The ACSA process

Published: 12/08/2019


Your ACSA report

Following the onsite review, the report-writing process is led by the staff reviewer with the contributions of the rest of the team to ensure its accuracy. The review team’s role is to report to the ACSA committee their observations on whether the evidence presented meets the standards set out in the ACSA standards document. However, the final decision of whether or not the department meets these standards, and/or is awarded accreditation is solely that of the ACSA committee.

The report includes an accreditation decision. You will be either ‘accredited’ or ‘not yet accredited’, which means that accreditation is conditional upon implementation of a number of recommendations. It is very rare that a department is 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’ priority one standards and change them to ‘met’.

The report should make clear which changes must be implemented in order for the department to be considered for accreditation. The conclusions and recommendations will enable you to write a business case detailing where investment is needed (if necessary) and will provide supporting evidence to take to your executive board, or equivalent.

Evidence submission

Following publication of the finalised report, you will review the unmet standards and upload the requested evidence to the portal as you work through them. You will be provided with an evidence tracker that will document all the priority one standards highlighted as ‘not met’ in your report. All evidence will be circulated to the original review team and the ACSA committee to determine whether the evidence submitted is sufficient for the standard to be met. As/when standards are accepted as met the evidence tracker will be updated accordingly.


Once all priority one standards are accepted as met, then accreditation will be awarded and you will receive:

  • a plaque to display in your anaesthetic department
  • a letter of acknowledgement from the RCoA president
  • continued access to your appointed College Guide for the duration of the four year accreditation cycle
  • use of the ACSA quality mark, denoting your commitment to quality and patient care, when advertising to potential employees and trainees

When awarded, continued accreditation will depend upon receipt by the College of the annual subscription fee and acceptance of your annual compliance submission by the ACSA Committee.


On the anniversary of your accreditation, you will be asked to update your self-assessment form on the portal against the latest set of ACSA standards. You will need to rate all of the standards, but will be asked to include further detail on any standards that were marked as ‘met with recommendations’ (you will see these in your report and evidence tracker) as well as any new standards. Once returned you will then be asked to submit evidence or a small selection of standards which will be reviewed by the ACSA Committee. If accepted you will be deemed compliant for year 2 of your accreditation cycle.

The process highlighted above will repeat at years 3 and 4 in the same way, again against the latest set of standards at that time. It is therefore recommended that you start reviewing yourself against the standards as early as possible once they have been published to continue to quality improvement process . After 4 years, the accreditation cycle starts again with an onsite visit.