The ACSA process

Published: 12/08/2019

The review visit

As a rule, you should aim to set visit date within 12 months of subscribing to the ACSA scheme. An onsite 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. Please note that due to a backlog after the pandemic we currently require 12-18 months' notice to schedule a visit. 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 an onsite visit date the department will be sent the following documents to complete:

    • Self-assessment against the latest set of ACSA Standards – this is accessed via the portal and will need to be completed ahead of the review visit for the review team to go over
    • Review information form – this is to be completed alongside your self-assessment and submitted to the ACSA team. It provides contextual information for the review team and confirms staffing and bed numbers
    • A copy of the standards with full GPAS references and a summary of changes from the last set of standards
    • A draft agenda – to be amended by the ACSA lead to confirm logistics for the visit (e.g. areas to visit, individuals and groups to speak to)
    • A briefing note and poster – these are helpful for raising awareness of the onsite visit
    • A review presentation template – to prepare for the morning session of day one

    It is vitally important that you complete your self-assessment according to the deadline communicated by 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 to determine which areas to assess at the visit and will also come up with a list of information that they would like to request in advance (e.g. copies of policies, minutes etc). The idea behind this is to reduce the amount of paperwork to look at during the actual visit. After the meeting, the ACSA team will send you a list of ‘classroom standards’ and the list of the documentation they would like to request. You are made aware of the classroom standards in advance of the visit so that you 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:
      • senior nurses and key staff who assist the anaesthetic team
      • trainees and staff grade, associate specialist and specialty doctors
      • clinical director and managers
      • consultants and service leads
    • 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.