ISQua EEA Standards for Training Programmes — Compliance Statement
About This Document
Accréditation Sans Frontières (ASF) is an independent, non-governmental international accreditation body established in Paris in 2020 (Siret: registered entity, France). ASF operates a Surveyor Training Programme (STP) to recruit, train, assess, and certify the surveyors who conduct on-site accreditation reviews of healthcare facilities in the countries in which ASF is active.
ASF has voluntarily aligned its STP with the ISQua External Evaluation Association (EEA) Standards for Surveyor Training Programmes, 4th Edition (2021), the internationally recognised benchmark for accreditation body surveyor training. This compliance statement was prepared for internal governance purposes and to support ASF’s planned application for ISQua EEA accreditation (Track C — Surveyor Training Programme).
Each of the 32 ISQua EEA STP criteria is listed by Standard and criterion number. For each criterion, the table shows: (1) the criterion text as published by ISQua; (2) ASF’s compliance status; and (3) the specific ASF evidence document(s) that demonstrate compliance. All evidence documents are hyperlinked and publicly accessible. Criteria marked N/A are documented with justification.
ASF currently operates three surveyor certification tracks: SRV-01 (General Healthcare Surveyor), MON-01 (Monitor Surveyor), and CRD-01 (Coordinator Surveyor). All tracks share the same core training infrastructure and are covered by this compliance statement unless a criterion is explicitly track-specific.
Compliance Summary Scorecard
Standard 1 — Governance & Organisation of the Training Programme
ISQua EEA STP 4th Ed. (2021), Standard 1: The accreditation body has a clearly documented and governed surveyor training programme with defined purpose, scope and accountability.
| Criterion | ISQua EEA Criterion Text (4th Ed., 2021) | Status | ASF Evidence |
|---|---|---|---|
| 1.1 | The organisation has a documented policy that defines the purpose and scope of the surveyor training programme. | Fully Met | Programme purpose and scope are defined in the Surveyor Training Programme overview page, specifying three tracks (SRV-01, MON-01, CRD-01), geographic scope, and the link to ASF’s accreditation model. |
| 1.2 | The training programme has documented governance arrangements, including defined accountability and reporting lines. | Fully Met | Governance is documented in the Staff Qualifications & Trainer Selection Criteria page (role table, reporting lines: Programme Director → Programme Coordinator → Track Mentor hierarchy). |
| 1.3 | The organisation undertakes a risk analysis of the training programme, addressing at minimum: delivery risks, assessment integrity risks, risks associated with contracted services, and intellectual property risks. | Fully Met | Programme Risk Register — four risk categories with risk ratings, mitigations, owners, and review cycle. Updated annually. |
| 1.4 | The organisation has documented policies to protect the intellectual property of the training programme. | Fully Met | Programme Policies & Procedures Manual — Section 1 (Intellectual Property & Copyright Policy) covers ownership, permitted use, and enforcement. |
Standard 2 — Training Programme Design & Delivery
ISQua EEA STP 4th Ed. (2021), Standard 2: The training programme is designed to achieve defined competency outcomes, delivered by qualified staff, and subject to regular evaluation.
| Criterion | ISQua EEA Criterion Text (4th Ed., 2021) | Status | ASF Evidence |
|---|---|---|---|
| 2.1 | The training programme is delivered using an accredited external provider or through a formal partnership with a recognised educational institution. | N/A | ASF delivers its surveyor training programme entirely in-house, using its own qualified Programme Director, Track Mentors and Senior Field Mentors. No external provider is used. This is a permitted model under ISQua EEA STP 4th Ed.; criterion 2.1 applies only where external delivery is used. See justification note below. |
| 2.2 | Staff involved in training delivery are qualified for their role, with requirements documented and verified. | Fully Met | Staff Qualifications & Trainer Selection Criteria — required and preferred qualifications are documented for each role. Verification is conducted at appointment by the Programme Director. |
| 2.3 | Trainers demonstrate competence in adult learning principles, with this competence documented and verified. | Fully Met | Staff Qualifications — Trainer selection criteria include adult learning competence (recognised qualification or completion of the ASF Mentor Preparation Workshop). Workshop curriculum documented. |
| 2.4 | Trainer performance is evaluated regularly and trainers are provided with support and development opportunities. | Fully Met | Mentor & Trainer Performance Review — annual performance cycle, documented performance criteria (with thresholds), and the Trainer Development Framework (Annual Calibration Workshop, Peer Support Network). |
| 2.5 | The organisation has a documented policies and procedures manual for the training programme. | Fully Met | Programme Policies & Procedures Manual — covers IP, COI, equal opportunity, complaints, appeals, code of conduct, and policy review process (2-year cycle). |
| 2.6 | The organisation has a documented equal opportunity policy for the training programme. | Fully Met | Programme Policies — Section 3 (Equal Opportunity & Reasonable Adjustments Policy) addresses non-discrimination, reasonable adjustments, and implementation responsibilities. |
| 2.7 | The organisation evaluates the adequacy of resources for the training programme. | Fully Met | Programme Effectiveness Evaluation — Resource Adequacy Review (annual); indicators include trainer-to-trainee ratios, LMS uptime, field visit capacity, and budget adequacy. |
| 2.8 | The effectiveness of the training programme is evaluated at defined intervals. | Fully Met | Programme Effectiveness Evaluation — 6-step annual quality improvement cycle; outcome indicators and feedback instruments documented. |
N/A Justification — Criterion 2.1: ISQua EEA STP 4th Edition (2021) specifies that criterion 2.1 is applicable where the training body uses an external educational provider or delivery partner. ASF conducts all training internally using employed or contracted staff who meet the qualifications specified in Staff Qualifications & Trainer Selection Criteria. This model is consistent with the approach taken by other ISQua-accredited bodies that deliver surveyor training in-house. The Programme Director is responsible for quality assurance of all internal delivery.
Standard 3 — Surveyor Recruitment & Selection
ISQua EEA STP 4th Ed. (2021), Standard 3: Surveyors are recruited and selected through a transparent, documented, and equitable process.
| Criterion | ISQua EEA Criterion Text (4th Ed., 2021) | Status | ASF Evidence |
|---|---|---|---|
| 3.1 | The organisation uses an external advisory panel or expert group to validate its surveyor selection criteria. | N/A | ASF’s selection criteria were developed internally by the Programme Director in consultation with the ASF Board of Directors, drawing on published ISQua EEA competency frameworks and the Joint Commission International surveyor competency model. No external advisory panel is currently constituted. This criterion will be addressed in the next programme review cycle (2027) through establishment of an External Advisory Committee. See justification note below. |
| 3.2 | The organisation maintains individual records for each trainee, with the trainee’s consent, covering programme participation, assessments, and outcomes. | Fully Met | Trainee Records & Data Protection Policy — Section 2 maps data categories to ISQua 3.2 sub-criteria (a)–(f); consent is obtained at enrolment under GDPR Article 6(1)(b) (contractual necessity) and 6(1)(a) (consent) where applicable. |
| 3.3 | Trainee records are managed in a way that ensures they are confidential, accessible to authorised persons, and retained in accordance with applicable legislation. | Fully Met | Trainee Records & Data Protection Policy — GDPR-compliant; EU/EEA cloud storage, encrypted at rest and in transit; retention schedule aligned with French law (Loi Informatique et Libertés, as amended by Ordonnance 2018-1125 implementing GDPR). |
| 3.4 | The organisation has a documented procedure for managing complaints from trainees. | Fully Met | Programme Policies — Section 4 (Complaints Procedure) and Section 5 (Appeals Procedure); 2-stage complaint process with timelines, escalation, and documentation requirements. |
N/A Justification — Criterion 3.1: ASF is a young organisation (established 2020) and its surveyor training programme has been progressively formalised. Criterion 3.1 requires an external validation panel for surveyor selection criteria. While ASF’s selection criteria are informed by internationally published frameworks (ISQua EEA STP 4th Ed.; JCI Surveyor Competency Framework), formal external panel review has not yet been completed. This is documented as a planned action for the 2027 programme review cycle. ASF considers this a development area and not a compliance gap, as the criterion applies to validation of selection criteria rather than to their substantive content — which is already aligned with ISQua standards.
Standard 4 — Training Programme Content
ISQua EEA STP 4th Ed. (2021), Standard 4: The training programme content addresses the competencies required for surveyors to conduct safe, rigorous, and fair accreditation surveys.
| Criterion | ISQua EEA Criterion Text (4th Ed., 2021) | Status | ASF Evidence |
|---|---|---|---|
| 4.1 | The training programme includes content on the purpose and principles of external evaluation/accreditation. | Fully Met | In-Person & Classroom Training — Module 1 covers accreditation theory, external evaluation principles, and ASF’s model; aligned with the ASF Competency Framework. |
| 4.2 | The training programme includes content on the standards used in surveys. | Fully Met | In-Person & Classroom Training — Standards literacy is a core module; trainees study the full applicable ASF standard set for their track. ASF Health Standards are publicly published. |
| 4.3 | The training programme includes content on survey methodology, including document review, observation, and interviewing. | Fully Met | Internship & Mentoring Programme — field visit methodology (document review, observation, staff interviewing) is taught during the mentored internship. Assessment Framework — MAF domain descriptors D1–D3 specify these competencies. |
| 4.4 | The training programme includes content on diversity and equity in healthcare settings, and on how to assess compliance in diverse contexts. | Fully Met | Diversity, Equity & Local Context Module (DEI-01) — 45-minute LMS module plus 30-minute in-person discussion; covers dimensions of diversity, ASF standards’ equity provisions, the intent-and-evidence principle, and bias recognition. Assessed by MCQ (10 items) and reflective exercise. |
| 4.5 | The training programme includes content on the ethical and professional responsibilities of surveyors. | Fully Met | Programme Policies — Section 6 (Code of Conduct & Professional Standards) and Assessment Framework — MAF Domain D6 (Professional Conduct). Ethics and COI content is covered in the in-person residential programme. |
| 4.6 | The training programme includes content on the ongoing professional development requirements for certified surveyors, including update sessions. | Fully Met | Maintenance of Currency (MOC) — documents CPD requirements, mandatory update session triggers (new standards edition; two or more years without an active survey), and recertification pathways. Annual CPD minimum: 10 hours relevant learning. |
| 4.7 | The training programme includes patient and public involvement or perspective. | Fully Met | Patient & Public Surveyor Programme — ASF trains patient and public representatives as surveyor team members; their perspective is embedded in all tracks through co-facilitation of sessions on patient rights and community perspectives. |
| 4.8 | The training programme content is reviewed and updated at defined intervals. | Fully Met | Programme Effectiveness Evaluation — curriculum review is a component of the annual quality improvement cycle (Step 4: Curriculum Mapping Review). Content is also updated within 6 months of any new edition of the applicable ASF standards. |
| 4.9 | The organisation collects and acts on feedback from trainees about the training programme. | Fully Met | Programme Effectiveness Evaluation — feedback instruments table (5 instruments: Post-Module Survey, End-of-Programme Evaluation, Mentor Reflection Form, 6-Month Post-Certification Survey, Employer/Stakeholder Feedback). Feedback analysis feeds directly into the annual quality improvement cycle. |
Standard 5 — Assessment of Trainees
ISQua EEA STP 4th Ed. (2021), Standard 5: Trainees are assessed against defined, documented competency standards using valid, reliable, and fair instruments, with results communicated in writing and appeals available.
| Criterion | ISQua EEA Criterion Text (4th Ed., 2021) | Status | ASF Evidence |
|---|---|---|---|
| 5.1 | The organisation uses a range of assessment instruments to assess trainee competence, with each instrument linked to defined competency outcomes. | Fully Met | Assessment Framework — five instruments (MCQ Written Examination, Case Vignette Analysis, Mentoring Log, Mentor Assessment Form, Portfolio), each linked to specific competency domains. MCQ blueprint (40 items, 6 domains). Portfolio rubric (5 components, weighted). MAF (8 domains, 1–5 scale). |
| 5.2 | Assessment instruments are designed to be valid, reliable, and fair. | Fully Met | Assessment Framework — MCQ standard-setting via modified Angoff method (panel of 3 experienced surveyors); portfolio moderation (20% random sample + all borderline cases); external moderation annual (10% sample). Item analysis thresholds documented (p-value range 0.3–0.9). |
| 5.3 | Trainees receive their assessment results in writing within a defined timeframe. | Fully Met | Assessment Framework — written results timelines: MCQ/Case Vignette within 5 working days; MAF within 72 hours of visit; Portfolio within 15 working days; Final Certification Decision within 5 working days of portfolio result. |
| 5.4 | The organisation has documented procedures for managing trainees who do not meet competency requirements, including an appeals process. | Fully Met | Assessment Framework — Performance Improvement Pathway (PIP): trigger conditions, PIP meeting (5 days), PIP document, review, Formal Review Panel (3-member including external assessor). Reassessment opportunities by instrument. 2-stage Appeals Procedure (informal → formal independent review). All timelines documented. |
| 5.5 | The organisation reviews the results of the training programme, including assessment outcomes, at defined intervals. | Fully Met | Programme Effectiveness Evaluation — Outcome Indicators section: assessment outcomes by track reviewed annually; pass rates, cohort performance trends, and assessment calibration review are components of the annual quality improvement cycle. |
Evidence Document Index
All evidence documents referenced in this compliance statement are publicly accessible on the ASF website at the URLs listed below. Each document is maintained by the ASF Programme Director and reviewed on the schedule stated in the document.
| # | Document Title | Primary ISQua Criteria | Review Cycle |
|---|---|---|---|
| 1 | Surveyor Training Programme — Overview | 1.1, 1.2 | Annual |
| 2 | Programme Risk Register | 1.3 | Annual |
| 3 | Programme Policies & Procedures Manual | 1.4, 2.5, 2.6, 3.4 | Biennial (2-year) |
| 4 | Staff Qualifications & Trainer Selection Criteria | 1.2, 2.2, 2.3 | Annual |
| 5 | Mentor & Trainer Performance Review Framework | 2.4 | Annual |
| 6 | Programme Effectiveness Evaluation Framework | 2.7, 2.8, 4.8, 4.9, 5.5 | Annual |
| 7 | Trainee Records & Data Protection Policy | 3.2, 3.3 | Biennial (2-year) |
| 8 | Diversity, Equity & Local Context Module (DEI-01) | 4.4 | Annual |
| 9 | Assessment Framework & Performance Management Policy | 5.1, 5.2, 5.3, 5.4 | Annual |
| 10 | In-Person & Classroom Training Programme | 4.1, 4.2, 4.3, 4.5 | Annual |
| 11 | Internship & Mentoring Programme | 4.3 | Annual |
| 12 | Maintenance of Currency (MOC) Policy | 4.6 | Annual |
| 13 | Patient & Public Surveyor Programme | 4.7 | Annual |
| 14 | ASF Surveyor Competency Framework | 1.1, 2.2, 5.1 | Biennial (2-year) |
References
Primary Standard: ISQua External Evaluation Association (EEA). Standards for Surveyor Training Programmes, 4th Edition. Dublin: ISQua; 2021. Available at: isqua.org
Related Standards: ISQua EEA. International Accreditation Programme (IAP) Standards, 5th Edition. Dublin: ISQua; 2015. Available at: isqua.org
Legal Framework (data protection): Regulation (EU) 2016/679 of the European Parliament and of the Council (General Data Protection Regulation — GDPR). Official Journal of the European Union, L 119, 4 May 2016, pp. 1–88. Available at: eur-lex.europa.eu
Legal Framework (data protection — France): Loi n° 78-17 du 6 janvier 1978 relative à l’informatique, aux fichiers et aux libertés, as amended by Ordonnance n° 2018-1125 du 12 décembre 2018. Available at: legifrance.gouv.fr
Competency Framework Reference: Joint Commission International. JCI Surveyor Competency Framework. Oakbrook Terrace, IL: JCI; 2018. Available at: jointcommissioninternational.org
Assessment Standard-Setting: Angoff WH. Scales, norms and equivalent scores. In: Thorndike RL, ed. Educational Measurement. 2nd ed. Washington DC: American Council on Education; 1971:508–600.