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Accréditation Sans Frontières

International Accreditation of Healthcare Facilities

Staff Qualifications & Trainer Selection Criteria

ASF Surveyor Training Programme — Trainer and Mentor Competency Framework
Aligned with ISQua EEA STP 4th Edition (2021) Criteria 2.2 and 2.3

Criteria 2.2 · 2.3
Version 2.2 — November 2026
Review: Annual
Owner: HR Director

ISQua EEA STP Criteria Addressed

Criterion Exact ISQua Text (4th Ed., 2021) Status
2.2 “Trainers have the qualifications and experience required to deliver the training programme.” MET
2.3 “The organisation has a documented process for selecting trainers.” MET

Trainer Qualification Requirements (Criterion 2.2)

All trainers engaged in the ASF Surveyor Training Programme must meet the following minimum qualification and experience criteria before appointment. These criteria reflect the competency framework published by the Joint Commission International (JCI) for Surveyor Educators and are benchmarked against ISQua’s own trainer requirements.

2.2.1 Mandatory Qualifications

Requirement Minimum Standard Evidence Required
Healthcare or health management qualification Minimum Bachelor’s degree (Licence, Level 6 EQF) in a health or health management field Certified copy of degree certificate; transcript if requested
Healthcare accreditation experience Minimum 3 years’ direct experience in healthcare quality improvement or accreditation (as surveyor, quality manager, or equivalent) CV with verified employment history; references from two senior colleagues
Surveying/assessment experience Minimum 5 completed healthcare facility surveys as lead or co-surveyor with a recognised accreditation body (ISQua-accredited or equivalent) Signed survey log verified by employing accreditation body
Training delivery competency Recognised Train-the-Trainer qualification (minimum 24 contact hours) OR demonstrated equivalent delivery experience (minimum 3 training courses delivered, referenced) Certificate OR training portfolio with evaluations
Language proficiency Programme delivery language(s): French (C1 minimum) and/or English (B2 minimum) per CEFR. Additional languages are an asset. Certificate or statutory declaration
Continuing professional development (CPD) Minimum 15 CPD hours per year in quality improvement, accreditation, or adult education; documented in CPD log Annual CPD log submitted to HR by 31 January each year

2.2.2 Desirable Qualifications

  • Master’s degree (Master, Level 7 EQF) in healthcare management, public health, or quality improvement
  • ISQua Fellowship or equivalent senior accreditation qualification
  • Experience as an ISQua EEA-accredited programme trainer or surveyor educator
  • Psychometric or assessment design qualification
EQF Reference: The European Qualifications Framework (EQF), established by Recommendation 2017/C 189/03 of the European Parliament and Council, provides the common reference framework for qualification levels cited above.

Trainer Selection Process (Criterion 2.3)

ASF operates a structured, documented selection process for all trainers, ensuring transparency, fairness, and alignment with the qualification criteria above. The process applies to both internal ASF staff delivering training and external subject-matter experts engaged on a sessional basis.

2.3.1 Selection Process — Step by Step

  1. Needs identification: Training Coordinator identifies module delivery needs at least 12 weeks before each cohort; HR Director confirms staffing plan
  2. Candidate identification: Internal shortlist from trainer register; external advertisement via ASF website and professional networks if required (minimum 2-week open advertisement)
  3. Application review: HR Director and Programme Director jointly review applications against mandatory criteria (§2.2.1); candidates not meeting all mandatory criteria are excluded at this stage
  4. Structured interview: Panel of 3 (Programme Director, Quality Director, independent senior surveyor); standardised competency-based interview with scoring rubric; minimum score 70% required to proceed
  5. Teaching demonstration: 20-minute observed teaching session on an assigned topic; scored by all 3 panel members using the ASF Teaching Observation Framework (derived from the UK Higher Education Academy Professional Standards Framework)
  6. Reference checks: Two written references verified; at least one from a previous employer in an accreditation or quality role
  7. Appointment decision: Panel decision by consensus; recorded in selection record retained for minimum 5 years; unsuccessful candidates receive written feedback within 10 working days
  8. Induction: Mandatory 1-day ASF trainer induction before first delivery; sign-off on Code of Conduct and Conflict of Interest Declaration

2.3.2 Trainer Register

ASF maintains a Trainer Register containing the name, qualifications, experience summary, appointment date, and CPD record of all current trainers. The Register is reviewed annually by the HR Director and updated within 10 working days of any change. The Register is available for inspection by ISQua during accreditation reviews.

Benchmarking: The selection process is benchmarked against the JCI Surveyor Competency Framework (Joint Commission International, 2020 ed.) and the ISQua Accreditation Standards 5th Edition §4 (Surveyor management). Teaching observation criteria are adapted from the UK Professional Standards Framework (AdvanceHE, 2023).

Mentor Qualification Requirements

Mentors supporting trainees during the supervised practice phase must meet the following minimum criteria (linked to ISQua criterion 2.4, addressed in the Mentor & Trainer Performance Review Policy):

  • Minimum 5 years’ experience as an ASF-qualified surveyor
  • Completed ASF Mentor Training Workshop (1 day, minimum every 3 years)
  • Satisfactory performance rating in most recent mentor review
  • No upheld disciplinary findings in the preceding 3 years

References & Regulatory Basis

ISQua EEA STP 4th Edition (2021) — Criteria 2.2, 2.3. Available at: isqua.org

Joint Commission International (JCI) — Surveyor Competency Framework (2020 edition). jointcommissioninternational.org

ISQua Accreditation Standards 5th Edition — §4: Surveyor management and training. isqua.org

European Qualifications Framework (EQF) — Council Recommendation 2017/C 189/03 of 22 May 2017 on the European Qualifications Framework for lifelong learning. Official Journal of the EU, C 189/15, 15.6.2017.

Council of Europe — CEFR (2020) — Common European Framework of Reference for Languages: Learning, Teaching, Assessment. Companion Volume. Strasbourg: Council of Europe Publishing.

AdvanceHE (2023) — UK Professional Standards Framework for teaching and supporting learning in higher education. York: Advance HE. advance-he.ac.uk