1. The International Society for Quality in Health Care (ISQua) – Guidelines

2. ISQua (ISQua) launched its International Accreditation Program in 1999. The program provides: Accreditation of healthcare external evaluation organisations Accreditation of healthcare standards that meet its international principles for such standards Accreditation of training programs for training surveyors/assessors/auditors.

3. Framework for Standards The standards have been grouped into functions The functions are: A) Leadership B) Support Services C) Service Delivery

4. Guidance Guidance is provided to help interpret the criteria in the Standards and is not intended to specify requirements that must be complied with. It provides examples that could meet the criteria and could be adapted locally. Achievement of a criterion is assessed on the basis of local relevance and whether the organisation has taken steps that conform to the intent of the criterion.

5. FUNCTION A: LEADERSHIP 1.0 Governance The organisation is responsibly governed to meet its defined purposes and objectives. 2.0 Strategic, Operational and Financial Management The organisation is effectively managed to meet its strategic operational and financial objectives. 3.0 Risk Management and Performance Improvement Risks and opportunities to improve are identified and managed to deliver safe quality services.

6. FUNCTION B: SUPPORT SERVICES 4.0 Human Resources Management Staff planning and management support the organisation’s objectives and staff are supported to deliver quality services. 5.0 Information Management Information management supports the business objectives

7. 6.0 Assessor Management Assessor planning, selection and management support the delivery of a high quality assessment service to participating organisations. 7.0 Assessment Management The external evaluation programs are consistent with the organisation’s objectives, facilitate objective and consistent decision making and meet the needs of participating organisations and other stakeholders. 8.0 Accreditation or Certification Awards The processes for determination, awarding and maintenance of Accreditation are objective, consistent and meet the organisation’s objectives. FUNCTION C: SERVICE DELIVERY

8. Governance Criteria 1.1 A clear vision and purpose or mission 1.2 A defined set of values 1.3 All decision-making and behaviour are guided by an explicit set of ethical principles 1.4 Governing body responsibilities. 1.5 Legal entity, impartiality 1.6 Role description. 1.7 Terms of reference, appointment and Authority 1.8 Governing body orientation, education 1.9 Relationships with stakeholders 1.10 Governance evaluation

9. Strategic, Operational and Financial Management Criteria 2.1 Chief executive responsabilites, objectives 2.2 Management arrangements 2.3 Contracting 2.4 Strategic planning 2.5 Operating plan 2.6 Financial and resource planning 2.7 Financial system 2.8 Financial & asset control 2.9 Evaluation

10. 3.1 Risk management planning 3.2 Risk reporting 3.3 Performance improvement system 3.4 Performance monitoring processes 3.5 Quality cycle 3.6 Policies and procedures 3.7 Document control 3.8 Complaints procedures 3.9 Evaluation Risk Management & Performance Improvement Criteria

11. 4.1 Staff planning 4.2 Recruitment and selection 4.3 Orientation and training 4.4 Training and development 4.5 Performance appraisal 4.6 Workplace issues 4.7 Personnel records 4.8 Health work procedures 4.9 Staff health and safety 4.10 Evaluation Human Resources Management Criteria

12. 5.1 Planning 5.2 Data management 5.3 Technology management systems 5.4 Data recovery 5.5 Design of information/education materials 5.6 Resource material accuracy 5.7 Defined production standards for information & education materials 5.8 Feedback from users of materials 5.9 Evaluation Information Management Criteria

13. 6.1 Assessor planning 6.2 Selection and appointment 6.3 Assessor contract or agreement 6.4 Orientation 6.5 New assessor competence 6.6 Skill development 6.7 Performance review 6.8 Assessor records 6.9 Evaluation Assessor Management Criteria

14. 7.1 Program development 7.2 Entry into program 7.3 Participating organisation relationships 7.4 Client education and information 7.5 Selection of assessment team 7.6 Assessment planning 7.7 Timetable of assessment 7.8 Conduct of assessment 7.9 Assessment reporting 7.10 Review processes and guidelines 7.11 Evaluation Assessment Management Criteria

15. Accreditation or Certification Awards Criteria 8.1 Entry into the program 8.2 Outcome of assessment, accreditation/ certification award 8.3 Accreditation certificate 8.4 Review and appeals process 8.5 Monitoring of outcomes 8.6 Maintenance of standards 8.7 Follow-up of concerns, issues 8.8 Use of certificate, logo 8.9 Public information, certificate 8.10 Assessment records 8.11 Evaluation