VersionV3.0 ✓ Published
Effective date2026-09-30
Approved byProf. Giorgi Pkhakadze, MD, MPH, PhD — President, Accréditation Sans Frontières
Applies toAll ASF Lead Surveyors and Associate Surveyors — whether employed, contracted, or volunteering
Related documentsASF-GOV-003 · ASF-GOV-004 · ASF-GOV-005 · ASF-OPS-001 · ASF-OPS-009 · ASF-OPS-010
SupersedesASF-OPS-002 V2.0 (2026-11-23)
Next reviewSeptember 2031, or earlier on trigger
Version History
| Version | Date | Nature of change | Approved by |
|---|---|---|---|
| V0.1 | 2024-12-08 | Initial draft | — |
| V1.0 | 2025-02-01 | First published version | Accreditation Decision Committee |
| V2.0 | 2025-09-15 | 6-domain competency framework; Lead vs Associate eligibility formalised | Standards Development Committee |
| V3.0 | 2026-09-30 | Annual calibration (70% threshold); 6-trigger performance monitoring matrix; approved for ISQua EEA package | Prof. G. Pkhakadze, ASF President |
1. Purpose
This policy establishes the standards ASF applies to the selection, training, competency assurance, and performance management of all ASF surveyors — Lead Surveyors (Coordinators) and Associate Surveyors (Monitors). It defines the two roles, eligibility criteria, the competency framework, the selection and appointment process, the training pathway, and the performance monitoring system.
2. Two Surveyor Roles
2.1(a)Lead Surveyor (Coordinator) — senior member of the survey team; accountable for the overall quality and completeness of the assessment and the survey report; may lead surveys independently.
2.1(b)Associate Surveyor (Monitor) — conducts assigned assessment activities in their domain under the Lead Surveyor’s direction; may not lead surveys independently until meeting Lead requirements.
Every survey team must include at least one Lead Surveyor and one Associate Surveyor. Both roles carry identical obligations under ASF-GOV-003 (Impartiality) and ASF-GOV-004 (Confidentiality).
3. Eligibility Criteria
Lead Surveyor — minimum requirements
- (a) Recognised professional qualification in medicine, nursing, pharmacy, allied health, health management, or public health
- (b) Minimum 7 years post-qualification experience in healthcare delivery, quality management, regulation, or accreditation
- (c) Direct experience of healthcare quality assessment (internal audit, external inspection, accreditation survey, or regulatory inspection)
- (d) ASF Surveyor Training and Examination Programme completed with ≥75% pass mark
- (e) Minimum two supervised assessment activities as an Associate Surveyor with satisfactory written feedback
- (f) No undisclosed conflict of interest; meets all requirements of ASF-GOV-003
Associate Surveyor — minimum requirements
- (a) Recognised professional qualification in medicine, nursing, pharmacy, allied health, health management, or public health
- (b) Minimum 5 years post-qualification experience in healthcare delivery or quality management
- (c) Current expertise in at least one assessment domain specified in ASF-OPS-010
- (d) ASF Surveyor Training and Examination Programme completed with ≥75% pass mark
- (e) Meets all requirements of ASF-GOV-003
4. Competency Framework
All surveyors are assessed against six competency domains, applied equally to Lead and Associate roles:
| Competency domain | Description | Assessment method |
|---|---|---|
| Knowledge of ASF standards | Thorough understanding of the applicable standard: structure, chapter organisation, criteria classification, scoring methodology, and evidence base. | Written examination (75% pass mark); annual update briefing |
| Assessment and evidence skills | Ability to plan and conduct a systematic assessment using document review, staff interviews, and direct observation; to triangulate evidence and document nonconformances with precision. | Written examination; supervised assessment(s) |
| Report writing | Ability to produce a complete, accurate survey report with nonconformance descriptions that are factual, specific, and directly linked to the criterion not met. | Assessed in training module 3; ADC Chair report quality review |
| Professional conduct | Maintenance of confidentiality (ASF-GOV-004); impartiality and CoI management (ASF-GOV-003); professional demeanour; managing sensitive situations constructively. | Module 4 training; per-survey declaration; annual review |
| Clinical or management domain expertise | Demonstrated expertise in the specific domains assigned, as defined in ASF-OPS-010. | Credential verification; CV and references; domain allocation aligned to expertise |
| Facilitation and communication | Ability to conduct opening/closing conferences and communicate with facility staff respectfully and constructively. | Observed during supervised assessments; facility feedback |
The competency framework is applied at: (a) initial appointment; (b) annually through calibration exercise and update briefing; and (c) on trigger when a concern is identified.
5. Selection and Appointment
Candidates complete a formal written application covering qualifications, employment history, assessment experience, domain expertise, and a Declaration of Impartiality. Shortlisted candidates attend a structured interview with the SDC Chair or delegated assessor. Successful candidates receive a conditional appointment subject to completing the training programme, passing the examination at ≥75%, and satisfactory supervised assessments. Full appointment to the Surveyor Register is confirmed on the ASF President’s counter-signature of the Surveyor Engagement Agreement.
6. Training and Examination
6.1All newly appointed surveyors complete the ASF Surveyor Training and Examination Programme (ASF-OPS-009) — a four-module, four-day course — before any independent assessment activity.
6.2Minimum pass mark: 75%. One re-sit permitted, no earlier than 30 days after the first attempt. Failure on the second attempt: not eligible for active status; may reapply after ≥6 months further development.
6.4Annual update briefings required for all active surveyors. Non-attendance → inactive status until completed.
6.5Annual calibration exercise: all active surveyors independently assess a standardised scenario. Agreement rates analysed; significant divergence is discussed individually with the surveyor concerned.
7. Performance Monitoring
| Trigger | Review process | Possible outcomes |
|---|---|---|
| Routine — annual | Review of survey activity, calibration results, update briefing attendance | Status confirmed; development needs identified; or escalation |
| Complaint upheld against surveyor | Investigation per ASF-GOV-005; root cause analysis | Formal guidance; remedial training; suspension; or removal from register |
| Survey report quality concern (ADC) | ADC Chair discusses with surveyor; gap identified | Targeted guidance; supervised survey; or formal review |
| Calibration score below 70% agreement | Surveyor reviews calibration discussion; re-sits if required | Targeted training; or formal competency review |
| Inactivity — no survey in 24 months | Refresher module required before next assignment | Refresher completed → active reinstated; not completed → inactive |
| Formal competency review | Full review by SDC Chair: records, reports, feedback, calibration results | Cleared; performance improvement plan; suspension; or removal from register |
8. Surveyor Register and Removal
A surveyor is removed from the register on: voluntary resignation; failure to maintain active status within 6 months of the due date; formal competency review finding of incompetence; knowing breach of ASF-GOV-003 (permanent removal); serious confidentiality breach; or conduct inconsistent with ASF’s professional standards. Removal is communicated in writing with reasons; the surveyor may appeal under ASF-GOV-005 within 30 calendar days. A surveyor removed for inactivity may reapply after completing the refresher module.
9. ISQua EEA Alignment
This policy addresses ISQua EEA Principle 5 (Surveyors): a defined competency framework; eligibility-verified selection; a structured training and examination programme; annual performance monitoring with calibration; and a managed surveyor register. The ASF ISQua EEA Crosswalk (ASF-EV-004) maps these provisions to the applicable EEA criteria.
10. References
| [1] | ISQua IAP. Principles for Standards. 6th Ed. ISQua EEA, Dublin, 2023. |
| [2] | JCI Accreditation Standards for Hospitals. 7th Ed. JCI, Oak Brook, 2020. |
| [3] | Accreditation Canada. Qmentum: Surveyor Competency and Training Framework. Ottawa, 2022. |
| [4] | ACHS. EQuIP National Survey Assessor Standards and Training Framework. Sydney, 2018. |
| [5] | ISO/IEC 17021-1:2015 — Conformity Assessment. §7 Resource Requirements. ISO, Geneva, 2015. |
| [6] | ISO 19011:2018 — Guidelines for Auditing Management Systems. ISO, Geneva, 2018. |
| [7] | Greenfield D, Pawsey M, Braithwaite J. What motivates professionals to engage in accreditation? Int J Qual Health Care. 2011;23(1):8–14. |
| [8] | Greenfield D, Braithwaite J. Health sector accreditation research: a systematic review. Int J Qual Health Care. 2008;20(3):172–183. |
| [9] | Shaw CD et al. Profiling health-care accreditation organisations. Int J Qual Health Care. 2013;25(3):222–231. |
| [10] | HQACI. Surveyor Competency Policy. ISQua EEA Accredited Document, 2026. |
| [11] | WHO. Patient Safety Curriculum Guide: Multi-professional Edition. Geneva, 2011. |
| [12] | ISO/IEC 17011:2017 — Conformity Assessment: Requirements for Accreditation Bodies. §6.4. ISO, Geneva, 2017. |
Document code: ASF-OPS-002 · Version: V3.0 · Effective: 2026-09-30 · Next review: September 2031 ·
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ASF-OPS-002 — Surveyor Competency, Selection and Calibration · Version V3.0