Coordinator & Monitor Handbook
The formal working reference for the two certified roles at the heart of the ASF quarterly cycle: qualifications, ethics, report-writing method, appeals, and renewal — free, public, and downloadable in full.
Document code ASF-QEM-001-01. Issued by the ASF Board on behalf of the Standards & Accreditation Committee. This handbook is a companion to, not a replacement for, the ASF Standards and the 47 institutional policies — where the two appear to conflict, the policy governs.
2.0 The Two Roles, Side by Side
3.0 Qualifications and Required Competencies
4.0 Ethics
5.0 Code of Good Practice
6.0 Writing a Verification Report
7.0 The No-Gift Rule
8.0 The Cycle: What Happens When
9.0 The Dispute Pathway — Findings
10.0 Appeals — Certification Decisions About You
11.0 Renewal, Leave, and Resignation
12.0 Records ASF Keeps About You
1.0 Philosophy
ASF’s verification model rests on one idea: a Monitor is a critical friend, not a judge. Verification confirms the facility’s own self-assessment and widens its view of where it can still improve — it does not exist to catch anyone out. A finding of Requires Evidence or Disputed is encouragement to close a real gap, never a verdict of failure. This does not soften the standard — a Non-Negotiable criterion that fails is still a failure. What it changes is tone: a Monitor who embodies this philosophy gets more honest self-disclosure from facility staff than one who arrives as an inspector, and a more honest disclosure is a safer facility.
2.0 The Two Roles, Side by Side
| Coordinator | Monitor | |
|---|---|---|
| Job in one line | Runs the self-assessment and evidence file | Independently verifies it is true |
| Reports to | The facility | ASF, via the ADC |
| Minimum age | No formal minimum; relevant qualification required | 30, reflecting the judgement verification requires |
| Time (Internal) | 25–35 hours/year, one facility | 1 day/year, one facility (Q4) |
| Time (External) | 25–35 hours/facility/year | 2 days/facility/year (Q2 online + Q4 on-site) |
| Max consecutive years | No limit stated | 3 (Internal) / 5 (External), then a 1-year gap |
3.0 Qualifications and Required Competencies
Minimum qualifications: a health science, public health, or relevant management qualification, or 5+ years’ operational experience in a healthcare facility; demonstrated quality-improvement experience running (not just observing) a quality system; current working knowledge of applicable health regulations; no disciplinary finding, relevant criminal conviction, or unresolved conflict-of-interest declaration.
| Core competency (both roles) | What it means in practice |
|---|---|
| Standards knowledge | Can explain the intent behind a criterion, not just quote its wording |
| Data collection & analysis | Draws on document review, observation, and interview together |
| Communication | Explains a finding in language a night-shift nurse and a director would both understand |
| Report writing | Concise, evidenced, actionable, on time |
| Adaptability | Works effectively across facilities of very different size and resourcing |
| Independent judgement (Monitor only) | Reaches a conclusion that would not change under pressure |
| Conflict management (Monitor only) | Delivers a difficult finding without it becoming personal |
4.0 Ethics
Confidentiality: keep everything learned about a facility confidential beyond the official report. No photos, audio, or video without written facility consent for a specific purpose. No document or sample removed for personal use. Destroy or return facility documents once the cycle’s decision is issued.
Conflict of interest: never use the role for personal advantage. No gift, hospitality, or benefit that could be seen to influence a finding. A Monitor may not verify a facility where they’ve provided paid consultancy or clinical service within the preceding 2 years. No request for any convenience beyond what ASF has already arranged. Disclose any conflict before accepting an assignment, and reconfirm at least annually even if nothing has changed.
Other obligations: respect the rights and dignity of everyone involved; never imply a facility will be certified before ASF’s official decision is published.
5.0 Code of Good Practice
- Review the self-assessment in advance; arrive with key questions already identified.
- Ask only for what’s genuinely needed — don’t pad a request out of habit.
- Never compare one facility’s performance to another’s by name.
- Never ask a patient about their care experience in public or in front of the staff who provided it.
- Connect every question back to what it means for patient care.
- Use plain language; combine observation with questioning.
- Give feedback specific enough to act on, but let the facility choose its own method wherever more than one reasonable solution exists.
6.0 Writing a Verification Report
GER, for every finding: Gist (the point, in one sentence) → Example (1–2 concrete examples) → Result/Relevancy (the outcome, or the impact if left unaddressed).
ADR, for commending good practice: Approach (what was done) → Deployment (how far it reaches) → Result (the measurable outcome).
Worked example: “The facility restructured its medication double-check process to require a second qualified nurse’s signature before any high-alert medication is administered (Approach). This applies across every inpatient unit, including the ICU (Deployment). Reported medication errors involving high-alert drugs fell from 4 per quarter to 0 in the two quarters since introduction (Result).”
Finish the report as close to the visit’s end as possible. Use positive, constructive language — state the goal, not a prescribed method, unless the criterion specifies one. A finding’s score and its written justification must always agree.
7.0 The No-Gift Rule at a Site Visit
- No gifts however small, no hospitality beyond a working lunch, no travel upgrades, no cash beyond the agreed day-rate and documented travel.
- A Monitor offered any of this declines it, notes it in the report regardless, and reports pressure to the Ethics Focal Point immediately.
8.0 The Cycle: What Happens When
Q1 Full self-assessment with mandatory evidence. Q2 Online verification, document review + video call, 3–4 hours. Q3 Update to self-assessment and Improvement Plan. Q4 Full in-facility verification, a working day, 100% criteria coverage — the quarter the annual decision is built on.
9.0 The Dispute Pathway — Findings
Requires Evidence and Disputed findings are the process working, not failing: Monitor documents the gap → Coordinator has 14 days to respond → if resolved, both sign off → if not, Monitor escalates to ASF → the ADC makes the final call.
10.0 Appeals — Certification Decisions About You
Different from Section 9 — this applies if you are personally refused certification, refused renewal, or suspended. Written appeal within 30 days → a 3-person Appeals Panel (a Board member as chair, a senior Coordinator/Monitor, the Ethics Focal Point as non-voting secretary) → 30 days to decide, extendable once by 30 more with written reasons → written decision within 15 days. The Board Chair’s decision on the appeal is final.
11.0 Renewal, Leave, and Resignation
Renewed annually: at least one completed assignment in the prior year, no unresolved ethics finding, satisfactory dispute record. Illness or emergency before a scheduled visit: notify ASF immediately so a replacement can be arranged. Extended absence: certification is placed on hold, not lapsed, and reactivates on return. Resignation: at least 30 days’ written notice.
12.0 Records ASF Keeps About You
Contact and qualification details, credential ID, a record of every assignment and dispute, training and renewal history, and any ethics disclosure on file — handled under Policy 16 (Data Protection and Privacy). You may request your own record at any time.
Download Full Handbook (PDF)
Coordinator Certification
Monitor Certification
