Accreditation Monitor & Coordination Standard
Eligibility, the quarterly evidence cycle, independent verification, training and certification, and structural separation for ASF-certified Coordinators and Monitors
Foreword
ASF’s accreditation model is built around a quarterly evidence cycle, pairing two certified roles — an ASF Monitor who independently verifies, and a facility’s own Accreditation Coordinator who operates the cycle day-to-day — rather than a single end-of-cycle survey. This document formalises that paired model as a published standard, in the same format ASF applies to every organisational standard it publishes.
The reasoning is practical, not merely procedural. A facility that assembles its evidence only in the weeks before a fixed survey date concentrates the burden of demonstrating quality onto a short, high-pressure window — for the staff compiling the evidence, and for the continuity of care delivered while they do it. A quarterly cycle, in which evidence is gathered continuously and reviewed incrementally, distributes that burden across the year instead of concentrating it at the end. The Coordinator’s core function is exactly this: ongoing, quarterly evidence collection, not a last-minute compilation exercise.
This standard supersedes ASF-SURV-STD-v2 (Surveyor Training Standard), which was written for ASF’s earlier, surveyor-led operating model. It is governed by the same International Standards Council, the same three-year revision cycle, and the same methodology set out in How ASF Develops and Revises Standards. It is the fourth pillar of ASF’s accreditation architecture, alongside organisational standards, standards development itself, and continuing education.
About This Standard
Scope
This standard applies to every individual certified by ASF as an Accreditation Monitor or an Accreditation Coordinator, whether serving one facility (Internal) or multiple facilities (External), and to any organisation ASF authorises to deliver Coordinator or Monitor training on its behalf.
Structure
This standard is organised into seven domains, presented in pathway order — Monitor first, Coordinator second — reflecting ASF’s certification pathway, in which Monitor and Coordinator certification may be pursued together, with Surveyor certification (ASF Surveyor Standard) open only to those holding both plus direct facility experience:
- Domain A — Monitor Eligibility and Candidacy
- Domain B — Monitor Verification Requirements
- Domain C — Coordinator Eligibility and Candidacy
- Domain D — The Coordinator’s Quarterly Operating Cycle
- Domain E — Training, Examination and Certification
- Domain F — Structural Separation and Governance
- Domain G — Training Programme Governance
Domain A — Monitor Eligibility and Candidacy
Standard A1 — Monitor Profile
A Monitor candidate has direct healthcare facility experience — a clinician, hospital quality manager, patient safety officer, or public health professional — sufficient to recognise what genuine practice looks like, since the Monitor verifies practice, not documentation alone.
- Candidate CV confirming direct facility experience
Standard A2 — Internal and External Tracks, Rotation Limits
An Internal Monitor serves the employing facility only, for a maximum of 3 consecutive years before a 1-year gap. An External Monitor may serve any facility, any region, for a maximum of 5 consecutive years before a 1-year gap — the rotation limit exists so that familiarity with a facility never substitutes for independent verification.
- Per-Monitor assignment history confirming rotation limits observed
Standard A3 — Conflict of Interest at Candidacy
A Monitor cannot be the Coordinator for the same facility in the same or preceding cycle, cannot verify a department they manage, and — for External Monitors — cannot have any employment or financial relationship with the facility.
- A completed, reviewed Conflict of Interest Declaration confirming no Coordinator overlap
Domain B — Monitor Verification Requirements
Standard B1 — Annual Virtual Milestone Review
Once each year, the Monitor conducts a virtual milestone review — a document-review-plus-video-call session, approximately 2–3 hours, no travel required — against the facility’s cumulative quarterly evidence record. This confirms progress, flags emerging gaps early, and agrees the Coordinator’s next steps. It is deliberately not a full criterion-by-criterion sign-off and does not substitute for the Standard B3 full verification; its purpose is continuity and early warning, with minimum disruption to the facility and its director.
- A completed Annual Virtual Milestone Review record per facility per year
Standard B2 — On-Site Visit for Complex Cases
Where the quarterly record or the annual virtual review identifies a case genuinely requiring direct, in-person support — a disputed finding that cannot be resolved remotely, a facility struggling with a specific criterion, or an early signal of a possible Non-Negotiable gap — the Monitor, or a Surveyor where escalation applies, conducts a targeted on-site visit outside the regular cycle. This is need-triggered, not scheduled by default, and is distinct from the Standard B3 full verification.
- A documented trigger reason and visit record for every on-site visit called outside the regular cycle
Standard B3 — Full In-Facility Verification at Renewal
At the close of each 3-year accreditation cycle, the Monitor conducts a full in-facility verification, covering 100% of applicable criteria through physical inspection, lasting 1–3 working days depending on facility size and the applicable ASF standard. This, not the annual virtual review, is the complete assessment underpinning the accreditation award.
- A completed Full In-Facility Verification record confirming full criteria coverage, at each 3-year renewal
Standard B4 — Criterion Sign-Off
At the Standard B3 full verification, the Monitor signs off each criterion as Verified, Requires Evidence, or Disputed, against observable evidence — what actually exists, not the Coordinator’s description of it — informed by the cumulative quarterly and annual-review record built across the cycle. Each signature carries professional liability.
- A signed disposition for every criterion in scope
Standard B5 — Dispute Pathway
A Disputed finding enters the 5-step dispute pathway; if it cannot be resolved between Monitor and facility, the Monitor reports it to the ADC.
- A documented record of every dispute, its pathway steps, and its resolution or ADC referral
Standard B6 — Inter- and Intra-Monitor Reliability
ASF assesses whether different Monitors rate the same evidence consistently (inter-rater reliability) and whether an individual Monitor rates consistently across their own assignments over time (intra-rater reliability). At minimum once per 3-year cycle, a sample of completed Standard B3 full verifications is independently re-reviewed by a second Monitor or Surveyor against the same evidence file; any significant rating divergence is addressed through calibration discussion and, if a pattern emerges for one Monitor, feeds the Standard F2 performance review.
- Reliability sample record per cycle, with any calibration action taken
id=”domain-c” style=”font:700 1.45rem/1.25 Georgia,serif;color:#14335c;margin:2.2rem 0 .8rem;padding-top:.6rem;border-top:2px solid #c9a227″>Domain C — Coordinator Eligibility and Candidacy
Standard C1 — Coordinator Profile
An Internal Coordinator holds a role within the facility consistent with operating a quality-improvement function — typically a quality manager, senior nurse, or administrator. An External Coordinator is a quality consultant, retired clinician, or public health professional engaged under a service contract copied to ASF.
- Documented role or service contract confirming the Coordinator’s profile
Standard C2 — Scope Limits
An Internal Coordinator serves one facility only. An External Coordinator may serve multiple facilities, with any engagement beyond five facilities disclosed to ASF — consistent with the Small Facility Track, under which one External Coordinator may serve up to five small facilities.
- A current list of facilities served per Coordinator, disclosed to ASF where the Small Facility Track applies
Standard C3 — Conflict of Interest Screening at Candidacy
Every Coordinator candidate completes the same Conflict of Interest Declaration (Annex A of How ASF Develops and Revises Standards) required of Council and Panel candidates, before certification.
- A completed, reviewed declaration for every certified Coordinator
Domain D — The Coordinator’s Quarterly Operating Cycle
This is the domain the rest of this standard exists to protect. The Coordinator’s function is ongoing evidence collection across the year, not compilation under pressure before a single assessment date.
Standard D1 — Quarterly Reporting
The Coordinator operates the ASF self-assessment tool on the facility’s behalf, submitting a full report in Q1, incremental updates in Q2 and Q3, and a full report in Q4 — each criterion answered with a mandatory evidence declaration, not a narrative claim alone.
- Four submitted quarterly reports per cycle year, on the published schedule
Standard D2 — Evidence File Maintenance
The Coordinator maintains an organised, time-stamped evidence file throughout the year — the record the Monitor verifies against at the annual virtual milestone and the 3-year renewal verification — rather than reconstructing evidence retroactively at the point of verification.
- A continuously maintained, time-stamped evidence file, reviewable at any point in the cycle
Standard D3 — Improvement Plan
The Coordinator submits and tracks an Improvement Plan each quarter, giving the Accreditation Decision Committee (ADC) visibility into the facility’s trajectory, not only its current state.
- A quarterly Improvement Plan submission, with prior-quarter items tracked to resolution
Standard D4 — Response to Monitor Findings
Where the Monitor marks a criterion “Requires Evidence,” the Coordinator supplies it within 14 days. A Coordinator who cannot meet this window because evidence does not yet exist has identified a genuine gap the quarterly cycle is designed to surface early, rather than at a single year-end survey.
- A documented 14-day response record for every “Requires Evidence” finding
Domain E — Training, Examination and Certification
Standard E1 — Monitor Training and Certification
A Monitor candidate completes a single 16-hour core training course, covering verification methodology across all ASF facility types, observes one full in-facility verification (Standard B3) alongside a certified Monitor, and passes a proctored examination at a minimum 85% mark. Certification (AM-XXXXX) is valid 2 years, listed in the public registry, and renewed every 2 years through 8 CPD hours, evidence of at least 2 active assignments, and re-examination.
- Training, supervised-observation, examination and renewal records; current registry listing
Every certified Monitor receives a reference guide covering verification methodology, the criterion sign-off framework, and common scenarios, to support consistent performance in the field. On certification, a Monitor completes a short orientation into practical allocation — how assignments are allocated, expense claim process, travel logistics for in-facility verification, and performance expectations — before their first independent assignment. Annual surveyor-capacity planning (projected facility caseload against certified Monitor numbers and skill mix) is conducted by the Secretariat and reported to the Council alongside the operating plan (ASF-POL-50).
Standard E2 — Coordinator Training and Certification
A Coordinator candidate completes a single 8-hour core training course, covering the Coordinator role and evidence-collection method across all ASF facility types, delivered online in the national language via GMJ Academy (EN / KA), and passes a proctored examination at a minimum 80% mark. Certification (AC-XXXXX) is valid 1 year, listed in the public registry, and renewed annually through CPD hours plus re-examination.
- Training completion and examination records; current registry listing
Standard E3 — Training Programme Accreditation
The training programmes themselves — delivered via GMJ Academy, ASF’s training platform partner — are accredited by the ASF International Standards Council, reviewed on the same three-year cycle as ASF’s published standards.
- Current Council decision accrediting both training programmes
Domain F — Structural Separation and Governance
Standard F1 — No Dual Roles
A Coordinator cannot be the Monitor for the same facility in the same or preceding cycle. The Coordinator cannot influence Monitor selection. Both are engaged under separate contracts, each copied to ASF — the first line of defence against gaming the system. Every Monitor and Coordinator contract states: responsibilities and expectations; remuneration and expense-reimbursement terms; the period of appointment and required availability; confidentiality and independence obligations; the Conflict of Interest Declaration (Standards A3/C3); and that performance review follows Standard F2.
- Separate, ASF-held contracts for Coordinator and Monitor at every facility
Standard F2 — Professional Liability
A Monitor with 3 significant discrepancies identified at re-verification has their credential suspended. Confirmed falsification of a verification report results in credential revocation, a 5-year exclusion, and publication on the ASF registry.
- A documented disciplinary record for every suspension or revocation
Standard F3 — External Review
The Coordinator and Monitor certification programmes are included within the external review of the Council’s own practice required under Section 7.5 of How ASF Develops and Revises Standards — the same reasoning ASF applies to every organisation and programme it accredits, applied without exception to its own certification programmes.
- Documentation confirming inclusion in the most recent Section 7.5 external review
Domain G — Training Programme Governance
Domains A–F govern individual Coordinators and Monitors. This domain governs the training programme itself as an institution — its planning, trainer quality, trainee management, delivery methodology, and assessment governance — verified criterion-by-criterion against ISQua EEA’s Guidelines and Standards for Surveyor Training Programmes, 4th Edition (March 2022), Standards 1–5.
Standard G1 — Programme Objectives, Planning and Risk
The International Standards Council sets and documents the objectives for the Coordinator and Monitor training programmes each year, as part of Standard E3 accreditation review (number of candidates per cohort, training timeframe, delivery format), and a delivery plan covering training type (initial/ongoing/specialist), planned activities and number of training events per type, required resources (trainer time, GMJ Academy platform capacity, exam proctoring), and timeframes, approved by the International Standards Council as part of Standard E3 accreditation. The programme is confirmed, before each delivery, to meet legal and ethical requirements including intellectual property and copyright in training materials, acknowledgement of sources, conflict of interest (Standards A3/C3), and candidate confidentiality agreements. A risk register specific to the training programme covers delivery (platform failure, trainer unavailability), assessment (exam security, proctoring failure), contracted services (GMJ Academy as delivery partner), and intellectual property (unauthorised reproduction of exam content), reviewed on the same cycle as ASF-POL-17.
- Documented training programme objectives; training-programme risk register, cross-referenced to ASF-POL-17
Standard G2 — Coordinator and Monitor Competency Framework
Defined, documented competencies for each role — knowledge (ASF standards and verification methodology), skills (evidence review, time management, analytical judgement), behaviours (set out in ASF-POL-31, Code of Conduct and Ethics), and experience — are published to candidates before training begins and form the direct basis of curriculum design under Standard E1/E2. Eligibility for Continuing Professional Development (CPD) point recognition from relevant professional bodies is assessed and documented at programme accreditation.
- Published competency framework per role; CPD-eligibility determination on file
Standard G3 — Trainer Selection, Evaluation and Development
Programme administration — candidate enrolment, scheduling, and records management — is managed by the ASF Secretariat under ASF-POL-40, while individuals delivering Coordinator or Monitor training are selected for a balance of adult-learning experience and ASF subject-matter expertise (senior Monitors, Surveyors, or Secretariat staff with standards-development background). Trainer performance is evaluated after each cohort using trainee feedback, and trainers receive their own development support, including access to train-the-trainer resources. Authority to approve each training programme before delivery, and to decide a candidate’s progression at each stage (training completion, examination, and — for Monitors — supervised observation), sits with the International Standards Council under Standard E3, exercised in practice by the Secretariat role designated under ASF-POL-32 (Delegation of Authority and Signatures).
- Trainer selection records; post-cohort trainer evaluation; trainer development records
Standard G4 — Equal Opportunity and Trainee Accommodation
Training design and delivery provides equal opportunity to participate throughout — not only at examination — with reasonable adjustments made for candidates’ physical, sensory, or language needs in accessing training sessions, materials, and the proctored examination, per ASF-POL-20 applied specifically to the training programme.
- Accommodation requests and responses on file for every candidate who raises one
Standard G5 — Learning Resources and Programme Evaluation
Learning materials, the GMJ Academy platform, and technological resources are evaluated at least annually to confirm they meet trainer and trainee needs. Feedback is collected from both trainees and trainers after each individual training session (not only at programme completion), analysed, and used to identify and plan improvements to that session specifically. Collated programme effectiveness is evaluated separately, using completion rates, exam pass rates, and the aggregated session-level feedback, with results feeding changes to curriculum or delivery — reviewed by the International Standards Council alongside the Standard E3 three-year accreditation cycle.
- Annual resource evaluation; programme-effectiveness report with resulting changes documented
Standard G6 — Information for Trainees
Before training begins, every candidate receives: participation requirements (duration, mode of delivery — online via GMJ Academy — IT requirements, and any costs); the trainee’s own rights and responsibilities, and separately ASF’s rights and responsibilities as the training provider (both under ASF-POL-31); assessment arrangements (pass mark, format); expected programme outcomes (Standard G2 competencies); and CPD-point eligibility (Standard G2).
- Candidate information pack, issued and acknowledged before training start
Standard G7 — Trainee Records
A trainee record is created on acceptance into training, with informed consent, covering personal data, recognition of prior learning, attendance, assessment completion and results, and overall outcome. Records are managed under Data Protection, IT and Cybersecurity (ASF-POL-18) and Records Management and Retention (ASF-POL-40): confidential, accessible to the trainee on request, and retained per the certification-cycle-plus-3-years schedule already published in ASF-POL-40.
- Consented trainee record for every candidate, held per ASF-POL-18/ASF-POL-40
Standard G8 — Trainee Complaints
Trainees are informed of the complaints channel under Feedback, Complaints and Incident Management (ASF-POL-21) before training begins, with complaints about the training programme specifically acknowledged within 3 working days and resolved within 15 working days, the same timeline ASF-POL-21 already sets.
- Complaints channel stated in the candidate information pack (Standard G6)
Standard G9 — Curriculum Content and Practical Element
Both curricula cover: planning and preparation, conducting verification, report writing, and post-verification activities (quality assurance review of the verification record, and any follow-up with the facility on outstanding Requires Evidence findings) — Coordinator: evidence-file preparation; Monitor: annual virtual milestone and 3-year full verification, dispute handling, and ADC submission follow-up; standards interpretation and applicable legal requirements; interpersonal skills, negotiating skills, and professional practice (ASF-POL-31); and diversity and equity in the local setting, including how these concepts are addressed in ASF’s own standards and assessed in practice. Both tracks include a practical onsite element: Monitor candidates observe one full in-facility verification at renewal, Standard B3 (already required under Standard E1); Coordinator candidates now likewise shadow one quarterly evidence-review cycle at a live facility before independent practice, closing the gap between the two tracks.
- Curriculum map covering all listed content areas; shadowing record for every Coordinator candidate
Standard G10 — Update Training
Annual mandatory refresher training for certified Coordinators and Monitors is based on identified training needs (drawn from Standard G5 evaluation data, dispute-pathway patterns, and Monitor re-verification findings under Standard F2) and includes updates on any relevant legal or standards changes since the previous cycle.
- Annual refresher training record for every active Coordinator and Monitor
Standard G11 — Learning Objectives and Adult-Learning Methodology
Each training session has defined learning objectives and expected outcomes, tied to the Standard G2 competency framework. Delivery uses adult-learning methods appropriate to each topic — case studies drawn from ASF’s own Field Testing Record, role play including full mock verification exercises and dispute-handling/difficult-conversation scenarios, problem-based exercises using real (anonymised) evidence files, and self-reflection for ongoing/refresher training once a candidate has field experience.
- Session-level learning objectives; curriculum showing methods used per topic
Standard G12 — Assessment Plan and Results
Each assessed training session has a defined assessment task, scoring criteria, and required resources, set out in an assessment plan. A documented assessment procedure governs how performance is marked, recorded in the candidate’s trainee record (Standard G7), and escalated if performance is poor — including whether a candidate may retake a specific session exercise before the final examination. Results are issued to candidates in writing, stating their score against the published pass mark (80% Coordinator, 85% Monitor). A candidate unable to complete training due to illness or unforeseen circumstances, or who does not meet the pass mark, may request rescheduling or one re-sit per cycle; arrangements are documented per candidate. Collated results are reviewed after each cohort to confirm the programme’s learning objectives were met, feeding Standard G5.
- Assessment plan per session; written results per candidate; post-cohort results review
References
- ISQua External Evaluation Association. Guidelines and Standards for Surveyor Training Programmes, 4th Edition, Version 1.0. Geneva: ISQua EEA; March 2022.
- ISQua External Evaluation Association. Guidelines and Standards for External Evaluation Organisations, 5th Edition, Version 1.1. Geneva: ISQua EEA; March 2022.
- International Organization for Standardization. ISO 21001:2018, Educational Organizations — Management Systems for Educational Organizations — Requirements with Guidance for Use. Geneva: ISO; 2018.
- International Organization for Standardization/International Electrotechnical Commission. ISO/IEC 17024:2012, Conformity Assessment — General Requirements for Bodies Operating Certification of Persons. Geneva: ISO/IEC; 2012.
| Document Reference | ASF-MON-STD-v1.1 |
| Status | Published — v1.1 |
| Date of Publication | 5 October 2026 |
| Next Scheduled Review | 5 October 2029 |
| Supersedes | ASF-SURV-STD-v2 |