Reviewer Qualifications, Assignment & Challenge Policy
A formal policy of the Commission for Health, Safety & Professional Standards, Inc. Normative clauses use “shall.”
| Field | Value |
|---|---|
| Document ID | CHSPS-AUD-400 |
| Title | Reviewer Qualifications, Assignment & Challenge Policy |
| Edition | 2026.1 |
| Status | Published Policy — effective August 19, 2026 |
| Owner | Audit Oversight Committee |
| Supersedes | New document |
| Next review | No later than August 2028, or earlier upon material change |
| Publication authority | CHSPS controlled-document publication authority |
Purpose
To define who may review for CHSPS, how reviewers are authorized and kept calibrated, how files are assigned, and the applicant’s right to challenge a reviewer for conflict.
1. Roles
1.1 Accreditation Reviewer: evaluates evidence against the Core Requirements and program standards and drafts findings.
1.2 Lead Reviewer: plans the review, coordinates the team, and is accountable for findings quality on the file.
1.3 Technical Specialist: contributes defined deep expertise (e.g., psychometrics, security, pharmacy practice) to specific clauses.
1.4 Performance Data Validator: performs data-lineage, sampling and reperformance work under the validation standard.
2. Minimum qualifications
2.1 Accreditation Reviewer: at least 5 years of professional experience in credentialing, assessment, education quality, audit or a directly relevant discipline; completion of CHSPS reviewer training; and a passed knowledge assessment.
2.2 Lead Reviewer: reviewer authorization plus at least 8 years of relevant experience and satisfactory performance on no fewer than 5 CHSPS files (supervised files count).
2.3 Technical Specialist: demonstrable recognized expertise in the specialty engaged, evidenced by credentials, publications or verifiable senior practice.
2.4 Performance Data Validator: professional experience in data analysis, audit or quality measurement, plus CHSPS validation training and assessment.
2.5 Equivalency may be granted by the Audit Oversight Committee in writing, with the rationale recorded.
3. Authorization lifecycle
3.1 Authorization shall proceed: application → qualification and conflict screening → required training → knowledge assessment → observed or simulated review → a minimum of 2 supervised files → authorization by the Audit Oversight Committee.
3.2 Authorization is role- and program-specific, lasts 3 years, and is renewable on satisfactory performance, current calibration and continuing education of at least 8 hours per year.
3.3 Authorization may be suspended or terminated for cause — including confidentiality or impartiality breaches, persistent quality failure, or failure to complete calibration — with written reasons and an appeal to the Audit Oversight Committee.
4. Calibration and quality
4.1 Every authorized reviewer shall complete annual calibration using standardized cases; results shall be recorded and inter-rater consistency monitored.
4.2 CHSPS shall quality-review a sample of files each year, including blinded duplicate reviews where volume permits, and shall track findings-quality metrics by reviewer.
5. Assignment
5.1 Files shall be assigned by the accreditation function’s management, matching program expertise and specialty needs, balancing workload, and honoring every screening rule of CHSPS-GOV-002.
5.2 The same person shall not serve as Lead Reviewer for the same organization for more than two consecutive accreditation cycles.
5.3 No reviewer shall be assigned to a file for which their per-assignment conflict attestation is unresolved.
6. Applicant notice and challenge
6.1 The applicant shall be notified in writing of the review team’s composition no fewer than 10 business days before technical review begins.
6.2 The applicant may challenge any team member within 5 business days of notice, in writing, on conflict grounds: competitive relationship, prior consulting or employment relationship, close personal relationship, or demonstrated bias.
6.3 Challenges shall be decided within 5 business days by the accreditation function’s management (or, if the challenged person is that manager, by the Audit Oversight Committee); the decision-maker shall not be the person challenged.
6.4 A sustained challenge results in replacement of the reviewer without penalty to the applicant’s timeline; an overruled challenge shall be answered with written reasons and is recorded in the file.
6.5 The right to challenge is for conflicts — it does not extend to objecting to a reviewer’s anticipated rigor.
7. Compensation
7.1 Reviewers shall be compensated for professional time at published or contracted rates; compensation shall never depend on findings, outcomes, or any accreditation-revenue measure.
8. Records
8.1 Qualification files, training and calibration records, assignment and challenge records shall be retained per CHSPS-ACC-104; challenge decisions shall be retained with the accreditation file.
Related documents
Auditors & Validators overview · Impartiality & COI (CHSPS-GOV-002) · Applicant Handbook · Policy Manual
Where this policy and a page-level summary elsewhere on this site differ, this controlled document governs. Substantive changes follow the published revision process and never apply retroactively to in-flight matters.