Standards › ASF Health Standards v10 › Standard 2A
Standard 2A
Governance and Safety Culture
Who is accountable for safety and quality, how policy is followed, how patient data is kept secure, and how serious incidents are investigated.
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.
Why it matters. A facility with no clearly accountable governing body has no one answerable for safety and quality when things go wrong. Named members with documented authority make that accountability real.
What the surveyor checks
- Is there a documented governing body with named members and defined terms of office?
- Does the governing body meet on a fixed schedule with minutes retained?
- Does the board formally review quality and safety performance at each meeting, not only financial performance?
- Is clinical governance oversight of clinical effectiveness, audit and risk explicitly assigned to a named board responsibility, rather than left implicit within general quality oversight?
- Is financial stewardship (budget oversight, financial risk and resource allocation) a defined board responsibility, distinct from day-to-day financial management?
Documents
E-learning
- Governance & Management (H-07)
- Safety Management System & Leadership (MGMT-01)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
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.
Why it matters. A facility without a written plan drifts, and its resources follow whichever problem is loudest that week. A written plan with a mission, values and code of conduct sets the direction that staff and the board can be held to.
What the surveyor checks
- Is there a written strategic plan covering at least a multi-year horizon?
- Does the plan include a clear mission statement describing who the facility serves and how?
- Can a resourcing decision from the last year be traced back to something in the plan?
- 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?
Documents
E-learning
- Quality Management in Healthcare (A-02)
- Safety Management System & Leadership (MGMT-01)
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
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.
Why it matters. Many facilities have a complete set of policies that nobody follows. A policy that staff cannot explain in practice is a document, not a control.
What the surveyor checks
- Can staff describe how a specific, named policy is applied in their daily work?
- Is there a mechanism to check policy adherence, not just policy existence?
- When a policy-practice gap is found, is there a defined response, not just noting the discrepancy?
- 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?
- Is the quality improvement plan itself formally evaluated on a defined schedule, with the evaluation used to revise the plan?
- 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?
- Is every policy, procedure and plan reviewed against a defined timescale to confirm it is still current, not left in place indefinitely once approved?
Documents
E-learning
- Documentation Fundamentals (A-03)
- Document Control and the Records System (T-02)
- Document Control Fundamentals (A-06)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
Health information is protected with defined access controls and a breach response plan, using practical, achievable security measures appropriate to the facility’s resources.
Why it matters. Patient health information is sensitive, and a breach can harm patients and families. Defined access controls and a breach response plan keep it protected, even in a temporary setting.
What the surveyor checks
- Are access controls in place restricting patient data access to staff who need it for their role?
- Is there a documented breach response plan, specific and actionable?
- Have access controls and the breach plan been reviewed or tested recently?
Documents
E-learning
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
A retention policy governs how long records are kept and how they are disposed of, aligned with a stated requirement for the country where the facility operates, not a generic assumption.
Why it matters. Keeping records forever is costly and risky, and destroying them too early can break the law and remove evidence a patient needs. A retention policy sets the period for each record type, and the disposal is recorded.
What the surveyor checks
- Does a written retention policy exist, specifying how long different record types are kept?
- Is the retention period aligned with the stated requirement for the country where the facility operates?
- Is disposal of records past their retention period conducted securely and documented?
Documents
E-learning
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
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.
Why it matters. Root cause analysis finds why an incident happened, not who was involved. A tracked action plan that is followed through is what makes the investigation worth doing.
What the surveyor checks
- Is a structured root cause analysis method used for serious incidents, not just a brief incident note?
- Does the RCA result in a specific, tracked action plan?
- Are action plan items tracked to completion, not left open indefinitely?
Documents
E-learning
- Incident Reporting, Just Culture and Open Disclosure (T-09)
- Nonconformity, Corrective Action and Risk (T-04)
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
A validated survey measures whether staff feel safe raising concerns, conducted regularly and acted on, not assumed from the absence of complaints.
Why it matters. Staff who are afraid to raise a concern will stay silent about the mistake that harms a patient. A validated survey, repeated and acted on, shows whether they feel able to speak up.
What the surveyor checks
- Is a validated safety culture survey conducted, not an informal or ad hoc check?
- Is the survey conducted regularly, on a defined schedule?
- Are survey results reviewed and acted on, with visible follow-up?
Documents
E-learning
- Incident Reporting, Just Culture and Open Disclosure (T-09)
- Safety Management System & Leadership (MGMT-01)
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
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.
Why it matters. Patients who ask only after they leave may not say what went wrong during their stay. Feedback gathered during care, while there is still time to act, improves the care the patient is actually getting.
What the surveyor checks
- Is patient experience measured through structured feedback during the stay, not only after discharge?
- Is feedback collected broadly, not only from patients who happen to volunteer it?
- Is collected feedback reviewed and used to inform improvements?
Documents
E-learning
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
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.
Why it matters. Clinical staff sometimes face decisions about care that are hard to make alone, such as when treatment should stop. A usable ethics consultation route gives them somewhere to go before a poor decision is made.
What the surveyor checks
- Is there an accessible ethics consultation process: a committee, named resource or external arrangement?
- Do staff know how to access it, not just that it exists somewhere in policy?
- Has the process been used for a case, or does it exist only theoretically?
Documents
E-learning
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
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.
Why it matters. A service designed without the people who use it misses what matters to them. A patient or family representative in governance brings the view from outside the staff room.
What the surveyor checks
- Does at least one patient or family representative have a structured role in quality review or governance discussions?
- Is this representative included in discussion, not present only as an observer?
- Can the facility point to a specific instance where patient or family input shaped a decision?
Documents
E-learning
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
Back to ASF Health Standards v10 · Standards Map · E-learning by standard · References