransition and fragile: MustStandard: Must
For an organisation operating multiple sites, explicit, documented governance defines which decisions belong to central or corporate leadership and which belong to site-level leadership, with no ambiguity about who holds authority for a given decision.
Rating: Minimum in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Why it matters. A multi-site organisation where no one knows which decisions belong to the centre and which to the site leads to disputes and missed safety decisions. A written split of authority settles it.
Questions the surveyor asks
- Does every decision type have a named owner, central or site? The surveyor checks the decision rights table (NET-FRM-001) and the decision rights policy (NET-POL-001) for an owner against each decision type in the sample.
- Is the table shared with every site lead? The surveyor checks the distribution record for the table and asks a site lead to show their own copy.
How the surveyor verifies this criterion
Sample. Review the decision rights table, and the record of sharing with each site lead.
1. Every decision type has an owner in central or site leadership.
Method. Check the table for an owner against each decision type.
Evidence to show. Decision rights table ( NET-FRM-001 ).
Pass when. Every decision type has an owner recorded.
2. The table is shared with every site lead.
Method. Check the sharing record for each site lead.
Evidence to show. Decision rights table ( NET-FRM-001 ).
Pass when. Every site lead has the table with a sharing date recorded.
3. A decision made is recorded against the table.
Method. Check the last 3 site decisions for the owner recorded.
Evidence to show. Decision rights table ( NET-FRM-001 ).
Pass when. Every sampled decision has an owner from the table recorded.
Immediate fail (any one means the criterion is not met)
- . A site closes a ward with no central decision and no record.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. The decision-rights table is reviewed each year with every site lead, and each site lead signs to confirm the decisions that are theirs.
Partial because. The table exists, but site leads do not sign it and decisions are taken outside it.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Chief executive ISCO 1120 |
Approves the decision rights table | Must | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | NET-FRM-001 NET-POL-001 |
| Manager ISCO 1342 |
Keeps the table and shares it with each site lead | Must | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | NET-FRM-001 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Governance and Management (H-07) (H-07-EN) GMJ Academy: English · Georgian |
Chief executive, Manager | None |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NET-FRM-001 · Decision rights table Form (record) |
Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
| NET-POL-001 · Decision rights between central and site leadership Policy |
Chief executive (ISCO 1120) | Governing body members | N/A | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
References
- Pan American Health Organization (2020). Framework for the Response of Integrated Health Service Delivery Networks to COVID-19. Used for: network governance and response across integrated health service delivery networks (COVID-era). https://news.gmj.ge/guideline/framework-for-the-response-of-integrated-health-service-delivery-networks-to-covid-19/
18.2
Incident Learning Is Shared Across Sites, Not Siloed
Humanitarian settings: MinimumTransition and fragile: MediumStandard: Must
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.
Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.
Why it matters. A serious incident at one site that is not shared with the others means the same thing can happen again elsewhere. Sharing the learning across all sites prevents repeats.
Questions the surveyor asks
- Is each serious incident reviewed and shared across the sites? The surveyor checks the incident learning log (NET-REG-001) for each serious incident, with its review and the sites informed.
- Do lessons reach staff at the other sites? The surveyor checks the actions recorded at each site informed, and the record of the briefing given to staff.
How the surveyor verifies this criterion
Sample. Review the incident learning log for the last 12 months, with the sites informed and the actions recorded.
1. Each serious incident triggers a review and is shared across the sites.
Method. Check each serious incident for the review and the sites informed.
Evidence to show. Incident learning log ( NET-REG-001 ).
Pass when. Every serious incident has a review and sites informed recorded.
2. Lessons reach relevant staff at the other sites.
Method. Check each entry for the lessons shared and to whom.
Evidence to show. Incident learning log ( NET-REG-001 ).
Pass when. Every entry records lessons shared with relevant staff.
3. Actions are recorded at each site informed.
Method. Check each site informed for an action recorded.
Evidence to show. Incident learning log ( NET-REG-001 ).
Pass when. Every site informed has an action recorded.
Immediate fail (any one means the criterion is not met)
- . A fall death at one site is never mentioned to the others.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Incident summaries are circulated to all sites within a set time, and each site reports back what it changed.
Partial because. Incidents are reviewed centrally, but the lessons do not reach frontline staff at the other sites.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Manager ISCO 1342 |
Logs serious incidents and shares lessons | Medium | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | NET-REG-001 |
| Secretary ISCO 3344 |
Keeps the incident learning log | Medium | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | NET-REG-001 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Incident Reporting, Just Culture and Open Disclosure (T-09) (T-09-EN) GMJ Academy: English · Georgian |
Manager, Nurse | None |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NET-REG-001 · Incident learning log Register |
Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
References
- World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Used for: incident reporting, learning systems and quality across all settings. https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/
18.3
Clinical Policy Is Standardised Across Sites, With Any Local Variation Explicitly Justified
Humanitarian settings: MinimumTransition and fragile: MediumStandard: Must
Core clinical policies are standardised across every site in the network, with any permitted local variation explicitly documented and specifically justified, not silent or unexplained drift between sites.
Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.
Why it matters. Each site doing clinical care in its own way makes the network hard to trust and hard to audit. Core policies should be the same everywhere, and any local difference should be written and justified.
Questions the surveyor asks
- Is the core clinical policy the same at every site? The surveyor checks the standard clinical policy (NET-POL-002) against the version in use at each site.
- Is each local variation justified and approved? The surveyor checks the register of justified local variations (NET-REG-002) for the justification and approval of each variation.
How the surveyor verifies this criterion
Sample. Review the network standard list of core clinical policies and the register of justified local variations.
1. Core clinical policies are standardised across every site.
Method. Compare each site's core policy against the network standard list.
Evidence to show. Register of justified local variations ( NET-REG-002 ).
Pass when. Every site follows the network standard for each core policy, or a variation is recorded.
2. Each local variation is documented.
Method. Check each site variation against the register.
Evidence to show. Register of justified local variations ( NET-REG-002 ).
Pass when. Every variation found is in the register.
3. Each local variation is specifically justified and approved.
Method. Check each entry for the justification and the approval.
Evidence to show. Register of justified local variations ( NET-REG-002 ).
Pass when. Every entry has a justification and an approval.
Immediate fail (any one means the criterion is not met)
- . Two sites give the same drug with different protocols and no reason.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. The network publishes its core policy set in one place, and each site lead reviews the register of variations each year.
Partial because. Core policies are shared, but local variations are not recorded in the register.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Manager ISCO 1342 |
Owns the network list of core policies | Medium | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | NET-REG-002 |
| Specialist physician ISCO 2212 |
Justifies and signs each local variation | Medium | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | — |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Governance and Management (H-07) (H-07-EN) GMJ Academy: English · Georgian |
Chief executive, Manager | None |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NET-REG-002 · Register of justified local variations Register |
Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
| NET-POL-002 · Standard clinical policy and local variation Policy |
Chief executive (ISCO 1120) | Governing body members | N/A | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
References
- World Health Organization (2019). Surgical Care at the District Hospital. Used for: standard policy and quality in first-referral sites. https://news.gmj.ge/guideline/surgical-care-at-the-district-hospital/
- World Health Organization (2017). Medication Without Harm: Global Patient Safety Challenge on Medication Safety. Used for: policy, standards and reporting of medication safety across health care settings. https://news.gmj.ge/guideline/medication-without-harm-global-patient-safety-challenge-on-medication-safety/
18.4
Credentialing and Privileging Are Centrally Verified and Consistently Recognised
Humanitarian settings: MustTransition and fragile: MustStandard: Must
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 practice without current credentials confirmed for that site.
Rating: Must in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Why it matters. A clinician who is verified at one site and not at another can practise where they are not safe. One central verification, recognised everywhere, closes that gap.
Questions the surveyor asks
- Is each clinician's credential verified centrally? The surveyor checks the verified clinician register (NET-REG-003) and the central credentialing policy (NET-POL-003) for a sample of clinicians.
- Does each site recognise a clinician only after the central check? The surveyor checks the date of the central check against the date each site recognised the clinician.
How the surveyor verifies this criterion
Sample. Review the central credentialing procedure, the verified clinician register and the site recognition record for 5 clinicians.
1. Each clinician's credentials and privileges are verified through a single central process.
Method. Check each clinician for the central verification record.
Evidence to show. Verified clinician and site recognition register ( NET-REG-003 ).
Pass when. Every clinician has a central verification recorded.
2. Each site recognises the clinician only after the central check.
Method. Check each site recognition against the central verification date.
Evidence to show. Verified clinician and site recognition register ( NET-REG-003 ).
Pass when. Every site recognition follows a recorded central check.
3. Credentials are current at each site where the clinician practises.
Method. Check the expiry for each recognised site against the rota.
Evidence to show. Verified clinician and site recognition register ( NET-REG-003 ).
Pass when. No clinician practises at a site with expired credentials.
Immediate fail (any one means the criterion is not met)
- . A clinician is granted privileges at one site with no check at the central office.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Credentials are checked centrally before a clinician starts at any site, and the central check is repeated at each renewal date.
Partial because. The central check is made, but a site allows practice before the central confirmation arrives.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Manager ISCO 1342 |
Runs the central credentialing check | Must | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | NET-REG-003 |
| Secretary ISCO 3344 |
Keeps the verified clinician register | Must | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | NET-REG-003 NET-POL-003 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Credentialing, Competence and the Training Matrix (T-14) (T-14-EN) GMJ Academy: English · Georgian |
Manager, Secretary | None |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NET-REG-003 · Verified clinician and site recognition register Register |
Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
| NET-POL-003 · Central credentialing and privileging Policy |
Chief executive (ISCO 1120) | Governing body members | N/A | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
References
No external guideline is cited for this criterion.
18.5
Central Resource and Staffing Decisions Are Evaluated for Site-Level Patient Safety Impact
Humanitarian settings: MinimumTransition and fragile: MediumStandard: Must
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.
Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.
Why it matters. A central decision to cut staff or move equipment can be safe on paper and dangerous at one site. Checking the patient safety impact at the site before the decision takes effect prevents that.
Questions the surveyor asks
- Is each central staffing or resource decision checked for patient safety impact? The surveyor checks the safety impact evaluation (NET-FRM-002) for a sample of central decisions, completed before the decision was finalised.
- Is a mitigation agreed for any impact found? The surveyor checks each evaluation that found an impact for an agreed mitigation.
How the surveyor verifies this criterion
Sample. Review the template for central decisions and the safety impact evaluation for the last 3 decisions.
1. Each central decision on staffing, equipment or resources is evaluated for site patient safety impact.
Method. Check each decision in the sample for the evaluation.
Evidence to show. Central decision safety impact evaluation ( NET-FRM-002 ).
Pass when. Every sampled decision has a safety impact evaluation.
2. The evaluation is completed before the decision is finalised.
Method. Check each evaluation date against the decision date.
Evidence to show. Central decision safety impact evaluation ( NET-FRM-002 ).
Pass when. Every evaluation is completed before the decision is finalised.
3. Any impact found has a mitigation agreed.
Method. Check each evaluation for the mitigation recorded.
Evidence to show. Central decision safety impact evaluation ( NET-FRM-002 ).
Pass when. Every impact found has a mitigation recorded.
Immediate fail (any one means the criterion is not met)
- . A site loses its night nurse with no safety review.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Each proposed central decision on staffing or equipment carries a short safety impact note, reviewed by the site lead before it is confirmed.
Partial because. The evaluation is made, but it is completed after the decision has been announced.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Chief executive ISCO 1120 |
Makes the central decision | Medium | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | NET-FRM-002 |
| Manager ISCO 1342 |
Completes the safety impact evaluation | Medium | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | NET-FRM-002 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Governance and Management (H-07) (H-07-EN) GMJ Academy: English · Georgian |
Chief executive, Manager | None |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NET-FRM-002 · Central decision safety impact evaluation Form (record) |
Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
References
- World Health Organization (2017). Hospital Safety Index: Guide for Evaluators, second edition. Used for: evaluating hospital safety before a central decision takes effect. https://news.gmj.ge/guideline/hospital-safety-index-guide-for-evaluators-2nd-ed/
18.6
Site-Level Quality Data Is Reviewed by Central Governance
Humanitarian settings: MinimumTransition and fragile: MediumStandard: Must
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.
Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.
Why it matters. Quality data sent up from each site means little if no one at the centre reads it or acts on a warning. Central review, with follow-up, is what turns the data into safer care.
Questions the surveyor asks
- Is site quality data reviewed by central governance? The surveyor checks the central quality review register (NET-REG-004) for each site's metrics at each review.
- Is follow-up checked at the next review? The surveyor checks that each metric showing a problem has an action, and that the follow-up is recorded at the next review.
How the surveyor verifies this criterion
Sample. Review the central quality review record for the last 4 quarters, with the actions taken for each site.
1. Quality and safety metrics from each site are reviewed by central governance each quarter.
Method. Check the register for each site in each quarter.
Evidence to show. Central quality review register ( NET-REG-004 ).
Pass when. Every site is reviewed in every quarter.
2. Each metric showing a problem has an action.
Method. Check each problem metric for the action recorded.
Evidence to show. Central quality review register ( NET-REG-004 ).
Pass when. Every problem metric has an action and follow-up date.
3. Follow-up is checked at the next review.
Method. Check the next quarter's review for the follow-up.
Evidence to show. Central quality review register ( NET-REG-004 ).
Pass when. At least 90% of actions are followed up at the next review.
Immediate fail (any one means the criterion is not met)
- . A site with a rising infection rate is not noticed at the centre.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Quality dashboards are shown to central governance at each meeting, with a named owner for each action and a date for the follow-up.
Partial because. Metrics are reviewed centrally, but actions are not assigned to a named owner.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Chief executive ISCO 1120 |
Reviews site metrics each quarter | Medium | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | NET-REG-004 |
| Manager ISCO 1342 |
Records actions and follow-up | Medium | Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file | NET-REG-004 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Governance and Management (H-07) (H-07-EN) GMJ Academy: English · Georgian |
Chief executive, Manager | None |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| NET-REG-004 · Central quality review register Register |
Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
References
- World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Used for: incident reporting, learning systems and quality across all settings. https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/
Role details: reporting, supervision and training
Each role links to its own terms of reference, which holds the full reporting line, supervision, training and competency record.
| Role | Reports to | Supervises | Core training |
|---|---|---|---|
| Chief executive ISCO 1120 | The board of directors. | Managers of each site and the heads of department. | No course is required for this role in this standard. |
| Manager ISCO 1342 | The chief executive. | Nurses and site staff in the unit. | No course is required for this role in this standard. |
| Specialist physician ISCO 2212 | The head of department (per specialty). | Clinicians of the specialty at each site. | No course is required for this role in this standard. |
| Secretary ISCO 3344 | The head of department (per specialty). | No direct reports. | No course is required for this role in this standard. |
Who is responsible for Standard 18
Each criterion below names the positions responsible for it.
| Criterion | Positions responsible or involved | |
|---|---|---|
| 18.1 | Governance Structure Defines Authority Between Central and Site-Level Leadership | Chief executive · Manager |
| 18.2 | Incident Learning Is Shared Across Sites, Not Siloed | Manager · Secretary |
| 18.3 | Clinical Policy Is Standardised Across Sites, With Any Local Variation Explicitly Justified | Manager · Specialist physician |
| 18.4 | Credentialing and Privileging Are Centrally Verified and Consistently Recognised | Manager · Secretary |
| 18.5 | Central Resource and Staffing Decisions Are Evaluated for Site-Level Patient Safety Impact | Chief executive · Manager |
| 18.6 | Site-Level Quality Data Is Reviewed by Central Governance | Chief executive · Manager |
Quality oversight
The quality chain keeps this standard under review, from the governing body down to the teams that run each process.
Related courses in the GMJ Academy
These courses cover the same subjects in more depth or for a specific type of facility. They are optional. They are not required by the criteria.
| Course | Subject | Criteria |
|---|---|---|
| Governance & Management (H-07) GMJ Academy: English · Georgian |
Governance and management | 18.1 |
| Incident Reporting, Just Culture and Open Disclosure (T-09) GMJ Academy: English · Georgian |
Incident reporting and open disclosure | 18.2 |
| Credentialing, Competence and the Training Matrix (T-14) GMJ Academy: English · Georgian |
Credentialing and competence | 18.4 |
Questions and answers
The criterion text is the authority. These answers summarise it.
Who does Standard 18 apply to?
It applies to organisations that run more than one site under shared governance. It is optional for every facility type. Section 4 shows the detail.
What do the colours mean for this standard?
Red means Must, required in every setting. Yellow means Medium, required and adapted to what a transition setting can realistically do. Green means Minimum, the lowest acceptable level in a humanitarian setting.
Does a single-site facility need this standard?
No. It is optional. A facility that runs several sites under one governance applies it to the central governance of those sites.
Who decides across the sites?
The decision rights table sets an owner, central or site, for every decision type, and it is shared with every site lead (criterion 18.1).
Must serious incidents be shared between sites?
Yes. Each serious incident triggers a review, and the lessons are shared with the other sites, where actions are recorded (criterion 18.2).
Can a site change a clinical policy?
Only with a documented justification that is approved and recorded in the register of local variations. The core policy is the same at every site (criterion 18.3).
Is a clinician’s credential verified once for all sites?
Yes. It is verified centrally, and each site recognises the clinician only after that central check. Credentials must be current at each site where the clinician works (criterion 18.4).
Must central staffing and resource decisions be assessed for safety?
Yes. Each central decision is evaluated for its effect on patient safety before it is finalised, and any impact found has an agreed mitigation (criterion 18.5).
Is site quality data reviewed centrally?
Yes. Quality and safety metrics from each site are reviewed by central governance, and each metric that shows a problem has an action (criterion 18.6).
Which e-learning courses are required?
Governance and Management (H-07) is required for the chief executive and manager. Incident Reporting, Just Culture and Open Disclosure (T-09) is required for the manager and nurse. Credentialing, Competence and the Training Matrix (T-14) is required for the manager and secretary.
Who is the specialist physician in this standard?
The specialist physician is named in the criteria for the clinical roles. The role is linked to the consultant physician terms of reference on france-asf.fr.
What does In development mean?
The course is named in the criteria and may still be in preparation. Where a course is published, the English or Georgian version is linked.
Who is responsible for each criterion?
The criteria assign responsibility to the chief executive, the manager, the secretary and the specialist physician. Each record should show who wrote and who reviewed it.
How is evidence shown to the surveyor?
The records named in each criterion’s documents table, covering the period stated in the criterion.
Is the reference cited in a criterion mandatory?
No. A cited guideline is a reference for the criterion, not a requirement. A facility may use other guidance that meets the same criterion.
Do I have to use the forms on this page?
No. They are reference drafts. Adapt them, write your own, or upload your own, provided the same criterion is met and the evidence can be shown.
E-learning by standard
These are the GMJ Academy courses named in the criteria of this standard. Each course name opens the course page in the academy. Where a course is published in English and in Georgian, both versions are linked. Evidence of completion is a verified micro-credential in the GMJ Academy micro-credential portfolio, or a training certificate in the staff file.
| E-learning course | Who must take | Who is recommended | Criteria |
|---|---|---|---|
| Governance and Management (H-07) (H-07-EN) GMJ Academy: English · Georgian |
Chief executive, Manager | None | 18.1, 18.3, 18.5, 18.6 |
| Incident Reporting, Just Culture and Open Disclosure (T-09) (T-09-EN) GMJ Academy: English · Georgian |
Manager, Nurse | None | 18.2 |
| Credentialing, Competence and the Training Matrix (T-14) (T-14-EN) GMJ Academy: English · Georgian |
Manager, Secretary | None | 18.4 |
References and guidelines for this standard
The guidelines and references cited in the criteria above are listed here. Each link opens the full text.
- Pan American Health Organization (2020). Framework for the Response of Integrated Health Service Delivery Networks to COVID-19. Used for: network governance and response across integrated health service delivery networks (COVID-era). https://news.gmj.ge/guideline/framework-for-the-response-of-integrated-health-service-delivery-networks-to-covid-19/
- World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Used for: incident reporting, learning systems and quality across all settings. https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/
- World Health Organization (2019). Surgical Care at the District Hospital. Used for: standard policy and quality in first-referral sites. https://news.gmj.ge/guideline/surgical-care-at-the-district-hospital/
- World Health Organization (2017). Medication Without Harm: Global Patient Safety Challenge on Medication Safety. Used for: policy, standards and reporting of medication safety across health care settings. https://news.gmj.ge/guideline/medication-without-harm-global-patient-safety-challenge-on-medication-safety/
- World Health Organization (2017). Hospital Safety Index: Guide for Evaluators, second edition. Used for: evaluating hospital safety before a central decision takes effect. https://news.gmj.ge/guideline/hospital-safety-index-guide-for-evaluators-2nd-ed/
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