The accreditation review process for training hospitals

Process of an Accreditation Review

The accreditation review will utilise processes that are open, consultative, and transparent to both the Council and the hospital concerned.

The Council will appoint an accreditation team to undertake the 5-yearly accreditation review.  The team will be typically be comprised of 3 members.

The accreditation team will designate one of its members to be a primary liaison person with hospital personnel to discuss and agree the accreditation review programme

An accreditation review for a previously-accredited training hospital will typically involve the following activities:

  1. Training hospital submits a self-assessment report to the Council
  2. Training hospital provides Council with names and contact details of trainees
  3. Accreditation team conduct phone interviews with trainees
  4. Accreditation team reviews self-assessment report and requests any further information as required
  5. Accreditation team reviews report and information from trainee interviews against the standards
  6. Accreditation team prepares a report of its findings
  7. Hospital is given an opportunity to comment on the draft report
  8. Accreditation team submits its final report to the Council
  9. The Council considers the accreditation report and makes a final decision on the accreditation status for the hospital concerned
  10. The Council informs the hospital of its decision
  11. The Council monitors the hospital in respect of any required/recommended improvements
  12. The hospital submits annual reports to the Council

An accreditation review for a new training hospital will typically involve a very similar process to the one above except that an accreditation site-visit will also take place. The accreditation team will visit the training hospital and conduct interviews with relevant groups and individuals as well as view the various training hospital facilities.

The accreditation team will then draft a report based on the self-assessment documentation and the accreditation visit. For more detailed information please review the Accreditation Standards for Training Hospitals (Anaesthetic Technology).