VersionV3.0 ✓ Published
Effective date2026-09-30
Approved byProf. Giorgi Pkhakadze, MD, MPH, PhD — President, Accréditation Sans Frontières
Next reviewSeptember 2031
V3.0 — Lead and Associate Surveyor full role specifications with eligibility, pre-survey/during-survey/post-survey responsibilities; 6-row team composition matrix; domain allocation rules; 5-question CoI screening; conduct requirements (objectivity, neutrality, confidentiality, boundaries); 10 references
1. Purpose
This document specifies the roles, responsibilities, eligibility conditions, and conduct requirements for ASF’s two surveyor grades: Lead Surveyor and Associate Surveyor. Where a survey involves a single surveyor only, that surveyor is designated Lead and assumes all responsibilities in both specifications.
2. Lead Surveyor
Eligibility
Current ASF Surveyor Authorisation at Lead grade; ≥7 years professional experience in healthcare management, clinical quality, or regulation (≥3 years at senior level); ≥2 supervised assessments at Lead grade; most recent calibration exercise at or above 70% threshold; not under active performance monitoring or supervised status.
Pre-survey
Reviews application documentation; prepares survey plan with domain allocations; completes CoI screening and Declaration of Impartiality (submitted ≥5 working days before survey); briefs Associate Surveyor(s); confirms logistics with facility; confirms interpretation arrangements.
During survey
Conducts opening meeting; coordinates team; conducts own domain assessments; reviews Associate Surveyor findings at checkpoints; manages on-site issues; conducts closing meeting presenting preliminary findings and inviting factual corrections (not assessment challenges).
Post-survey
Produces survey report within 15 working days; submits to QMS Coordinator for quality review (issues addressed within 5 further working days); does not communicate findings to the facility or influence ADC deliberations.
3. Associate Surveyor
Eligibility
Current ASF Surveyor Authorisation at Associate grade; ≥5 years professional experience; most recent calibration exercise at or above 70% threshold; not under active performance monitoring or supervised status.
Responsibilities
Conducts allocated domain assessments; gathers evidence using the same methods and recording standards as the Lead Surveyor; reports findings at checkpoints; contributes to closing meeting at Lead Surveyor’s direction; submits domain findings within 3 working days of the survey. Associates with ≥3 completed surveys may supervise a candidate’s first supervised assessment.
4. Survey Team Composition
Ambulatory/small (≤50 beds): 1–2 total (Lead + 0–1 Associate). Hospital/medium (51–200 beds): 2 total (1+1). Hospital/large (>200 beds): 3 total (1+2). LTC any size: 1–2. Fitness and Wellness: 1 (Lead only). Mid-term/surveillance: 1 (Lead only). For specialist clinical areas, a subject-matter specialist may accompany the team in an advisory role only — they do not independently assess criteria or contribute to the report.
5. Domain Allocation
All criteria in scope must be allocated to a named surveyor. Critical criteria are reviewed by the Lead Surveyor personally, unless explicitly delegated with a written justification in the survey plan. No surveyor may be allocated more domains than can be assessed rigorously within the available time. Domains with a potential CoI are re-allocated.
6. Conflict of Interest Screening
Before every survey, each surveyor answers 5 screening questions: (a) worked for or consulted to the facility in the past 36 months? (b) personal or family relationship with facility leadership? (c) financial interest in the facility? (d) quality improvement consultancy at the facility in the past 36 months? (e) any other circumstance affecting impartiality? A ‘yes’ answer is disclosed immediately to the QMS Coordinator, who determines whether the conflict is manageable (domain reallocation) or requires surveyor replacement. No surveyor may commence a survey without a completed Declaration of Impartiality on file.
7. Conduct Standards
Objectivity (findings based on evidence, not impressions); neutrality (no opinions on management or culture); confidentiality (no disclosure outside team/ASF office); boundaries (no consultancy advice during the survey — refer to CAP); professional demeanour (courtesy, punctuality, consistent with ASF’s professional standing).
8. ISQua EEA Alignment
Supports ISQua EEA Principle 5 (Surveyors) in full — role definition, eligibility, responsibilities, team composition, CoI management, and conduct. The ASF ISQua EEA Crosswalk (ASF-EV-004) maps these provisions to the applicable EEA criteria.
Document code: ASF-OPS-010 · Version: V3.0 · Effective: 2026-09-30 ·
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ASF-OPS-010 — Surveyor Role Specifications · Version V3.0