Page 1 of 12
ACSA
Anaesthesia Clinical Services Accreditation
ACCREDITATION STANDARDS 2016
ACCREDITATION
Summary of major changes to the ACSA Standards document
New ACSA standards/evidence
These are new standards that have never appeared in ACSA before
1.1.1.22
1.1.1.25
1.1.1.26
1.2.4.8
1.2.4.9
1.5.0.8
1.5.0.9
4.3.1.2
4.6.2.4
4.8.0.5
1.3.1.2
Additions/amendments to existing ACSA standards/evidence/priority
Any additional wording or amendment to the existing standard/evidence. Additions are underlined.
1.1.1.1
1.1.1.2
1.1.1.3
1.1.1.4
1.1.1.5
1.1.1.11
1.1.1.12
1.1.1.14
1.1.1.15
1.1.1.18
1.1.1.19
1.2.1.1
1.2.1.3
1.2.1.4
1.2.1.5
1.2.2.1
1.2.2.2
1.2.3.3
1.2.4.3
1.2.4.6
1.2.4.7
1.3.2.2
1.4.1.2
1.4.1.5
1.4.2.5
1.4.2.6
1.4.3.1
1.4.3.2
1.4.4.3
1.4.4.4
1.4.5.2
1.4.5.3
1.5.0.1
1.5.0.2
1.5.0.4
1.5.0.5
1.5.0.7
1.6.0.1
1.7.0.1
1.7.0.2
2.1.1.2
2.1.1.5
2.1.1.6
2.1.1.7
2.1.1.8
2.1.1.10
2.1.1.11
2.1.1.13
2.2.1.3
2.2.3.2
2.2.3.3
2.4.2.1
2.4.2.2
2.4.3.1
2.5.1.1
2.5.2.2
2.6.2.1
2.6.5.4
3.1.2.2
3.2.2.2
3.3.1.1
3.3.2.2
3.3.3.1
3.4.0.1
4.1.0.2
4.1.0.3
4.1.0.4
4.2.1.1
4.4.1.1
4.4.3.2
4.5.1.1
4.5.1.3
4.6.2.3
4.8.0.1
4.8.0.2
4.8.0.5
Deletions of ACSA standards
Standards which have been deleted from the document
1.1.1.6
1.2.1.6
1.2.2.3
1.2.2.4
1.2.4.1
1.2.4.4
1.4.1.3
1.4.4.5
2.1.1.12
2.1.2.1
2.2.1.1
2.4.1.1
2.5.2.1
2.6.1.1
3.1.2.3
3.1.2.4
3.1.2.5
3.2.2.1a
3.3.1.2
3.3.2.1
3.3.3.4
4.4.3.1
4.5.1.4
4.6.2.2
4.6.3.1
4.6.3.2
4.6.3.3
4.6.4.1
4.7.0.1
4.8.0.4
Page 2 of 12
ACSA
Anaesthesia Clinical Services Accreditation
ACCREDITATION STANDARDS 2016
ACCREDITATION
A comprehensive list of changes to the ACSA Standards document
THE CARE PATHWAY
ACSA Standard
Description of change
1.1.1.1
Addition to evidence This should be visible on the anaesthetic record, on the rota, on display in the
department and visible in the obstetric area
1.1.1.2
Amendment to standard When children are admitted for surgery their care is supervised jointly with
a surgeon and paediatrician Previously ‘A consultant paediatrician is available for advice for every
paediatric patient undergoing anaesthesia’
Amendment to evidence Indicate clear arrangement/written guidance for access to paediatrician
Previously ‘This should be a duty paediatrician or a local arrangement with a nearby hospital and
staff should be able to provide a verbal account of the local policy. A hospital policy document
should be available’
1.1.1.3
Addition to evidence A copy of the policy should be provided. Policy should include provision for
review of ‘not for resuscitation’ orders prior to surgery
1.1.1.4
Addition to standard Where sedation is provided by an anaesthetist there is a policy for the provision
of this service including all subspecialty areas and the specifications of the facilities provided,
including paediatrics
1.1.1.5
Addition to evidence A copy of policies and protocols should be provided
1.1.1.6
Deleted standard There is a documented policy for the transfer of patients requiring anaesthetic
supervision and care, including any additional requirements for transfers to another geographical
site
Deleted evidence A copy of the policy should be provided
1.1.1.10
Amendment to priority Priority 1 Previously Priority 2
1.1.1.11
Amendment to evidence Multidisciplinary guidelines should be provided Previously ‘previous CNST,
NHSLA or equivalent evidence should be provided’
1.1.1.12
Amendment to standard An appropriate early warning score is in use for all patients including
emergencies, obstetric patients and children Previously ‘An appropriate Modified Early Warning
Score (MEWS) is in use for all patients including emergencies and obstetric patients’
Amendment to evidence Early warning scores should be visible on patient observation charts.
Paediatric early warning scores should be visible on all age-specific observation charts Previously
‘MEWS and MEOWS should be visible on patient observation charts’
1.1.1.14
Addition to standard There should be locally agreed policies for the 24-hour cover of emergency
surgery, prioritisation of emergency cases according to clinical urgency, and seniority of clinical staff
according to patient risk.
1.1.1.15
Amendment to standard There is a locally agreed and documented policy for the provision of
anaesthetic care, with or without transfer, for specialties not available onsite e.g. paediatrics
Previously ‘There is a locally agreed and documented policy for the provision of anaesthetic care,
with or without transfer, for specialties not available on-site e.g. paediatric care
Amendment to evidence Patient pathways should be relayed by staff members Previously ‘The
service level agreement should be relayed by staff members’
1.1.1.17
Amendment to priority Priority 1 previously Priority 2
1.1.1.18
Amendment to standard There is a documented policy to address the airway management of
adults and children in the emergency department Previously ‘There is a documented policy to
address the airway management of patients in the emergency department’
Page 3 of 12
ACSA
Anaesthesia Clinical Services Accreditation
ACCREDITATION STANDARDS 2016
ACCREDITATION
1.1.1.19
Amendment to standard There are documented policies for the anaesthetic management of
adults and children in radiology and MRI suites Previously ‘There are documented policies for the
anaesthetic management of patients in radiology and MRI suites’
1.1.1.22
New standard Care pathways and evidence of engagement with available regional paediatric
(anaesthetic/surgical/critical care) networks, based on the complexity of procedure, age and comorbidity of children, as well as clinical urgency and geography, are developed and agreed
Evidence Local and regional network standards, care pathways and policies available including
a policy clearly defining local surgical provision for children. Evidence of attendance at regional
network meetings and use of regional guidelines or involvement in network audits
Priority 2
CQC KLoE Safe, Responsive, Well-led
GPAS References 10.6.1, 10.6.2, 10.6.3, 10.6.5
1.1.1.25
New standard Policies for children’s surgical services are formulated and reviewed by a
multidisciplinary team including leads from the following specialities; paediatrics, anaesthesia,
surgery and nursing
Evidence Demonstrate committee overseeing services for children (minutes of meeting) and
hospital engagement in regional network (agenda, minutes)
Priority 2
CQC KLoE Safe, Effective, Responsive, Well-led
GPAS References 10.6.4
1.1.1.26
New standard There are clear criteria and standards for paediatric day surgery with regards the
children attending, discharge pathway and also the environment and staff where it is delivered
Evidence Policies and guidelines available including comorbidities and common conditions,
appropriate staff rotas
Priority 2
CQC KLoE Safe, Caring
GPAS References 10.3.8, 10.3.9, 10.3.10, 10.3.13
1.2.1.1
Addition to standard All patients, including parents and children, undergoing anaesthesia or
sedation have an appropriate preoperative assessment
1.2.1.3
Addition to evidence A verbal explanation should be provided regarding how patients are ranked
in urgency when there is competition for beds, how patients are recovered when anaesthetised
remotely (outside main theatres), what plans are in place for booking level 2 and level 3 care and
the access of obstetric and paediatric patients to level 2 and level 3 care
1.2.1.4
Addition to standard All patients, including children and their carers, undergoing anaesthesia or
sedation are seen by an anaesthetist after admission, prior to the procedure
Addition to evidence Patient records should have evidence that patients have been seen. Staff
should be able to give verbal confirmation that the assessment happens privately. Audit of parental
feedback and satisfaction.
1.2.1.5
Addition to standard There are agreed local policies for preoperative preparation of patients e.g.
fasting, investigations, cross-match, thromboprophylaxis, diabetes, latex-allergy, antacid prophylaxis
and others where appropriate
Addition to evidence A copy of the policy/policies should be provided and staff should give verbal
confirmation that they are fit for purpose and followed. In children, similar policies should be
provided including fasting and pregnancy testing in adolescents.
Page 4 of 12
ACSA
Anaesthesia Clinical Services Accreditation
ACCREDITATION STANDARDS 2016
ACCREDITATION
1.2.1.6
Deleted standard There is a designated area suitable for private communication with patients
Deleted evidence The designated area should at least be a curtain around a bed and should be
seen
1.2.2.1
Amendment to standard Adults and paediatric patients and their carers are given adequate
information upon which to base their decision regarding anaesthesia, post operative care and pain
relief Previously ‘Patients are given adequate information upon which to base their decision about
informed consent’
Amendment to evidence There is a record that patients have received information describing the
options, risks and benefits of the proposed procedures. Documentation of discussion of procedures
and risk e.g. on the anaesthetic record Previously ‘Leaflets are given and the anaesthetic chart
(or equivalent) shows a record that patients having epidurals or regional blocks have had risks
explained to them. The system should be robust.’
1.2.2.2
Amendment to evidence A copy of the staff induction pack should be provided. Staff taking
consent for paediatric anaesthesia have documented knowledge of legislation and good practice
guidance involving rights of the child, child protection processes and consent. Consent is taken by
a qualified person. Previously ‘A copy of the staff induction pack should be provided and include
specification that consent is taken by a qualified person’
1.2.2.3
Deleted standard There are written arrangements to cover consent for patients agreeing to
participate in research studies
Deleted evidence A copy of the policy should be provided
1.2.2.4
Deleted standard Separate written arrangements for consent apply for children under sixteen
Deleted evidence A copy of the national policy for consent for children should be provided
1.2.3.3
Amendment to priority Priority 1 Previously Priority 2
1.2.4.1
Deleted standard National policy for patient identification is followed
Deleted evidence Evidence that patients are labelled, that labels are replaced and that patient
name and number are both used at every stage of the WHO process (all checks) should be seen
1.2.4.3
Amendment to evidence Brief presentation of an example scenario which may be requested
at your ACSA review visit Previously ‘A copy of the policy should be provided. The policy should
include the involvement of physicians. Evidence that audit takes place, including audit data,
should be provided.’
1.2.4.4
Deleted standard Any changes to lists are agreed by all relevant parties
Deleted evidence Verbal confirmation should be given that protocols are in place and that they
comply with the WHO checklist
1.2.4.6
Addition to evidence A copy of rotas and lists showing dedicated theatre lists should be provided.
An audit demonstrating minimal delays to elective procedures to support local arrangements.
1.2.4.7
Amendment to standard Arrangements are in place for the multidisciplinary management
of vulnerable older patients Previously ‘Arrangements are in place for the multidisciplinary
management of vulnerable elderly patients’
1.2.4.8
New standard Children are separated from adult patients throughout their care pathway, including
theatres, recovery, inpatient wards, day ward and critical care unit. These areas should be safe and
accessible to parents and carers.
Evidence Demonstrate separate pathway and environment – seen at ‘walkabout’ session during
ACSA review visit. Prioritisation on mixed lists.
Priority 2
CQC KLoE Caring, Effective, Responsive
GPAS References 10.2.18, 10.6.6, 10.6.9
Page 5 of 12
ACSA
Anaesthesia Clinical Services Accreditation
ACCREDITATION STANDARDS 2016
ACCREDITATION
1.2.4.9
New standard Services and facilities take account of the specific needs of adolescents, where these
are different from those of children and adults
Evidence Demonstrate appropriate information on anaesthesia and surgery, provision of privacy
and policy on consent
Priority 2
CQC KLoE Responsive
GPAS References 10.2.22
1.3.1.2
New standard When a child undergoes anaesthesia, all staff (operating department practitioners/
assistants/anaesthetic nurses/recovery) have paediatric training and experience
Evidence Evidence of staff experience, regular training, rotas or policy. A lead paediatric nurse
should be directly involved with the organisation of the service and training of staff
Priority 2
CQC KLoE Safe
GPAS References 10.1.3
1.3.2.2
Addition to standard Devices for monitoring and maintaining or raising the temperature of
the patient are available throughout the perioperative pathway including control of theatre
temperature
Amendment to evidence Devices, including those suitable for use on children, should be seen and
need to be in working order so that they can be used intra-operatively Previously ‘Devices need to
be seen and need to be in working order so that they can be used intra-operatively’
1.4.1.2
Addition to standard An emergency call system is in place and understood by all relevant staff. This
must be both audible and visible.
Addition to evidence Verbal confirmation of the system and how it is used should be given by any
member of staff when asked. The review team may request a demonstration of the system at the
review visit.
1.4.1.3
Deleted standard Devices for maintaining or raising the temperature of the patient are available
Deleted evidence Devices should be seen
1.4.1.5
Addition to evidence Discharge criteria on a form for adults and children
1.4.2.5
Amendment to standard Whenever emergency surgery is undertaken, the recovery unit is
adequately staffed Previously ‘Whenever emergency surgery is undertaken, the recovery unit is
open continuously and adequately staffed’
1.4.2.6
Amendment to priority Priority 1 Previously Priority 2
Amendment to standard At any given time at least one member of recovery staff present is certified
at an appropriate level in life support Previously ‘At any given time at least one member of recovery
staff present is certified as an advanced life support provider or equivalent’
1.4.3.1
Amendment to standard There is a recognised process for the referral of day-case patients requiring
inpatient admission to an appropriate facility Previously ‘There is a recognised process in place for
the referral of patients requiring inpatient admission to an appropriate facility’
Addition to evidence A written policy should be provided for adults and children
1.4.3.2
Addition to standard There is a recognised process for the referral of patients requiring critical care,
including paediatric and obstetric patients, to an appropriate facility
Addition to evidence A written policy should be provided for adults and children
Page 6 of 12
ACSA
Anaesthesia Clinical Services Accreditation
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ACCREDITATION
1.4.4.3
Addition to standard Specialist acute pain management advice and intervention is available at all
times including escalation plans
Addition to evidence A system by which anaesthetists can be called at any time for advice should
be relayed verbally by any member of staff, including nursing staff, for adults and children.
1.4.4.4
Addition to standard There is a dedicated acute pain nurse specialist service which also covers the
needs of children
Addition to evidence Verbal confirmation should be given of pain service and staffing. Audits of
pain management and adult and paediatric guidelines available, such as those for multi-modal
analgesia. Demonstrate use of age appropriate pain tools. Records showing regular pain scores
being taken.
1.4.4.5
Deleted standard Multi-modal analgesia for children should be available in all settings
Deleted evidence A policy document on analgesia in paediatrics should be available
1.4.5.2
Amendment to standard There is an agreed procedure for the removal of supraglottic airways
Previously ‘There is an agreed procedure for the removal of endotracheal tubes and supraglottic
airways’
1.4.5.3
Addition to evidence A written policy should be provided for adults and children
1.5.0.1
Addition to standard Fully resourced, dedicated daytime emergency and trauma lists are provided
appropriate to local demand
1.5.0.2
Amendment to standard There is appropriate restriction to clinical areas for the safety of patients
and staff Previously ‘There is access to all clinical areas for appropriate staff at all times e.g. with
swipe cards’
1.5.0.4
Amendment to standard There are clear escalation processes should two emergencies occur
simultaneously Previously ‘There are clear guidelines available on whom to call if two emergencies
occur simultaneously’
1.5.0.5
Amendment to standard There is appropriate staffing of emergency areas to allow immediate
stabilisation and transfer of emergency patients Previously There is adequate staffing of emergency
areas to allow safe movement and transfer of emergency patients
1.5.0.7
Addition to evidence Evidence should be seen on the anaesthetic record for adults and children
1.5.0.8
New standard Paediatric critical care facilities delivered locally are appropriate for the surgery
performed, as part of the regional network, and there are appropriate facilities to stabilise and
provide ongoing critical care prior to transfer to the regional centre if required
Evidence Engagement with network, named lead consultant locally; guidelines and policies
regarding post-operative critical care, stabilisation of common conditions e.g. sepsis, respiratory
failure, head injury; identified paediatric resuscitation areas in ED and general ICU.
Priority 2
CQC KLoE Safe, Responsive
GPAS References 10.6.2, 10.6.3, 10.3.1, 10.3.2, 10.3.7, 10.3.5, 10.2.21
1.5.0.9
New standard Hospitals have arrangements within their network for the transfer of sick infants and
children to the regional specialist centre including time critical transfers
Evidence Network and local policies, evidence of multidisciplinary working, named lead consultant
Priority 2
CQC KLoE Safe, Responsive
GPAS References 10.6.3
Page 7 of 12
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1.6.0.1
Amendment to standard There are policies for the management of immediate and delayed
complications of neuraxial blockade Previously ‘There are policies for the management
complications of neuraxial blockade’
Amendment to evidence Written policies should be provided Previously ‘A written policy should be
provided’
1.7.0.1
Amendment to standard A person skilled in intubation is onsite to support the resuscitation team
Previously ‘ A person skilled in intubation is available to support the resuscitation team when
requested’
1.7.0.2
Addition to evidence Verbal confirmation should be given. Evidence of appropriate mandatory
training for age range of patients.
EQUIPMENT, FACILITIES AND STAFFING
ACSA Standard
Description of change
2.1.1.2
Addition to standard Equipment for monitoring, including capnography, ventilation of patients’ lungs
and resuscitation including defibrillation is available at all sites where patients are anaesthetised or
sedated and on the delivery suite. This includes equipment specifically designed for children.
2.1.1.5
Addition to evidence Staff should be asked what range of local and regional blocks they feel is
lacking based on the procedures they undertake for adults and children
2.1.1.6
Addition to evidence Verbal confirmation should be given for adults and children
2.1.1.7
Addition to evidence The difficult airway trolley should be seen and the equipment on it should be
checked. All members of staff should be able to confirm its location for adults and children
2.1.1.8
Amendment to evidence Evidence of the Control of Substances Hazardous to Human Health
(COSHH) data Previously ‘Verbal confirmation should be given’
2.1.1.10
Addition to evidence Portable ventilators and monitoring should be seen for adults and children
2.1.1.11
Addition to evidence An adequate number of PCAs epidural pumps and the arrangements for their
use should be available for the services being provided for adults and children
2.1.1.12
Deleted standard There is equipment available to monitor and maintain patient temperature
Deleted evidence Equipment should be seen
2.1.1.13
Addition to evidence Cylinders should be seen and paper records of checks should be provided
along with an operational policy for backup oxygen provision
2.1.2.1
Deleted standard A named consultant oversees the provision of anaesthetic equipment
Deleted evidence The name of this person should be given
2.2.1.1
Deleted standard Access to the British National Formulary (BNF) and BNF for Children is available
Deleted evidence Written copies or verbal evidence of a procedure to access the information by
phone should be provided
2.2.1.3
Addition to standard In every site where anaesthesia is given emergency drugs including intralipid,
sugammadex and dantrolene are readily available and in-date supply is maintained
2.2.3.2
Addition to evidence Equipment should be seen for adults and children
2.2.3.3
Addition to evidence Equipment should be seen with evidence of ongoing training for adults and
children
2.4.1.1
Deleted standard The anaesthetic room and operating theatre conform to Department of Health
building standards
2.4.2.1
Amendment to standard Appropriate facilities for rest are available for staff working at night
Previously ‘Appropriate facilities for rest are available for on-call/on-duty staff
Page 8 of 12
ACSA
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2.4.2.2
Amendment to priority Priority 1 Previously Priority 2
New evidence Verbal confirmation and viewing area where staff can make tea/coffee
2.4.3.1
Amendment to standard Time, space and equipment is made available for resuscitation and
theatre team training Previously ‘Space is made available for resuscitation and theatre team
training’
2.5.1.1
Addition to evidence Majority of permanent staff should report that they are satisfied
2.5.2.1
Deleted standard There is evidence that there is whole team training for both technical and nontechnical skills
Deleted evidence Verbal confirmation should be given
2.5.2.2
Addition to standard Midwives trained to an agreed standard in the management of regional
analgesia are available before an obstetric epidural block is established. An appropriate number
of midwives trained to an agreed standard are available for the case mix of patients with regional
analgesia.
Amendment to evidence Staff working in obstetric anaesthesia should report that they are satisfied
with local arrangements and that epidurals are not being denied to patients due to the nonavailability of trained staff Previously ‘Staff working in obstetric anaesthesia should report that they
are satisfied with local arrangements and that epidurals are not being denied to patients due to
the availability of trained staff. Departments which have achieved CNST, NHSLA or equivalent
automatically meet this standard.’
2.6.1.1
Deleted standard Where transfer is necessary patients are always accompanied by appropriately
trained staff
Deleted evidence A written policy should be provided
2.6.2.1
Amendment to standard There are consultant clinical leads with responsibility in the following areas:
resuscitation, day surgery, acute pain management, obstetrics, emergency anaesthesia, remote
sites (including the emergency department/trauma), ECT (if available), research, paediatrics,
ICM, anaesthetic equipment, pre-operative assessment, simulator training (if available), airway
management (to include difficult and awake intubation management protocols). Previously
‘There is a consultant clinical lead with responsibility in the following areas: Resuscitation, day
surgery, acute pain management, obstetrics, emergency anaesthesia, remote sites (including the
emergency department/trauma), ECT, paediatrics, ICM, anaesthetic, pre-operative assessment,
simulator training (if available), airway management (to include difficult and awake intubation
management protocols)’
Addition to evidence The names of individuals should be provided. Identified paediatric lead,
evidence of wider delivery of surgical / anaesthetic services for children e.g. training, guidelines,
peer meetings
2.6.5.4
Amendment to standard Medically led obstetric units have a minimum of ten consultant
anaesthesia DCC PAs per week Previously ‘Consultant led obstetric units have a minimum of ten
consultant anaesthesia DCC PAs per week’
PATIENT EXPERIENCE
ACSA Standard
Description of change
3.1.2.2
Addition to standard Patients and their advocates understand the choices available and the
associated risks and side effects of their anaesthetic procedure, including pain relief
Amendment to evidence Patient information and feedback should be provided for adults and
children; good communication via available leaflets; leaflets that set out risks and benefits of
particular procedure; anaesthetic record shows that patients received this. Previously ‘Patient
information and written feedback should be provided’
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ACCREDITATION
3.1.2.3
Deleted standard Patients and their advocates understand the risks and outcomes associated with
their procedure
Deleted evidence Patient information and feedback should be provided
3.1.2.4
Deleted standard Alternatives are explained to patients and their advocates
Deleted evidence Patient information and feedback should be provided
3.1.2.5
Deleted standard Patients and/or their advocates are given information about the possible side
effects of pain relief drugs
Deleted evidence Patient information and feedback should be provided
3.2.2.1a
Deleted standard There is an appropriate facility for privacy and confidentiality for pre-operative
discussion about anaesthetic care
Deleted evidence An area where confidential discussion can take place should be seen
3.2.2.2
Addition to evidence Staff should report that they are satisfied with the support for adults and
children with particular requirements, for example learning disabilities.
3.3.1.1
Amendment to standard Day surgery patients are given clear and concise written information after
discharge including access to a 24-hour staffed telephone line for advice Previously ‘Day surgery
patients must have access to a 24-hour staff telephone line for advice after discharge’
Amendment to evidence Leaflets given to patients on discharge from the hospital include a
telephone number for advice. The information on the leaflets should include warning signs of serious
complications and appropriate actions to take. There should also be information on what to do,
and what not to do, following discharge including post-discharge analgesia protocols. The postoperative instructions facilitate ongoing self-care by the patient, and should include a help-line in
case of concerns for adults and children. Previously ‘Verbal confirmation should be given’
3.3.1.2
Deleted standard Day surgery patients should be given clear and concise written information prior
to discharge
Deleted evidence The information should include warning signs or serious complications and
appropriate actions to take. The post-operative instructions facilitate ongoing self-care by the
patient, and should include a help-line in case of concerns
3.3.2.1
Deleted standard Alternative language leaflets are available appropriate to the needs of the local
population
Deleted evidence Copies of leaflets should be provided
3.3.2.2
Amendment to standard Patients and/or advocates have access to adequate interpretation
services according to their needs or protected characteristics Previously ‘Patients and/or advocates
have access to an interpreter’
Amendment to evidence Leaflets should be provided that cover a range of patient groups. Verbal
confirmation should be given that access to interpretation services is available for patients who do
not understand English. Previously ‘ Verbal confirmation should be given’
3.3.3.1
Amendment to standard Information given to adult and paediatric patients and/or advocates
includes what to expect in the anaesthetic room, operating theatre, recovery room and obstetrics
department, as appropriate Previously ‘Verbal and written information given to patients and/or
advocates includes what to expect in the anaesthetic room, operating theatre and recovery room’
Amendment to evidence Copies of written information should be provided. Leaflets that cover a
variety of ages and levels of understanding appropriate to the patient, including confirmation of
whether a 24 hour epidural service is available Previously ‘Verbal confirmation and copies of written
information should be provided’
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ACCREDITATION
3.3.3.4
Deleted standard Patients and/or advocates are provided with information that is specific to their
level of understanding
Deleted evidence Simplified versions of leaflets and children’s leaflets should be provided. Verbal
confirmation of the discussion around the consent process should be given
3.4.0.1
Amendment to standard Senior clinicians are involved in breaking bad news and discussions around
futility and end of life decisions Previously ‘Senior clinicians are involved in the discussion of end of
life pathways’
CLINICAL GOVERNANCE
ACSA Standard
Description of change
4.1.0.2
Amendment to standard The whole theatre and maternity team engage in, and document,
the use of the WHO process including team brief and debrief in all settings where anaesthesia is
administered Previously ‘The whole theatre and maternity team engage in, and document, the use
of the WHO checklist in all settings where anaesthesia is administered’
Addition to evidence Verbal confirmation from staff. Records should be provided.
4.1.0.3
Amendment to standard Up-to-date, clear and complete information about operating lists is printed
and displayed and any changes to lists are agreed by all relevant parties Previously ‘Up-to-date,
clear and complete information about operating lists is immediately available. Any changes are
agreed by all relevant parties’
4.1.0.4
Amendment to standard Where relevant there must be adequate doctors available to
simultaneously cover commitments in obstetrics, critical care and emergency theatres Previously
‘Arrangements for the cover of obstetrics, ICM and general work are monitored with respect to the
workload’
Amendment to evidence Verbal confirmation that there is a mechanism to recognise issues should
be given. Example of scenario at review visit if requested. Previously ‘Evidence of audit should be
provided and verbal confirmation that there is a mechanism to recognise issues should be given’
4.2.1.1
Addition to evidence Verbal confirmation of should be given. Minutes of governance meetings and
risk register should be seen.
4.3.1.2
New standard There are specific systems in place for review of the following relating to babies and
children; perioperative deaths within 30 days of surgery, serious untoward incidents, untoward
incidents and transfers of children for surgery elsewhere. These are reported to the relevant national
agency.
Evidence Minutes of meetings and multidisciplinary reviews, completed reports and local audits
Priority 1
CQC KLoE Responsive, Safe
GPAS References 10.5.3
4.4.1.1
Addition to standard An obstetric anaesthetist takes part in regular multidisciplinary ‘labour ward
forum’ or equivalent meetings
4.4.3.1
Deleted standard A representative range of resuscitation equipment, matching that in use and
including mannequins, is available for training purposes
Deleted evidence Equipment should be shown by the resuscitation training officer
4.4.3.2
Addition to standard There is regular multidisciplinary team training for emergency situations
4.5.1.1
Amendment to standard The department has evidence of engagement with, and implementation
of national audit projects and quality improvement programmes, including obstetrics Previously ‘The
department has evidence of engagement with national audit projects, including obstetrics’
4.5.1.3
Addition to standard The emergency surgery workload is continually monitored and reviewed and is
used to plan future workload
Page 11 of 12
ACSA
Anaesthesia Clinical Services Accreditation
ACCREDITATION STANDARDS 2016
ACCREDITATION
4.5.1.4
Deleted standard The department has evidence of implementation of appropriate local and
national audit recommendations e.g. NAP and NCEPOD
Deleted evidence Written evidence should be provided
4.6.2.1
Amendment to priority Priority 1 Previously Priority 2
4.6.2.2
Deleted standard There is a resuscitation officer responsible for coordinating and training of staff
Deleted evidence The name of this person should be provided
4.6.2.3
Amendment to priority Priority 1 Previously Priority 2
Addition to standard All permanent members of staff should receive adequate time, resources and
support for all activities related to appraisal and revalidation
4.6.2.4
New standard All staff undertaking paediatric practice have evidence of maintaining their
knowledge and skills through CPD, including resuscitation and safeguarding/child protection (level
2)
Evidence Evidence of appraisal for paediatric anaesthesia, appropriate supervision of trainees/nontraining grades, training records. Named leads for training, including safeguarding lead with level 3
competencies
Priority 2
CQC KLoE Safe, Well-led
GPAS References 10.4.1, 10.4.4, 10.4.6, 10.4.7
4.6.3.1
Deleted standard Resources are available for all staff to have up to date training, which is
appropriately funded, in resuscitation relevant to their clinical practice including paediatric
resuscitation and obstetrics where relevant
Deleted evidence Records of funded training should be seen and the name of the person within the
department with responsibility for ensuring all staff are up to date with mandatory training should be
given
4.6.3.2
Deleted standard All staff have up to date training relevant to their clinical practice including
emergency surgery
Deleted evidence Records that the training has happened and rotas for emergency surgery lists
should be provided
4.6.3.3
Deleted standard All staff undertaking paediatric practice have evidence of maintaining their
knowledge and skills through CPD, including child protection
Deleted evidence Records of training should be seen and the name of the person within the
department with responsibility for ensuring all staff are up to date with mandatory training should be
given
4.6.4.1
Deleted standard Non-consultant staff have unimpeded access, for advice, to a nominated
consultant
Deleted evidence Written policies should be provided and specific groups should be able to relay
how they would know who to contact. For example; names are displayed or on the rota
4.7.0.1
Deleted standard All research is R&D reviewed and REC reviewed
Deleted evidence Written documentation from the ethics committee should be provided
Page 12 of 12
ACSA
Anaesthesia Clinical Services Accreditation
ACCREDITATION STANDARDS 2016
ACCREDITATION
4.8.0.1
Amendment to standard The department has developed an annual plan or equivalent highlighting
operational, strategic and workforce developments to ensure developing and responsive resources
for perioperative care and the safe delivery of emergency surgical and non-theatre workload
Previously ‘The department has a business plan to ensure necessary resources for perioperative
care’
Amendment to evidence The clinical director should provide a copy of the document Previously
‘The Clinical Director should provide verbal confirmation’
4.8.0.2
Amendment to evidence The clinical director should provide written evidence Previously ‘The
Clinical Director should provide verbal confirmation’
4.8.0.4
Deleted standard The department has a business plan in place for the delivery of safe emergency
surgical workload
Deleted evidence The Clinical Director should provide verbal confirmation
4.8.0.5
New standard The department has a plan in the event of a major incident
Evidence A written policy. Staff should be aware of their role in the event of a major incident
Priority 2
CQC KLoE Safe, Effective, Well-led
GPAS References 5.5.36, 5.4.5, 16.6.20, 16.6.21