Your ACSA Review Visit


Details on the format, who to invite and what to expect


Before the visit, we will request your self-assessment and ask you to give a small explanatory note for any standards you have marked as ‘unmet’ or ‘not applicable’. 

We will also request some items to be sent via email before the review visit; this may be some policies to evidence a few ACSA standards, an anaesthetic chart or some meeting minutes, for example.

The ACSA review team will usually be five or, a maximum of, six people comprising:

  • Clinical Reviewers.
  • Lay Reviewers.
  • A member of the ACSA team

You are likely to have a two day visit if you are seeking ACSA accreditation for one site, and a three day visit if you are seeking accreditation for two sites.  Three or more sites may result in a longer visit or may have to be done separately, depending on the distance between the sites. 

Depending on the length of the visit you will be provided with a two day or three day drafted agenda containing information on how the visit will run. On the morning of the first day you will be asked to give a presenation that will introduce the review team to your department. You will then go into the classroom session where you will present evidence for a set of standards you have been advised of in advance.There are then several sessions where the review team will want to meet with various staff members and the agenda will advise who you should to invite to each of the sessions. One of the other main sessions of the visit is the 'walkabout' where the review team will tour the department and assess it against the ACSA standards. 

If you would like to see an example of a timetable please contact: 

What happens next?


After the review visit, your review team will write a report of their observations and findings.  The report will then be sent back to you for factual accuracy checking.  Following this, the report will be sent to the ACSA committee, the Group who oversee ACSA, to make a final decision on ACSA accreditation.  To clarify, the review team’s role is to report to the ACSA committee their observations and their opinions on whether the evidence presented meets the standards set out in the ACSA standards document. However, the final decision of whether or not the hospital meets these standards, and/or is awarded accreditation is solely that of the ACSA committee. The ACSA committee therefore reserves the right to change a standard from ‘met’ to ‘not met’, if the evidence presented in the report and/or subsequent to the visit does not, in their collective opinion, meet the standard required.

The decision you will receive from the ACSA committee will be one of the following:

  • Accredited – unconditionally accredited
  • Not yet accredited – accreditation is conditional upon implementation of a number of recommendations. The report will contain suggested actions that could be carried out to meet the standard, and the College guide is available to provide additional assistance and advice where required. The ACSA committee will require written confirmation once the recommendations have been implemented in order to award accreditation.

It is very rare that a department will be accredited straight away.  It is also important to understand that ACSA is not a ‘pass/fail’ exercise and there should always be an opportunity for a department to gain accreditation if they are willing to work through any ‘unmet’ standards and change them to ‘met’.  Your appointed college guide is available to assist you with meeting any unmet standards after the visit.