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ASF Standards · Primary Health Clinic · Standard 11

Standard 11 — Supporting the Care Workforce

8 criteria · 3 core · 5 standard-level · Version 1.0 · Aligned to ISQua EEA Principle 8, 6th Edition

Criteria in this standard

11.1 — Every Member of the Workforce Is Genuinely Credentialed for Their Actual Role
11.2 — Ongoing Competency Is Genuinely, Regularly Evaluated
11.3 — Staff Have Genuine Access to Ongoing Education and Skill Development
11.4 — Workforce Health and Safety Is Genuinely Protected
11.5 — Workplace Issues Raised by Staff Are Genuinely Investigated and Resolved
11.6 — Staff Are Genuinely Protected From Violence and Aggression
11.7 — Workforce Feedback Is Genuinely Gathered and Acted On
11.8 — Sick Leave and Attrition Data Genuinely Inform Organisational Learning
11.9 — Equality, Diversity and Inclusion Across the Workforce Are Genuinely Monitored
11.1

Every Member of the Workforce Is Genuinely Credentialed for Their Actual Role

Core

Every member of the clinic’s workforce — employed clinicians, community health workers, visiting specialists, and volunteers alike — has genuine assurance of the qualifications and scope of practice their role requires, including community health workers whose training and scope are often genuinely distinct from licensed clinical staff.

In plain terms: Everyone involved in care here — including community health workers, who have a genuinely distinct kind of training — has had their real qualifications and scope genuinely checked and respected.

Facility category Crisis Transition Small Standard
Applicability Adapted Full Full Full

Why this matters

Community health workers play a genuinely vital, distinct role in primary care, often bridging clinical services and community outreach without holding a formal clinical licence — their training is real and valuable but genuinely different from a nurse’s or physician’s, and a credentialing process that fails to distinguish this creates a real risk: either their legitimate role is undervalued, or their actual scope of practice is exceeded without anyone noticing.

What good looks like

  • Genuine assurance extends to community health workers appropriately.
  • Scope of practice is genuinely verified and respected.
  • A real corrective process exists for a scope mismatch.

Common failure modes

  • Community health workers’ training basis is never documented or verified.

Worked example

In practice
A clinic employing community health workers with no documented scope.
BeforeCommunity health workers’ training had never been formally documented, and their actual scope of practice in the field was undefined, leading to inconsistent practice.
ActionA clear scope-of-practice document was created specific to the community health worker role, matched to their genuine training background.
AfterThe Monitor reviewed the scope document and confirmed it was genuinely specific to this role, not a generic clinical scope. Verified.

If you are starting from zero — do this first

  1. Document the genuine training basis and scope for community health worker roles specifically.
The most common mistake: Applying a generic clinical credentialing framework that doesn’t genuinely fit the distinct training basis of community health workers.

Self-assessment questions

1. Does genuine assurance extend to community health workers? — Real, consistent coverage appropriate to their genuinely distinct training.
Evidence: Role-specific credential records
2. Is scope of practice genuinely verified and respected in daily practice? — A specific, documented match.
Evidence: Scope verification record
3. Is there a real process if someone practises outside their verified scope? — A genuine corrective process.
Evidence: Correction procedure

Common reasons for a PARTIAL answer

  • Licensed clinicians are credentialed but community health workers’ basis is undocumented.

Implementation plan

When What
Week 1-2 Document role-specific scope for community health workers.

How the Monitor verifies this

Method What Detail
DOCUMENT Credential review Reviews role-specific credential records across all workforce categories.

Supervisor tips

  • Ask specifically about community health workers’ documented scope.

Evidence base

World Health Organization. Community Health Worker Programmes: Guidelines. Geneva: WHO; 2018.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

11.2

Ongoing Competency Is Genuinely, Regularly Evaluated

Core

The continued competency of every workforce member is genuinely, regularly evaluated against their actual job description and scope, including the genuinely distinct competencies required of community-facing and preventive care roles.

In plain terms: Staff competency keeps getting genuinely checked — including the specific skills community health workers and preventive care staff actually need.

Facility category Crisis Transition Small Standard
Applicability Adapted Full Full Full

Why this matters

Preventive care and population health practice evolve genuinely over time — vaccination schedules, screening guidelines, health education approaches — and competency evaluation needs to reflect this evolving, distinct knowledge base, not a generic clinical competency check that doesn’t actually match this role’s real focus.

What good looks like

  • Competency is genuinely evaluated on a real schedule.
  • Evaluation genuinely covers actual current duties.
  • A genuine gap triggers a real response.

Common failure modes

  • A generic evaluation form doesn’t actually reflect preventive care-specific competencies.

Worked example

In practice
A clinic using a generic evaluation form for all staff.
BeforeA single generic evaluation form was applied to all staff roles, with no distinct criteria for community health workers or preventive care specialists.
ActionRole-specific evaluation criteria were developed, reflecting the genuine current competencies preventive care and community outreach roles actually require.
AfterThe Monitor reviewed a recent evaluation and confirmed it genuinely reflected role-specific competencies. Verified.

If you are starting from zero — do this first

  1. Build role-specific evaluation criteria for each distinct workforce category.
The most common mistake: A generic evaluation form applied uniformly, not reflecting each role’s genuinely distinct focus.

Self-assessment questions

1. Is ongoing competency genuinely evaluated on a real schedule? — A real, periodic evaluation.
Evidence: Evaluation records
2. Does evaluation genuinely cover actual current duties? — A specific, role-relevant check.
Evidence: Role-specific criteria
3. Does a genuine gap trigger a real response? — A genuine corrective process.
Evidence: Correction record

Common reasons for a PARTIAL answer

  • Evaluation happens but uses a generic form.

Implementation plan

When What
Week 1-2 Build role-specific evaluation criteria.

How the Monitor verifies this

Method What Detail
DOCUMENT Evaluation review Reviews evaluation for genuine, role-specific substance.

Supervisor tips

  • Compare a community health worker’s evaluation to a nurse’s — they should look genuinely different.

Evidence base

Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington DC: National Academies Press; 2003.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

11.3

Staff Have Genuine Access to Ongoing Education and Skill Development

Standard

Every workforce member has genuine access to ongoing education — including public health and preventive care updates genuinely relevant to a primary care setting’s population-health role — not education treated as a one-time induction event.

In plain terms: Staff can actually keep learning — specifically in public health and preventive care, genuinely central to this setting’s work.

Facility category Crisis Transition Small Standard
Applicability Adapted Full Full Full

Why this matters

Public health guidance — vaccination schedules, screening recommendations, outbreak response — evolves genuinely and sometimes rapidly, and staff without ongoing access to this evolving knowledge risk delivering outdated preventive care advice to the communities relying on them.

What good looks like

  • Genuine, ongoing access to education beyond induction.
  • Real development opportunities in public health specifically.
  • Staff can describe a real opportunity taken.

Common failure modes

  • Education stops after induction, missing evolving public health guidance.

Worked example

In practice
A clinic with no ongoing public health education.
BeforeStaff had received no update training on the latest vaccination schedule changes.
ActionA biannual public health update session was introduced.
AfterThe Monitor interviewed staff who could describe the recent update. Verified.

If you are starting from zero — do this first

  1. Introduce a biannual public health guidance update.
The most common mistake: Assuming public health guidance changes slowly enough not to need genuine, ongoing staff education.

Self-assessment questions

1. Does every workforce member have genuine, ongoing access to education? — Real, continuing access.
Evidence: Education policy
2. Are genuine development opportunities offered in public health specifically? — Real opportunities.
Evidence: Training calendar
3. Can staff describe a real opportunity taken in the past year? — A real, specific example.
Evidence: Staff interview

Common reasons for a PARTIAL answer

  • Education exists but isn’t specifically focused on evolving public health guidance.

Implementation plan

When What
Week 1-2 Schedule biannual public health update sessions.

How the Monitor verifies this

Method What Detail
ASK Staff interview Asks staff about recent public health education.

Supervisor tips

  • Ask specifically about recent vaccination schedule or guidance updates.

Evidence base

World Health Organization. Global Strategy on Human Resources for Health: Workforce 2030. Geneva: WHO; 2016.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

11.4

Workforce Health and Safety Is Genuinely Protected

Core

The clinic genuinely protects the health and safety of its workforce — required vaccinations, personal protective equipment, prevention of needlestick injuries — including community health workers conducting outreach visits outside the clinic itself, who face genuinely distinct safety considerations.

In plain terms: The people working here are genuinely kept safe — including community health workers out doing home or outreach visits, who face a genuinely different kind of risk.

Facility category Crisis Transition Small Standard
Applicability Adapted Full Full Full

Why this matters

Community health workers conducting field visits work without the physical safety infrastructure of a clinic — no colleagues nearby, no panic alarm, no controlled environment — and a safety policy designed purely around clinic-based risks genuinely misses this real, distinct exposure.

What good looks like

  • PPE is genuinely available and used.
  • Field-based safety is genuinely, specifically addressed.
  • Vaccinations are genuinely tracked.

Common failure modes

  • Safety protocols cover the clinic building but say nothing about field visits.

Worked example

In practice
A clinic whose safety protocol never mentioned field work.
BeforeCommunity health workers conducted home visits alone with no check-in protocol or safety plan specific to field conditions.
ActionA field-visit check-in protocol was introduced, including a scheduled call-back and a defined escalation step if contact was missed.
AfterThe Monitor interviewed a community health worker who could describe the check-in protocol in genuine, real use. Verified.

If you are starting from zero — do this first

  1. Introduce a field-visit safety check-in protocol for community health workers.
The most common mistake: A safety policy that only genuinely addresses risks inside the clinic building, overlooking field-based staff entirely.

Self-assessment questions

1. Is PPE genuinely available and used? — Real, observed use.
Evidence: Direct observation
2. Are genuine, specific measures in place for field-based staff safety? — Real, specific measures appropriate to this distinct risk.
Evidence: Field protocol documentation
3. Are required vaccinations genuinely tracked and current? — Real, verified tracking.
Evidence: Vaccination records

Common reasons for a PARTIAL answer

  • Clinic safety is strong but field safety has never been formally addressed.

Implementation plan

When What
Week 1-2 Introduce a field-visit safety protocol.

How the Monitor verifies this

Method What Detail
ASK Staff interview Asks a community health worker about field safety practice.

Supervisor tips

  • Specifically ask about field or outreach work, not just in-clinic safety.

Evidence base

World Health Organization. Health Worker Safety Charter. Geneva: WHO; 2020.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

11.5

Workplace Issues Raised by Staff Are Genuinely Investigated and Resolved

Standard

A genuine process exists for investigating and resolving workplace issues raised by staff — including whistleblowing concerns — with real protection from adverse treatment, not a grievance process that exists on paper with no real follow-through.

In plain terms: When staff raise a concern, it actually gets looked into, and they’re genuinely protected.

Facility category Crisis Transition Small Standard
Applicability Adapted Full Full Full

Why this matters

A genuine, trusted reporting channel is what allows real problems — understaffing, unsafe field conditions, care quality concerns — to surface before they compound. Staff who don’t trust the process will often stay silent precisely when their observations matter most.

What good looks like

  • A genuine, accessible process exists.
  • Real evidence of genuine resolution.
  • Genuine protection from adverse treatment.

Common failure modes

  • Concerns are discussed informally but never formally raised.

Worked example

In practice
A clinic where community health worker concerns rarely reached management.
BeforeField-based concerns were mentioned informally during check-ins but never formally logged or tracked to resolution.
ActionA simple logging step was added to the field check-in process, with a defined review cycle.
AfterThe Monitor reviewed the log and a documented resolution. Verified.

If you are starting from zero — do this first

  1. Add a formal logging step for concerns raised during field check-ins.
The most common mistake: Field staff concerns discussed informally but never formally tracked through to resolution.

Self-assessment questions

1. Is there a genuine, accessible process for raising issues? — A real, known process.
Evidence: Process documentation
2. Is there real evidence of genuine resolution? — Genuine follow-through.
Evidence: Resolution log
3. Are staff genuinely protected from adverse treatment? — Real, demonstrated protection.
Evidence: Staff interview

Common reasons for a PARTIAL answer

  • A process exists for clinic-based staff but field-based concerns aren’t genuinely captured.

Implementation plan

When What
Week 1-2 Add formal logging to field check-in processes.

How the Monitor verifies this

Method What Detail
DOCUMENT Resolution log review Reviews the log for genuine, documented resolution.

Supervisor tips

  • Ask specifically whether field-based staff have a genuine reporting route.

Evidence base

International Labour Organization. Violence and Harassment Convention, 2019 (No. 190). Geneva: ILO; 2019.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

11.6

Staff Are Genuinely Protected From Violence and Aggression

Standard

The clinic takes genuine, concrete steps to protect staff from aggression — including the genuinely distinct risks faced by community health workers conducting home or outreach visits, who often work without the physical safety infrastructure of a clinic setting.

In plain terms: Real, specific steps protect staff from aggression — including community health workers, who face genuinely higher risk in uncontrolled field settings.

Facility category Crisis Transition Small Standard
Applicability Adapted Full Full Full

Why this matters

A community health worker conducting a solo home visit genuinely lacks the safety infrastructure of a clinic — no security presence, no colleagues nearby, no controlled environment — making this a genuinely distinct and elevated risk requiring its own specific protective measures, not an afterthought to clinic-based security planning.

What good looks like

  • Genuine, specific measures exist for field-based risk.
  • Incidents are genuinely tracked.
  • Staff can describe a real instance where a measure worked.

Common failure modes

  • Field staff have no check-in protocol or escalation plan.

Worked example

In practice
A clinic whose field staff had no safety protocol.
BeforeCommunity health workers conducted home visits with no defined safety plan or check-in system.
ActionA scheduled check-in system with a defined escalation path was introduced, alongside basic situational awareness training.
AfterThe Monitor confirmed the check-in protocol was genuinely in daily use. Verified.

If you are starting from zero — do this first

  1. Introduce a check-in system for field-based staff.
The most common mistake: Treating field-based aggression risk as outside the scope of workplace safety planning entirely.

Self-assessment questions

1. Are genuine, specific measures in place for field-based risk? — Real, specific measures appropriate to this setting.
Evidence: Field safety documentation
2. Are incidents genuinely tracked and reviewed? — Real, systematic tracking.
Evidence: Incident log
3. Can staff describe a real instance where a measure worked? — A real, concrete example.
Evidence: Staff interview

Common reasons for a PARTIAL answer

  • A check-in protocol exists but isn’t genuinely followed consistently.

Implementation plan

When What
Week 1-2 Introduce a check-in and escalation system for field staff.

How the Monitor verifies this

Method What Detail
ASK Staff interview Asks field staff about the real check-in protocol.

Supervisor tips

  • Ask a community health worker directly about field safety.

Evidence base

World Health Organization. Framework Guidelines for Addressing Workplace Violence in the Health Sector. Geneva: WHO/ILO/ICN/PSI; 2002.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

11.7

Workforce Feedback Is Genuinely Gathered and Acted On

Standard

The clinic has a genuine, systematic approach to gathering staff feedback — including community health workers whose field-based role can easily leave them disconnected from clinic-based feedback processes — with real analysis and a genuine, implemented response.

In plain terms: Staff, including those out in the field, get genuinely asked how working here actually is, and real changes happen as a result.

Facility category Crisis Transition Small Standard
Applicability Adapted Full Full Full

Why this matters

Feedback processes scheduled around clinic-based meetings genuinely risk excluding field-based staff, who are physically absent from the clinic for much of their working time and whose distinct experience — isolation, transport challenges, community relationship dynamics — may never be captured by a clinic-centered process.

What good looks like

  • Feedback genuinely reaches field-based staff.
  • Feedback is genuinely analysed.
  • A documented instance shows a genuine, implemented change.

Common failure modes

  • Feedback sessions happen only during clinic-based meetings field staff rarely attend.

Worked example

In practice
A clinic whose feedback sessions rarely reached field staff.
BeforeFeedback discussions happened during in-clinic staff meetings that community health workers, often out in the field, rarely attended.
ActionA separate feedback channel was introduced for field staff, with a brief phone survey during a scheduled check-in call.
AfterThe Monitor reviewed response data showing genuine participation from field staff. Verified.

If you are starting from zero — do this first

  1. Check whether field staff genuinely participate in current feedback processes.
The most common mistake: Feedback processes structured around in-clinic meetings, systematically excluding field-based staff.

Self-assessment questions

1. Does feedback genuinely reach field-based staff? — Real, ongoing collection.
Evidence: Response data
2. Is feedback genuinely analysed? — A real, documented analysis.
Evidence: Analysis notes
3. Is there a documented instance of feedback genuinely leading to a change? — A real, concrete example.
Evidence: Change record

Common reasons for a PARTIAL answer

  • Feedback is gathered but field-staff response rate remains genuinely low.

Implementation plan

When What
Week 1-2 Introduce a field-specific feedback channel.

How the Monitor verifies this

Method What Detail
DOCUMENT Response rate review Reviews feedback response data by role.

Supervisor tips

  • Specifically check field-staff response rates.

Evidence base

NHS England. NHS Staff Survey National Results. Leeds: NHS England; 2023.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

11.8

Sick Leave and Attrition Data Genuinely Inform Organisational Learning

Standard

The clinic genuinely monitors staff sick leave and the real reasons people leave, using this to inform genuine changes supporting workforce wellbeing and retention, not attrition treated as an unexamined, unavoidable cost of doing business.

In plain terms: The clinic actually looks at why staff get sick or leave, and genuinely uses what it learns to make things better.

Facility category Crisis Transition Small Standard
Applicability Adapted Full Full Full

Why this matters

Primary care, and community health worker roles specifically, often carry genuine attrition risk from the demands of field work, community exposure, and sometimes lower relative compensation — a facility that never genuinely investigates these patterns misses real, actionable insight into what would actually improve retention.

What good looks like

  • Sick leave data is genuinely monitored.
  • Real reasons for leaving are actually captured.
  • A documented instance shows a genuine, implemented change.

Common failure modes

  • Community health worker attrition is never separately examined from clinical staff attrition.

Worked example

In practice
A clinic with high community health worker turnover never separately investigated.
BeforeCommunity health worker attrition was combined with overall staff turnover, masking a genuinely higher rate specific to this role.
ActionAttrition was tracked separately by role, revealing a genuine pattern linked to transport burden for field visits, leading to a transport stipend.
AfterThe Monitor reviewed the role-specific data and the resulting change. Verified.

If you are starting from zero — do this first

  1. Break down attrition data by role, not just overall.
The most common mistake: Combining attrition data across all roles, masking genuinely distinct patterns specific to community health worker positions.

Self-assessment questions

1. Is sick leave data genuinely monitored? — Real, ongoing analysis.
Evidence: Sick leave records
2. Are real reasons for leaving actually captured? — Real, specific exit data.
Evidence: Exit interview records
3. Is there a documented instance of this data genuinely informing a change? — A real, concrete example.
Evidence: Change record

Common reasons for a PARTIAL answer

  • Attrition data exists but isn’t broken down by role.

Implementation plan

When What
Week 1-2 Break down attrition data by role and investigate patterns.

How the Monitor verifies this

Method What Detail
DOCUMENT Exit data review Reviews role-specific exit data and any resulting change.

Supervisor tips

  • Ask whether community health worker attrition is tracked separately.

Evidence base

International Council of Nurses. The Global Nursing Workforce and the COVID-19 Pandemic. Geneva: ICN; 2021.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

11.9

Equality, Diversity and Inclusion Across the Workforce Are Genuinely Monitored

Standard

The organisation genuinely monitors and responds to real patterns of equity across recruitment, work allocation, scheduling, and promotion — including across the clinic’s clinical and community health worker staff — not an assumption that fair treatment exists simply because no formal complaint has been raised.

In plain terms: The clinic actually looks at real patterns — who gets hired, which shifts or routes people get, who gets promoted — not just assuming things are fair because nobody has formally complained.

Facility category Crisis Transition Small Standard
Applicability Adapted Full Full Full

Why this matters

Inequity in recruitment, scheduling, or promotion can genuinely persist for years without a single formal complaint — people often don’t report a pattern they can’t fully see themselves, or don’t trust reporting to change anything. This genuinely matters across both clinical staff and the clinic’s community health worker workforce, who may have less visibility into organisational patterns than office-based staff. Genuine, proactive monitoring of real workforce data is what actually surfaces a pattern that individual complaints alone would likely never reveal.

What good looks like

  • Workforce data is genuinely monitored for patterns.
  • A genuine pattern triggers a real response.
  • A real instance shows monitoring informing a change.

Common failure modes

  • No formal complaint has been raised, so the organisation genuinely assumes no issue exists, with no actual data ever reviewed.

Worked example

In practice
A clinic that had never reviewed its own route-assignment data for community health workers.
BeforeField route assignments were managed informally with no genuine review of whether certain workers consistently received less favourable or more difficult routes.
ActionA quarterly equity review was introduced, which identified and corrected a genuine, unintentional pattern.
AfterThe Monitor reviewed the review documentation and the resulting correction. Verified.

If you are starting from zero — do this first

  1. Introduce a regular review of recruitment, scheduling, and promotion data across clinical and community health worker staff.
The most common mistake: Assuming fairness exists because no one has formally complained, with no actual data ever reviewed.

Self-assessment questions

1. Is workforce data genuinely monitored for patterns of inequity? — A real, documented monitoring process.
Evidence: Monitoring protocol
2. Where a genuine pattern is identified, is there a real, defined response? — A genuine corrective process.
Evidence: Response record
3. Is there a real, documented instance of this genuinely informing a change? — A concrete, real example.
Evidence: Change record

Common reasons for a PARTIAL answer

  • Data exists but has genuinely never been reviewed specifically for equity patterns among community health workers.

Implementation plan

When What
Week 1-2 Introduce a quarterly equity review covering recruitment, scheduling, routes, and promotion.

How the Monitor verifies this

Method What Detail
DOCUMENT Equity review record Reviews the monitoring data and any resulting corrective action.

Supervisor tips

  • Ask to see the actual data behind the last equity review, including community health worker routes specifically.

Evidence base

World Health Organization. Gender Equity and Human Rights in the Health Workforce. Geneva: WHO; 2019.

ASF training courses on GMJ Academy →

Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.

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