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.

The two day and three day agenda contains information about who to invite to each of the sessions (this is in bold beneath each of the section headings), and session times.

Please select the number of days of your review visit:

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. 

The components of an ACSA visit

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 Quality Management of Service Group (QMSG), 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 QMSG 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 QMSG. QMSG 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 QMSG 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 QMSG 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.