CONFIDENTIAL

Anaesthesia Clinical Services Accreditation (ACSA)

Report from ACSA onsite review

NAMEOFHOSPITAL/TRUST:

Date of visit:

Report date:

Thisreporthasbeenpreparedbyareviewteam(listedbelow)toprovidearecordoffindingsfromanACSAonsitereview visittoNAME OFHOSPITAL.It isintendedto summarisethe organisation’sperformance againstthe standardsassessed duringthe review. Therecommendationscontainedinthisreportaredesignedtoguidelocalquality improvementdiscussions.

THE ACSA REVIEW TEAM (ACSA RT)

X, Lead reviewer

X, Second reviewer

X, Lay reviewer

X, Admin reviewer

X, Observer (if applicable)

PRIMARY LOCAL CONTACTS (main contacts only)

X, ACSA Clinical Lead

Contents

1Introduction and background

2Summary ofconclusionsand recommendationscontainedin thereport

3Detailsofthevisit

4CompliancewithACSAStandards2015

5Detailedrecommendations

6Library of Good Practice

7Nextsteps

8Accreditation decision

1.Introductionandbackground

  • Location

TEXT

  • Patient Population

TEXT

  • Staff and Facilities

TEXT

  • Level of Activity

TEXT

  1. Summary of conclusions and recommendations contained in the report

A)Areas of good practice: (headings may change accordingly)

  • The Care Pathway

TEXT

  • Equipment, Facilities and Staffing

TEXT

  • Patient Experience

TEXT

  • Clinical Governance

TEXT

  • Subspecialties

TEXT

  • Other

TEXT

B)Areas for improvement: (headings may change accordingly)

  • The Care Pathway

TEXT

  • Equipment, Facilities and Staffing

TEXT

  • Patient Experience

TEXT

  • Clinical Governance

TEXT

  • Subspecialties

TEXT

  • Other

TEXT

  1. Details of the visit

Meetings:

A)Meetings with Trainees and SAS/SD doctors:

NUMBER trainees and NUMBER SAS/SD doctors were interviewed

TEXT

B)Meetings with Consultants:

NUMBER consultants (excluding the clinical lead) were interviewed

TEXT

C) Meetings with Service Leads and Managers:

NUMBER service leads and managers were interviewed

TEXT

Clinical areas visited:(headings may change accordingly)

A) Emergency Department

TEXT

B) Pre-assessment

TEXT

C) Surgical Centre

TEXT

D) Theatres

TEXT

E) Recovery Room

TEXT

F) MRI Scanner

TEXT

Any other areas of interest that the ACSA RT noticed during their review visit:

TEXT

4. Compliance with ACSA Standards

Bypre arrangement, theACSA RTdecidedtoreviewNUMBERstandardsindetailfor evidence ofcompliance using the on-site reviewprocess outlinedabove. NUMBERS of these standards werecommunicatedtotheclinicalleadinadvancesothatevidencecouldbemadeavailableforscrutiny atthereview in the classroom session.

TheACSA RTconsideredthatsatisfactoryevidencewassuppliedforthefollowing(Priority2/3standardsareboldandunderlined):

The care pathway

Policies:

Pre assessment:

Consent:

Access to investigations:

List planning:

Assistance for medical staff:

Equipment:

Monitoring:

Theatre access:

Access to pre procedural investigations:

Recovery facilities:

Staffing:

Escalation of level of care:

Pain management:

Handover:

Emergencies:

Management of complications:

Resuscitation:

Equipment, facilities and staffing

Anaesthetic equipment and monitoring:

Maintenance and replacement policies:

Storage, cleaning and sterilisation:

Availability of drugs, fluids and blood:

Access to blood and blood conservation techniques:

Storage and security:

Documentation of anaesthetic records:

Guidelines on space for department accommodation:

Hotel services:

Teaching facilities:

Non medical staffing numbers:

Adequacy of training:

Rota management of medical staff:

Consultants:

Career grade and speciality doctors:

Trainees:

Obstetrics:

Patient experience

Preoperative assessment - patient decision making:

Care of the individual - dignity:

Advocates:

End of life care:

Clinical governance

Patient safety:

Reporting incidents:

Outcome measurements:

Quality improvement:

Skills and drills:

Audit - participation:

Staff – induction:

Job plan and review:

Supervision of staff:

Staff safety:

Research:

Business planning:

TheACSA RTagreedthatsatisfactoryevidencewasnotrequiredforthefollowingstandardwhichisnotapplicabletothehospital:

TheACSA RTconsideredthatsatisfactoryevidencewasnotsuppliedforthefollowingstandardsatthe timeof theonsite review:

CONFIDENTIAL

5. Detailed recommendations

Pleasenote:recommendationshighlightedinbolditalictextarenotrequiredtomeetthestandard,butshouldbeconsideredbythehospitalforlaterimplementation.

Standard
Number / Priority / Standard wording / Trust Assigned Rating / Assessor AssignedRating
Assessor comments/observations
Recommendations
Standard
Number / Priority / Standard wording / Trust Assigned Rating / Assessor AssignedRating
Assessor comments/observations
Recommendations
Standard
Number / Priority / Standard wording / Trust Assigned Rating / Assessor AssignedRating
Assessor comments/observations
Recommendations
Standard
Number / Priority / Standard wording / Trust Assigned Rating / Assessor AssignedRating
Assessor comments/observations
Recommendations
Standard
Number / Priority / Standard wording / Trust Assigned Rating / Assessor AssignedRating
Assessor comments/observations
Recommendations
Standard
Number / Priority / Standard wording / Trust Assigned Rating / Assessor AssignedRating
Assessor comments/observations
Recommendations

CONFIDENTIAL

6. Library of good practice

Examples of good practice

7. Next steps

TheACSA RTrecommendsthattheNAMEdepartmentreviewstherecommendationsthoroughlyandidentifyandprioritiseactionstotake.

Below are somesuggestionsonhowdepartmentsmaychoosetodothis:

  • Holdadepartmental meetingtodiscussthefindingsofthereviewteam
  • Planandpilotnewprocesses/policies
  • Request examplesof how otherdepartments havemet standards

8. Accreditation decision

It has been confirmed by the College’s Quality Management of Service Group (QMSG) that NAME anaesthetic department has gained ACSA accreditation, DATE.