The ACSA process

As a rule, you should aim to set visit date within 12 months of subscribing to the ACSA scheme. A review will only take place by prearrangement and on a date that is mutually agreed. At least 12 months’ notice is required in order to schedule a date but the sooner you let the ACSA team know the better. To ensure a successful visit, avoiding setting a date in local school holidays or at times when the department will be particularly busy. 

Please note

If the proposed review date is cancelled with less than 8 weeks’ notice, the RCoA may recover any travel costs already incurred from the department.

Before the review

Upon agreement of a review date your assigned ACSA coordinator will set up a meeting with the ACSA lead/s to coordinate:

• A deadline for the completion of the self-assessment
• Collation of survey data from staff working in the department
• An agreed agenda – confirming logistics for the visit (e.g. areas to visit, individuals and groups to speak to)

It is vitally important that the self-assessment is completed according to the communicated deadline from the ACSA team. This is usually around 4-6 weeks before the visit is due to take place so that the review team have time to meet and plan how the standards will be assessed.

The review team will use the completed self-assessment and supporting evidence to determine which areas to further assess during the review. They will also come up with a list of any further information that they would like to request in advance. The idea behind this is to reduce the amount of paperwork to look at during the actual review.

After the review team meeting, the ACSA coordinator will send a list of ‘classroom standards’ and the list of any documentation they would like to request. The classroom standards are advised in advance of the review so that the department can prepare evidence to present in the classroom session of the visit.

Documentation that is commonly requested includes:

• anonymised and redacted anaesthetic charts
• a copy of the induction pack/department handbook for staff
• rotas
• patient leaflets available
• meeting minutes (departmental, morbidity and mortality, labour ward)
• copies of policies 
• audit data

Review agenda

The agenda of a review visit will vary slightly depending on the length of the visit. The main elements comprise of;

• an introductory presentation and classroom session: the host department will provide a presentation to the review team using a template provided and the requested classroom standards will be discussed in detail allowing the reviewers to go through the evidence for these standards
• discussions with staff groups which are split into several sessions:
  • consultants and autonomously practicing anaesthetists
  • senior nurses and key staff who assist the anaesthetic team
  • anaesthetists in training and any other anaesthetists requiring supervision 
  • anaesthesia associates
  • clinical director and managers
• accompanied walkabout of clinical areas: the review team will make their way around the department to visit all sites where anaesthesia is given
• discussion, clarification and testing of compliance with standards: the review team will lead the discussion as required
• sessions for the review team only: these give the review team protected time to discuss things between themselves
• feedback from the review team to the department and debrief of the visit: the review team will summarise areas of good practice and improvement they have noted against the ACSA standards.

The department will not be informed of any accreditation decision on the day but will be given a clear indication of areas to address. The accreditation decision is confirmed once the report has been written and finalised by the ACSA committee.