ACSA Review - The Royal College of Anaesthetists · Web viewAnaesthesia Clinical Services Accreditation (ACSA) Document 7 | CONFIDENTIAL Page 7 of 20 CONFIDENTIAL Review

CONFIDENTIAL

Review visit report<Date>

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Anaesthesia Clinical Services Accreditation (ACSA)Document 7 | <Date>CONFIDENTIAL

This report has been prepared by a review team (listed below) to provide a record of findings from an ACSA on site review visit to X. It is intended to summarise the organisation’s performance against the standards assessed during the review. The recommendations contained in this report are designed to guide local quality improvement discussions.

The ACSA review team (ACSA RT)X, Lead reviewerX, Second reviewerX, Lay reviewerX, Admin reviewerX, Observer

Primary local contactsX, ACSA clinical leadX, Clinical director

Contents1 Introduction and background

2 Summary of conclusions and recommendations contained in the report

3 Details of the visit

4 Compliance with ACSA standards 2016

5 Detailed recommendations

6 Library of good practice

7 Next steps

8 Accreditation decision

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1 Introduction and background1. Location

TEXT

2. Patient populationTEXT

3. Staff and facilitiesTEXT

4. Level of activityTEXT

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2 Summary of conclusions and recommendations contained in the report

Areas of good practice 1. The care pathway

TEXT

2. Equipment, facilities and staffingTEXT

3. Patient experienceTEXT

4. Clinical governanceTEXT

5. SubspecialtiesTEXT

6. OtherTEXT

Areas for improvement1. The care pathway

TEXT

2. Equipment, facilities and staffingTEXT

3. Patient experienceTEXT

4. Clinical governanceTEXT

5. SubspecialtiesTEXT

6. OtherTEXT

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3 Details of visit

Meetings1. Meetings with trainees and SAS/SD doctors

X trainees and X SAS/SD doctors were interviewedTEXT

2. Meetings with consultantsX consultants (excluding the clinical lead) were interviewedTEXT

3. Meetings with service leads and managersX service leads and managers were interviewedTEXT

Clinical areas visited1. Emergency department

TEXT

2. PreassessmentTEXT

3. Surgical centreTEXT

4. TheatresTEXT

5. Recovery room TEXT

6. MRI scannerTEXT

7. Any other areas of interest that the ACSA RT noticed during their review visitTEXT

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4 Compliance with ACSA standardsBy pre arrangement, the ACSA RT decided to review X standards in detail for evidence of compliance using the on-site review process outlined above. X of these standards were communicated to the clinical lead in advance so that evidence could be made available for scrutiny at the review in the classroom session.

The ACSA RT considered that satisfactory evidence was supplied for the following (Priority 2/3 standards are bold and underlined ):

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

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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:

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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:

The ACSA RT agreed that satisfactory evidence was not required for the following standard which is not applicable to the hospital:

The ACSA RT considered that satisfactory evidence was not supplied for the following standards at the time of the onsite review:

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5 Detailed recommendationsPlease note: recommendations highlighted in bold italic text are not required to meet the standard, but should be considered by the hospital for later implementation.

StandardNumber

Priority Standard wording Trust Assigned Rating Assessor Assigned Rating

Assessor comments/observations

Recommendations

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StandardNumber



Recommendations

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StandardNumber



Recommendations

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StandardNumber



Recommendations

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StandardNumber



Recommendations

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StandardNumber



Recommendations

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StandardNumber



Recommendations

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StandardNumber



Recommendations

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StandardNumber



Recommendations

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StandardNumber



Recommendations

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6 Library of good practiceExamples of good practiceTEXT

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7 Next stepsThe ACSA RT recommends that the X department reviews the recommendations thoroughly and identify and prioritise actions to take.

Below are some suggestions on how departments may choose to do this:

Hold a departmental meeting to discuss the findings of the review team Plan and pilot new processes/policies Request examples of how other departments have met standards

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8 Accreditation decisionIt has been confirmed by the College’s Quality Management of Service Group (QMSG) that X anaesthetic department has gained ACSA accreditation, X.

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ACSA Review - The Royal College of Anaesthetists · Web viewAnaesthesia Clinical Services Accreditation (ACSA) Document 7 | CONFIDENTIAL Page 7 of 20 CONFIDENTIAL Review