Annual conflict-of-interest disclosures
Preferred100%
Watch—
Review< 100%
Trust by design
Governance & Impartiality
CHSPS separates standards development, applicant support, technical review, accreditation decisions and appeals through defined governance roles, conflict controls and documented decision procedures.
Decision rule. Accreditation decisions are issued only by the five-member Accreditation Decision Committee. Quorum is four conflict-free voting members; recusals are recorded, and a case is deferred whenever quorum cannot be maintained.
Board of CommissionersGovernance oversight — never accreditation decisions
Standards Councildevelops standards
Technical Reviewersreview evidence
Accreditation Decision Committeedecides accreditation
Appeals Poolindependent challenge process
Oversight covers process and impartiality — no body above directs the outcome of a review, decision or appeal.
The model
Separated authority across governance, review, decisions and appeals
Every accreditation function that could bias another is structurally separated. Applicant support, technical review, accreditation decisions and appeals are assigned to separate functions with conflict-screening and recusal requirements.
- Board of Commissioners — corporate oversight, policy adoption and public accountability, including public members
- Standards Council — develops and maintains the standards through public comment
- Accreditation Decision Committee — makes every grant, deferral, suspension and withdrawal
- Appeals Pool / Appeals Panels — eligible independent members form the pool; a conflict-free panel is empaneled per appeal
- Technical reviewers & validators — conflict-screened per file, working to documented rubrics, with audit-quality oversight
- Measures Advisory Function — governs CHSPS Measures, CPDS and Validated Performance Data methodology
- Specialty accreditation panels — subject-matter governance for each published specialty accreditation standard
- Impartiality & Ethics function — conflict registers, recusals and the annual impartiality review under CHSPS-GOV-002
Seat structure & terms
Governance bodies, seats, terms and quorum
Governance bodies, seat structure, terms, quorum and conflict rules are published on this page. Current appointments are being finalized; office holders are confirmed to applicants and regulators on request at info@chsps.org.
Board of Commissioners
Board structure: seven seats in the governance model, staggered terms, documented conflict disclosures and no controlling majority by a single stakeholder category. The Board governs CHSPS but does not vote on individual accreditation cases.
Seats: Board Chair; Vice Chair; Treasurer & Commissioner; Commissioner — Education Quality; Commissioner — Credentialing; Public Commissioner; Commissioner — Measurement.
Standards Council
Five seats. The Council maintains standards through documented proposals, technical review, public comment, disposition, ratification and controlled revision. Council appointments run for a 3-year term; it does not decide whether an individual applicant conforms.
Seats: Council Chair; Education Quality Member; Research / Public Member; Credentialing Operations Member; Employer / Public Health Member.
Accreditation Decision Committee
Decision Committee structure: five qualified voting members; quorum of four conflict-free voting members; conflict-screened case assignment; reviewers and applicant-support personnel do not vote on cases they handled.
Seats: Committee Chair; Public Member; Quality Systems Member; Education / Certification Member; Health Systems Member.
Appeals Pool
The Appeals Pool is a seven-member pool of eligible independent members. Each appeal is assigned to a three-member Appeals Panel drawn from the pool, with no involvement in the original review or decision; members of the Accreditation Decision Committee are not eligible to serve in the Appeals Pool.
Stakeholder balance target: no single stakeholder category exceeds 40% of a standing governance or technical body.
Safeguards
Impartiality safeguards in practice
Conflict screening
Before any file is assigned, reviewers and committee members disclose employment, consulting, financial and personal relationships. Anyone with a material interest is recused and the recusal is recorded.
Separation of revenue
Education, membership, sponsorship and grant revenue is accounted for separately from accreditation fees, and purchasing anything from CHSPS is never required for — and never advantages — an application. Accreditation outcomes are insulated from revenue functions; operating surpluses are directed to standards development, reviewer training and public-interest work under the published governance model. External support is governed by the formal Sponsorship, Grants & External Funding Policy (CHSPS-DEV-600), with public information provided through Funding Disclosures in accordance with the applicable policy.
Documented decisions
Every decision cites the standards at issue and the evidence considered. Applicants receive written findings, including any corrective actions required, in plain language.
Decision consistency
Rubrics, reviewer calibration and periodic decision audits keep outcomes consistent across reviewers, sectors and time.
Confidentiality
Applicant materials are restricted to assigned, conflict-cleared personnel and used only for accreditation purposes.
Public accountability
Statuses — including suspensions and withdrawals — are published in the Verify Accreditation. Complaints about CHSPS itself follow the same documented process we require of others.
Claims discipline
CHSPS public claims are expected to remain consistent with the applicable standards, policies, governance records and official accreditation records. Standards are published before anyone is reviewed against them, fees are published before anyone pays them, decisions are documented, and current accreditation records and applicable public status actions are published under the controlled decision and publication rules. The Accreditation Mark & Claims Policy applies this discipline to every organization that carries the CHSPS seal.
Decision safeguards
How conflicts, recusals and quorum apply to an accreditation case
The governance rules separate evidence review from the decision itself and specify what happens when a conflict removes a voting member.
Reviewer / decision separation
No same-file vote
A technical reviewer or validator who evaluated an applicant's evidence may present factual clarification to the decision body but may not vote on that applicant's final accreditation decision.
Quorum after recusal
Conflict-free quorum is mandatory
A decision requires a quorum of four conflict-free voting members from the five-member Accreditation Decision Committee and the required majority under the committee charter. If recusals reduce the body below four, the decision is postponed and qualified alternate arrangements are made; quorum is never waived for convenience.
Cooling-off
24-month applicant-specific firewall
Anyone who provided applicant-specific consulting, policy drafting, evidence preapproval or other disqualifying support to an organization within the prior 24 months is excluded from that organization's technical review and decision roles.
Appeals are reconstituted
Appeals are heard by at least three conflict-free persons drawn from a seven-member independent Appeals Pool; panelists did not review the evidence, make the original decision or supervise anyone who did, and Decision Committee members are ineligible for the pool.
Recusals are recorded
The conflict declaration, recusal basis, replacement assignment and resulting quorum are recorded in the controlled case file.
No outcome-linked compensation
Reviewer, validator, committee and sales compensation may not depend on whether accreditation is granted, denied, renewed or expanded.
Governance operating targets
Governance reference criteria support impartiality monitoring
The governance model uses explicit thresholds for disclosure, recusal, stakeholder balance and participation.
Required recusals documented
Preferred100%
Watch—
Review< 100%
Largest stakeholder category share
Preferred≤ 40%
Watch40.1–49.9%
Review≥ 50%
Voting-body meeting attendance
Preferred≥ 80%
Watch70.0–79.9%
Review< 70.0%
Annual impartiality review completed
Preferred100%
Watch—
Review< 100%
Education firewall
No applicant-specific preapproval
Education may explain CHSPS requirements and evidence categories, but it may not rewrite applicant policies, preapprove evidence or predict an accreditation outcome.
Review firewall
No same-case overlap
Personnel with disqualifying prior consulting, education support or other conflicts are excluded from technical review and decision roles for that organization.
Decision firewall
No commercial outcome incentive
Reviewers and decision makers are not compensated or evaluated based on grants, denials, sales, membership or sponsorship.