ASF Monitor Certification
The ASF Accreditation Monitor is an independent, credentialled professional who verifies that a healthcare facility’s self-assessment is honest, evidence-based, and defensible. The Monitor’s signature carries professional liability — it is the structural safeguard on which the entire accreditation system rests.
The Role of the Monitor
A certified ASF Accreditation Monitor independently checks that the facility’s quarterly self-assessment evidence is genuine, complete, and correctly rated. The Monitor does not advise or improve — that is the Coordinator’s function. The Monitor verifies. Each criterion is marked Verified, Requires Evidence, or Disputed. This three-way classification is aligned with the evidence-declaration model used in Accreditation Canada’s Qmentum programme and the ISQua External Evaluation Association (EEA) surveyor standards.
Internal Monitor
- Employed by the facility
- Serves one facility only
- Cannot be the Coordinator or verify a department they manage
- Rotates after 3 consecutive years; 1-year gap required
- Time: annual virtual milestone (2–3 hrs) + full in-facility renewal (1–3 days, scaled to facility size)
- Covered by the facility’s professional liability insurance
External Monitor
- Independent, under a service contract copied to ASF
- May serve any facility in any country
- Cannot have employment or financial ties to any facility served
- Rotation limit: 5 years per facility, then 1-year gap
- Earns a day rate agreed with the facility; ASF publishes recommended rate bands
- Must carry professional indemnity insurance
MON-01 Certification Pathway
Certification follows a five-step pathway modelled on ISQua EEA surveyor certification requirements and Accreditation Canada’s surveyor training framework. Each step must be completed in sequence; there is no examination-only route.
Foundation Prerequisite — ASF-00
All applicants must first complete the shared ASF Foundation module (ASF-00), a free 30-minute online orientation covering ASF’s three-level structure, four roles, and accreditation cycle. This module is shared across all four tracks and is completed once.
ASF-00 · 30 min · Free · GMJ Academy
Online Training — 4 Core Modules (∼16 Hours)
Four e-learning modules delivered on GMJ Academy (academy.gmj.ge). Available in English, French, Georgian, and Russian. Each module includes video lectures, annotated reading materials, facility-based case studies, and an end-of-module formative quiz. All modules are currently in development and will be released progressively.
Scope of the Monitor mandate; the independence requirement; operating as an internal vs external Monitor; reading the Standard; working with the self-assessment platform. ∼4 hrs
The accreditation calendar; what the Monitor reviews at each quarter; the annual virtual milestone; the 3-year in-facility renewal visit; documentation requirements. ∼4 hrs
How to read and rate evidence across all facility types; applying the Verified/Requires Evidence/Disputed classification; the 14-day response protocol; the 5-step dispute pathway; escalation to the ADC. ∼4 hrs
Structuring the annual Monitor Report; writing objective findings; tracing every rating to its evidence source; professional liability; common errors and how they are detected in re-verification. ∼4 hrs
Modules in development at GMJ Academy
In-Person Mentoring & Supervised Field Observation
Before sitting the examination, every applicant must complete a structured mentoring programme alongside a certified, active ASF Monitor. This requirement is modelled on ISQua EEA’s surveyor practicum requirement and Accreditation Canada’s preceptorship model.
- Mentoring sessions: minimum 3 structured sessions (each 60–90 minutes) with an assigned ASF-approved mentor Monitor; sessions may be conducted in-person or via video call
- Supervised field visit: attend and observe one complete in-facility verification alongside the mentor Monitor; the applicant reviews documents, observes the evidence-rating process, and completes a parallel shadow assessment that is reviewed and debriefed by the mentor
- Mentoring log: the applicant maintains a signed log of all sessions and the field visit, submitted to ASF as part of the examination application
- Mentor assignment: ASF assigns a mentor from the certified Monitor registry; applicants may also propose a mentor who must be approved by ASF
Certification Examination
- Online, proctored examination via GMJ Academy
- Minimum pass mark: 85% (aligned with ISQua EEA surveyor examination standards)
- Format: 60 scenario-based multiple-choice questions drawn from real anonymised facility self-assessments; applicants rate evidence, classify disputes, and write a short Monitor Report extract
- Two resit attempts permitted; a mandatory 30-day gap between attempts
- Third failure requires completion of an additional supervised field visit before re-applying
Credential Issued — AM-XXXXX
- Credential number format: AM-XXXXX (Accreditation Monitor), facility-type designation appended (e.g. AM-04821-H for hospital)
- Listed in the public ASF Monitor Registry with name, credential type, facility types, and status
- Valid for 2 years from date of issue
- Credential card issued as a verifiable PDF with QR code linking to the registry entry
Continuing Professional Development (CPD) & Renewal
ASF’s CPD and renewal framework is aligned with the maintenance-of-certification standards of ISQua EEA, Accreditation Canada, and the Joint Commission International (JCI). All requirements below apply to the standard 2-year renewal cycle.
(min. 4 hrs in core accreditation topics)
evidenced in the renewal application
briefing (mandatory, free)
| CPD Category | Accepted Activities | Max Hours Per Cycle |
|---|---|---|
| Core accreditation learning | ASF online modules; ISQua, JCI, or Accreditation Canada surveyor CPD courses; accreditation methodology workshops | 8 hrs (no cap) |
| Peer learning & mentoring | Serving as a mentor Monitor for a new applicant; structured peer review sessions with another certified Monitor | 4 hrs |
| Related professional development | Patient safety training; quality management (ISO 9001, ISO 15189); clinical audit; health system governance courses | 4 hrs |
| Conference & publication | Presenting at a healthcare quality or accreditation conference; publishing a peer-reviewed article on accreditation or quality improvement | 2 hrs |
Recertification Process
Renewal is not automatic. The Monitor submits a renewal application 60 days before credential expiry. ASF reviews the application and issues a decision within 30 days.
Submit Renewal Application
Application includes: (a) completed CPD log with supporting documentation; (b) evidence of at least 2 active Monitor assignments (facility names, dates, role); (c) signed self-declaration of compliance with ASF’s Conflict of Interest Policy; (d) any mandatory reporting of complaints, disputes, or sanctions during the cycle.
Re-examination (every 2nd renewal = every 4 years)
At every second renewal, certified Monitors must pass a refresher examination. Format: 30 scenario-based questions, minimum 80% pass mark. This aligns with Accreditation Canada’s periodic re-examination requirement for surveyors. Monitors who pass their annual Standards Update briefing in both preceding years receive a 5-point examination waiver credit.
Credential Renewed
A new 2-year credential card is issued with an updated registry entry. The credential number (AM-XXXXX) is permanent; the cycle number is appended (e.g. AM-04821-H/C2 for cycle 2).
Sanctions, Suspension & Revocation
| Trigger | Consequence | Reinstatement Route |
|---|---|---|
| Signing a false verification report | Immediate credential suspension; ADC investigation opened | Subject to ADC ruling; re-examination and additional supervised visit required |
| 3 or more significant discrepancies found in re-verification of a Monitor’s prior assessments | Suspension for the duration of the investigation | Retraining (MON-M03 and MON-M04); re-examination; mandatory new supervised visit |
| Confirmed falsification or deliberate misrepresentation | Revocation; 5-year exclusion from all ASF roles; publication on the public ASF registry | Not applicable during exclusion period |
| Undisclosed conflict of interest | Suspension; invalidation of the affected assessment cycle | Resolution of COI; ADC review; re-examination |
Career Pathway & Practice Scope
Monitor certification opens a structured professional practice. ASF publishes recommended day-rate bands and a standard service-contract template for external Monitors.
| Practice Scale | Facilities Served | Approximate Annual In-Person Days | Role Model |
|---|---|---|---|
| Part-time practice | 5–10 facilities | 10–20 days | Clinician or quality manager with Monitor as a secondary activity |
| Mixed practice | 10–20 facilities | 20–40 days | Quality consultant adding Monitor work to an existing portfolio |
| Full-time Monitor practice | 25–30 facilities | 50–60 days | Independent accreditation professional |
| Supervisor Monitor | Conducts annual ASF supervision visits across the Monitor network; requires 5+ years active experience | Variable | Senior quality professional; pathway to ASF Surveyor (SRV-01–03) |
Who Should Apply
Recommended Backgrounds
- Clinicians with 5+ years of practice and an interest in quality systems
- Hospital quality managers and patient safety officers
- Retired healthcare professionals seeking structured part-time work
- Public health professionals with direct facility experience
- Existing surveyors from other accreditation bodies (Accreditation Canada, JCI, ACHS, COHSASA) who want to operate in their own language and country
- Laboratory quality managers (for ASF ISO 15189 Ready facilities)
Minimum Requirements
- Healthcare or public health qualification at degree level or equivalent
- Direct experience working in or with a healthcare facility
- Proficiency in the language(s) of the facilities to be served
- No active employment or financial interest in any facility to be monitored
- Completion of ASF-00 Foundation module before application
- No requirement for a clinical (physician) background
Next Step in the Pathway: Surveyor (SRV-01–03)
- Experienced Monitors who also hold PSV-01 and CRD-01 are eligible to apply for the full ASF Surveyor certification (SRV-01–03)
- ASF Surveyors lead full accreditation surveys, write findings reports, and make accreditation recommendations to the ADC
- The Surveyor pathway is the highest ASF professional credential — aligned with ISQua EEA Lead Surveyor standards
Apply for Monitor Certification
To register interest, receive the application pack, or find an ASF-approved mentor Monitor in your country, contact the ASF Training Office at training@france-asf.fr. Applications are accepted year-round. Training is available in English, French, Georgian, and Russian through GMJ Academy.