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ENGAGEMENT
SELF-ASSESSMENT
& GAP-ANALYSIS
REVIEW
ACCREDITATION
STEP
STEP
STEP
STEP
STEP
STEP
Department fills in the
registration form which
can be downloaded
from the website.
ACSA team sets up
informal (optional)
teleconference to
discuss details,
practicalities and
concerns or issues
arising.
3
Once the department
meets the majority
of the Priority 1
ACSA standards,
and are ready to
officially engage,
the department is
invoiced for services
(Priority 1 standards
are those that must
be achieved in order
for accreditation to be
awarded). On receipt
of payment, agreed
term of engagement
begins.
4
Department completes
self-assessment and
works to close the
gaps between current
practice and the
required standards
with the help of an
assigned College
Guide who is a clinical
expert provided by the
College.
5
Once department
assess themselves as
compliant with 100%
of the Priority 1 ACSA
standards, they request
an on-site review. The
review team comes to
visit the department.
6
When 100%
compliance with
Priority 1 standards is
confirmed by onsite
review team, and after
any recommendations
are implemented, the
department is awarded
with an accreditation
plaque.
PEER REVIEW FOR
QUALITY IMPROVEMENT
Department agrees to
engage with ACSA. A
‘lead’ is appointed to
act as the main point
of contact with ACSA
team.
2
CC
A
1
ROYAL C
O
CONTACT
TISTS
HE
ST
INTERNAL DECISION
GE OF ANAE
E
LL
R E D I TAT I O
N
ANAESTHESIA
CLINICAL SERVICES
ACCREDITATION
(ACSA)
Improving quality
in anaesthetic services
What is ACSA?
Why does it
matter?
Anaesthesia Clinical Services Accreditation
(ACSA) is a voluntary scheme for anaesthetic
departments in the UK to formally and
actively demonstrate their commitment
to high quality service provision and
improvement.
The ACSA accreditation process provides
clinical directors, managers and medical staff
the opportunity to benchmark their service
against existing national standards and
provides them with the necessary support to
achieve any unmet standards.
It is based on a set of standards
selected from the Guidelines for the
Provision of Anaesthetic Services (GPAS)
recommendations.
ACSA works with the department leadership
to ensure that all members of engaged
departments are actively involved in meeting
standards recognised by their peers, and
are committed to improvement through
establishing an action plan.
The standards focus on the following areas:
Care Pathway; Equipment, Facilities and
Staffing; Patient Experience and Clinical
Governance.
The scheme has been developed by the
Royal College of Anaesthetists (RCoA) Clinical
Quality Directorate and offers departments
quality improvement through peer review.
Reviews are undertaken by senior doctors
from within the speciality who know what to
look for in service delivery, thereby enabling
positive change.
ACSA standards are based on GPAS
recommendations. These standards are
reviewed annually to remain up to date with
current best practice in anaesthesia.
What does it mean
for my department?
●●
The ACSA process is a partnership
between the College and departments in
the pursuit of quality improvement
●●
It provides a benchmark to identify areas
for improvement, and to create a better
working/teaching/learning environment
for staff and better services for patients
●●
The CQC has stated that it regards
accredited departments as low risk
As a marker of quality, accredited
departments will become more attractive
to trainees/employees. Associations are
already being made between delivering
a high quality service and providing high
quality training. Patients will also be assured
that they are receiving outstanding service.
If you would like any further information, or if you have any questions, please contact
the RCoA directly at [email protected] or 020 7092 1697.
‘I strongly support the work on
accreditation being undertaken by
the Royal College of Anaesthetists.
The ACSA accreditation programme
should in due course be a very useful
source of information on the quality of
anaesthetic service for the Care Quality
Commission.’
Professor Sir Mike Richards,
Chief Inspector of Hospitals, Care
Quality Commission
‘Engaging in the process and working
together for a common purpose has
boosted department morale and team
spirit. The peer review process has led
to our going over every aspect of our
service with a fine tooth comb. We can
confidently evidence a high quality
service and care for our patients.’
Dr Sade Okutubo, Clinical Lead
in Perioperative, Critical Care &
Chronic Pain Services, Homerton
Hospital
‘This is a very positive step in the
continuous movement to improve the
safety of anaesthesia. The opportunity
to share best practice and learning
through the ACSA library is also to be
commended and is supportive of Don
Berwick’s ambition for the NHS to be a
system devoted to continual learning
and improvement of patient care.’
Dr Mike Durkin, National Director
of Patient Safety, NHS England