The ACSA process

Published: 12/08/2019

Self-assess against the ACSA standards

The most important part of the ACSA process is your gap analysis of current departmental practice against the ACSA standards. Prior to your review visit, you will need to submit a copy of the ACSA self-assement document to the ACSA team to be circulated to your visiting review team. You can access the self-assessment on the ACSA website.

It is recommended that you divide the ACSA standards into sections, assigning each section to a particular individual or team to complete . This is in order to increase buy-in, and also to ensure that any actions that are planned and changes that are made are sustainable (i.e. are not dependent upon a single individual). You will therefore need to agree how the standards are divided between individuals and teams prior to beginning your self-assessment. It is particularly recommended that you involve your trainee cohorts. Many of the standards require audit evidence to demonstrate compliance and these can form the basis of quality improvement projects.  

It is important to collaborate with your colleagues and measure agreement between you about which standards are ‘met’, ‘not yet met’ or ‘not applicable’. You may find that there are some areas in which you disagree, and you can discuss these. If you are unsure and require clarification on a standard, make sure you have first consulted the GPAS references for that standard. Reading through these should elucidate what the standard is looking for but if you require any further explanation do not hesitate to contact the ACSA team.

The prioritisation of standards

Every ACSA standard is assigned a priority. Standards are assigned a priority 1 if they must be achieved in order for accreditation to be awarded. Priority 2 standards should be achievable by most departments but are not required to be met for accreditation to be awarded. There is however, an expectation that you should be working towards meeting them. Priority 3 standards will be aspirational for most; however, they will provide targets for the highest performing departments to achieve. 

Non-applicable standards

You may find that some of the standards are not applicable to you and the services you deliver. Where this is the case, you can mark a standard as N/A. The ACSA review team may still ask about standards that you mark as N/A if they are unsure about why you have deemed them ‘not applicable’

If you do not provide obstetric services, you can mark obstetric specific standards as N/A. Similarly, if your department does not treat any children it is acceptable to mark child specific standards as N/A. If you treat children as emergency patients or those that are 16-17 years old, then the paediatric standards would still be considered applicable to a certain degree. In this instance, you will be required to provide further information on the pathway for these patients as this will assist the review team in taking a view of how those particular standards will apply to you. Where the standard refers to both children and adults you may disregard the paediatric aspect and mark the standard as ‘met’ if you feel you meet that standard for adult care or ‘not met’ if that isn’t the case.

Annual standards review

It is important to note that the ACSA standards are revised and published annually. This is to ensure that the standards reflect the latest guidance and take into account feedback from departments and reviewers on the clarity of standards. Standards could be removed, added, amended with additional wording/clarification or have the priority of the standard altered. All new standards are assigned a priority 2 in the first year they are added but may become a priority 1 in subsequent years.

The standards are published around April/May each year and when you have your review visit, you will be assessed against the current version of standards at that time so it is important to ensure you are assessing yourself against the latest version. If your visit date is likely to fall close to the standards publication date, please speak to the ACSA team who will confirm against which standards you will be assessed.