http://staff.wsha.local/Home.aspx

What is ACSA?

• Voluntary scheme for NHS and private providers run by the RCoA

• Anaesthesia is the largest single hospital speciality 250 departments in the UK

• Formally and actively demonstrate commitment to delivering a quality service

• An accredited department is recognised as delivering excellent care

• 172 standards across 4 domains

Domains

• Care Pathway• Equipment Facilities and Staffing• Patient Experience• Clinical Governance

4.1.0.3 Up-to-date, clear and complete information about operating lists is printed and displayed any changes are agreed by all relevant parties

1

SafeEffectiveWell-led

3.5.3

Written documentation should be provided and display should be seen

4.1.0.4 Arrangements for the cover of obstetrics, ICM and general work are monitored with respect to the workload

1

SafeEffectiveWell-led

9.1.6

Evidence of audit should be provided and verbal confirmation that there is a mechanism to recognise issues should be given

4.1.0.5 There is a formal handover process between shifts, multidisciplinary where appropriate

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SafeEffectiveWell-led

5.5.18, 9.1.7

Rotas should be provided and include the allocation of time and place as well as which staff should be present at handover

Why engage with ACSA?

• The CQC recognises accredited departments as low risk

• “I strongly support the work on accreditation and in due course this will be a very useful source of information for the CQC” Professor Sir Mike Richards

Why engage with ACSA?

• Encourages engagement in quality and cohesion within departments

• Accreditation provides evidence which may support future CQUIN payments

• Contributes to meeting QIPP• Deanery placement of trainees

Why ACSA here?

• Demonstrate convincingly the quality of our department to trainees, future employees, commissioners but most importantly patients.

• Engaging all the consultants in the quality agenda

• Outreach to theatre and recovery staff in main theatres and DSU

How?

• Involved management early• Support for the cost• 8 months to collate evidence to support each

standard: guidelines, patient information, audits• Stored on shared drive and departmental ACSA

handbook • Link on the intranet

Inspection

• Self declaration to the college in January 2015• On site review on March 3rd and 4th by the

inspection team• 2 CDs, patient representative and administrators• Departmental presentation• Met with clinicians, managers, nurses and

patients

16th April 2015

2nd Department in the UK