Accréditation Sans Frontières · ASF Health Standards 9.0
Standard 18 · Supporting the Care Workforce
9 criteria · base standard
Base standard. 9 criteria, of which 0 non-negotiable. Each criterion is numbered 18.Y, with its classification and verification questions.
Criteria
- 18.1 Every Member of the Workforce Is Credentialed for Their Actual Role (CORE)
- 18.2 Ongoing Competency Is Regularly Evaluated (CORE)
- 18.3 Staff Have Access to Ongoing Education and Skill Development (STANDARD)
- 18.4 Workforce Health and Safety Is Protected (CORE)
- 18.5 Workplace Issues Raised by Staff Are Investigated and Resolved (STANDARD)
- 18.6 Staff Are Protected From Violence and Aggression (STANDARD)
- 18.7 Workforce Feedback Is Gathered and Acted On (STANDARD)
- 18.8 Sick Leave and Attrition Data Inform Organisational Learning (STANDARD)
- 18.9 Equality, Diversity and Inclusion Across the Workforce Are Monitored (STANDARD)
18.1 Every Member of the Workforce Is Credentialed for Their Actual Role
CORE
Every member of the workforce — employed staff, independent practitioners with privileges, contracted care providers, and volunteers alike — has assurance of the qualifications, licences, and scope of practice their role requires, and does not practise beyond that scope — not credentialing confined to directly employed clinical staff while contracted and volunteer roles go unchecked.
VERIFICATION QUESTIONS
- Does credential assurance extend to every category of workforce
employed, privileged, contracted, and volunteer — not employed clinical staff alone? — Consistent coverage across every workforce category, not a gap for contracted or volunteer roles. - Is each person's actual scope of practice verified against their qualifications, not assumed appropriate for the role they have been assigned?
A specific, documented match, not an informal assumption that the role and the person's qualifications align. - Is there a defined process if someone is found practising outside their verified scope?
A corrective process, not a gap identified with no actual response.
18.2 Ongoing Competency Is Regularly Evaluated
CORE
The continued competency and ongoing performance of every workforce member is regularly evaluated against their actual job description and scope of practice — not competency assumed to remain current indefinitely once initial credentialing is complete.
VERIFICATION QUESTIONS
- Is ongoing competency evaluated on a defined schedule, not assumed to persist from initial hiring?
A periodic evaluation, not a one-time check treated as permanently sufficient. - Does this evaluation cover the person's actual current job description and scope, not a generic check unrelated to their duties?
A specific, role-relevant evaluation, not a generic form applied uniformly regardless of actual role. - When an evaluation identifies a performance gap, is there a defined response?
A corrective process, not a gap noted with no actual follow-through.
18.3 Staff Have Access to Ongoing Education and Skill Development
STANDARD
Every workforce member has access to ongoing education — formal courses and training sessions, whether internal or external — to maintain the performance their role requires and develop their skills further, not education treated as a one-time induction event with nothing meaningful offered afterwards.
VERIFICATION QUESTIONS
- Does every workforce member have ongoing access to education beyond initial induction?
Continuing access, not training treated as a one-time event at hiring. - Are opportunities for skill development and extension offered, not only the minimum required to maintain current performance?
Development opportunities, not only remedial or compliance-driven training. - Can staff asked directly describe an education opportunity they have taken in the past year?
A specific example, not a theoretical entitlement nobody uses.
18.4 Workforce Health and Safety Is Protected
CORE
The facility protects the health and safety of its workforce while they carry out their duties — required vaccinations, personal protective equipment, prevention of manual handling and needlestick injuries — not staff safety treated as secondary to patient safety rather than an equally protected concern.
VERIFICATION QUESTIONS
- Is personal protective equipment available and used by staff, not available in theory but inconsistently worn in practice?
Observed use, not equipment present but not worn. - Are specific measures in place to prevent manual handling and needlestick injuries, not a general safety policy with no concrete protective measures?
Specific protective measures, not a policy statement with no actual practice behind it. - Are required staff vaccinations tracked and current, not assumed complete with no verification?
Verified tracking, not an assumption that staff vaccination status is current.
18.5 Workplace Issues Raised by Staff Are Investigated and Resolved
STANDARD
A process exists for the investigation and resolution of workplace issues raised by workforce members — including whistleblowing concerns about organisational wrongdoing — with protection from adverse treatment for those who raise them, not a grievance process that exists on paper with no follow-through or protection.
VERIFICATION QUESTIONS
- Is there an accessible process for staff to raise workplace issues, including whistleblowing concerns?
A known process, not a theoretical right with no practical, accessible channel. - Is there documented evidence that raised issues lead to investigation and resolution?
Follow-through, not a process that receives concerns without acting on them. - Are staff who raise concerns protected from adverse treatment, not merely told they are?
Demonstrated protection, not a stated non-retaliation policy with no actual confidence behind it.
18.6 Staff Are Protected From Violence and Aggression
STANDARD
The facility takes concrete steps to protect staff from violence and aggression — whether from patients, visitors, or other staff — ranging from verbal abuse and harassment through to physical assault, not workplace violence treated as an unavoidable, unaddressed feature of healthcare work.
VERIFICATION QUESTIONS
- Are specific measures in place to protect staff from violence and aggression, not a general policy with no concrete protective steps?
Specific measures — de-escalation training, panic alarms, security response — not policy alone. - Are incidents of violence or aggression toward staff tracked and reviewed, not treated as isolated, unrecorded events?
Systematic tracking, not incidents that go unrecorded and therefore unaddressed at a pattern level. - Can staff describe a specific instance where a protective measure worked as intended?
A concrete example, not protective measures that exist only in policy, untested in practice.
18.7 Workforce Feedback Is Gathered and Acted On
STANDARD
The facility has a systematic approach to gathering feedback from its workforce about their experience of working there, with analysis of trends and an implemented response — not feedback collected occasionally with no pattern of actual improvement resulting from it.
VERIFICATION QUESTIONS
- Is workforce feedback gathered on a systematic, recurring basis
satisfaction surveys, exit interviews, consultations? — Ongoing collection, not a single historical survey treated as sufficient indefinitely. - Is collected feedback analysed for trends, not simply filed without examination?
A documented analysis process, not raw feedback collected and left unexamined. - Can the facility show a recorded case where workforce feedback led to an implemented change?
A concrete example, not a feedback process that has never produced a visible change.
18.8 Sick Leave and Attrition Data Inform Organisational Learning
STANDARD
The facility monitors and analyses data on staff sick leave and the reasons people leave, using this data to inform organisational learning and changes in practice that support workforce wellbeing and retention — not attrition treated as an unexamined, unavoidable cost of doing business.
VERIFICATION QUESTIONS
- Is staff sick leave data monitored and analysed, not simply recorded with no review?
Ongoing analysis, not data collected and left unexamined. - Are the reasons staff leave the organisation captured, not assumed or left uninvestigated?
Specific exit data, not departures treated as self-explanatory with no inquiry. - Can the facility show a recorded case where this data informed a change supporting staff wellbeing or retention?
A concrete example, not data gathered with no demonstrated influence on actual practice.
18.9 Equality, Diversity and Inclusion Across the Workforce Are Monitored
STANDARD
The organisation monitors and responds to patterns of equity across recruitment, work allocation, scheduling, and promotion — not an assumption that fair treatment exists simply because no formal complaint has been raised.
VERIFICATION QUESTIONS
- Is workforce data on recruitment, work allocation, scheduling, and promotion monitored for patterns of inequity?
A documented monitoring process, not an assumption that fairness exists by default. - Where a pattern is identified, is there a defined response?
A corrective process, not data collected with no follow-through. - Can the facility show a recorded example of this monitoring informing a change in practice?
A concrete example, not monitoring that has never changed anything. ————————————————————