2. 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

3. Domains Care Pathway Equipment Facilities and Staffing Patient Experience Clinical Governance

4. 4.1.0.3Up-to-date, clear and complete information about operating lists is printed and displayed any changes are agreed by all relevant parties 1 Safe Effective Well-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 Safe Effective Well-led 9.1.6 Evidence of audit should be provided and verbal confirmation that there is a mechanism to recognise issues should be given 4.1.0.5There is a formal handover process between shifts, multidisciplinary where appropriate 1 Safe Effective Well-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

5. 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

6. 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

7. 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

8. 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

9. Inspection Self declaration to the college in January 2015 On site review on March 3 rd and 4 th by the inspection team 2 CDs, patient representative and administrators Departmental presentation Met with clinicians, managers, nurses and patients

10. 16 th April 2015 2 nd Department in the UK