Theatre Accreditation, Audit & Services
Enhancing perioperative practice & patient safety in your theatres
AfPP Theatre Accreditation
AfPP Theatre Accreditation assesses the quality of perioperative care, helping hospitals uphold the highest standards while promoting continuous improvement.
The process begins with an initial visit to introduce the audit tool, typically over two days (or longer for hospitals with more than six theatres). This includes an in-depth review of:
- Management and Human Resources (mandatory)
- Five Steps to Safer Surgery (mandatory)
- Accountable Items (customisable based on hospital needs)
Following the visit, hospitals work through the audit tool independently, leveraging peer review opportunities. A follow-up visit assesses progress, with a final report determining accreditation status.
Accreditation acts as a quality ‘kite mark,’ valid for two years, confirming compliance with standards and a commitment to ongoing improvement.
Reaccreditation Visit
The reaccreditation visit is typically conducted over one day and follows a similar structure. For hospitals with more than six theatres, the visit will be extended to two days or more. Following the review, if it is determined that high standards are being maintained, the hospital will be awarded an additional two years of accreditation.
Review of Policies
We can review your current policies to ensure they align with AfPP Standards. This review is typically conducted offsite over the course of one day, following an initial call to discuss specific requirements. Using our Standards & Recommendations for Safe Perioperative Practice, we ensure a thorough evaluation of the policies in place.
A report will be provided following the review outlining areas where changes are required.
Review of Staffing
Maintaining adequate staffing ratios is essential for ensuring quality care, patient safety and staff wellbeing in the perioperative setting. Our consultants will review your current staffing levels and provide recommendations for improvements to uphold the highest standards. This review, based on the AfPP Staffing for Patients in the Perioperative Setting, is conducted offsite over one day, following an initial call to discuss specific requirements.
Following an assessment of service needs, theatre infrastructure and current staffing levels, a recommended safe staffing establishment report will be provided. This report will support the theatre team in delivering safe care, facilitate the implementation of recommended improvements and establish a framework to meet service requirements.
Perioperative Peer Review
AfPP’s Perioperative Peer Review is an observational exercise designed to assess theatre practices and provide constructive feedback. Often requested following poor CQC feedback, incidents, or concerns about practice, it offers reassurance and recommendations for improvement.
The review includes:
- A meeting with theatre practitioners
- Observation of patient care pathways
- Assessment of practices, policies, and documentation
Based on AfPP’s Standards & Recommendations for Safe Perioperative Practice, the review is not a formal audit but may reference the AfPP Perioperative Audit Tool. A formal report is provided with findings and suggested actions. Any immediate patient safety concerns are addressed on the spot and included in the final recommendations.
Audit Visit
An audit visit is conducted when a hospital requires assistance with using our Perioperative Audit Tool. Tailored to the hospital’s specific needs, the visit is typically carried out over two days to help the team get started with the toolkit, review findings and support the development of action plans for improvement. The duration may be longer depending on the size of the hospital and its requirements.
A formal report documenting the identified issues, discussions and findings will be provided following the visit. Should any instances of poor practice be observed that may compromise patient safety, these will be addressed either immediately upon observation or at the end of the visit.
All three types of review are based on professional judgment, with AfPP’s Standards and Recommendations for Safe Perioperative Practice 2022 serving as the guiding principle.
AfPP Nurse Consultants were very professional during their visits. In each visit, they provided comprehensive feedback and structure, supporting us to improve our clinical practice in the operating department to the highest standards and their expectations in the UK. The journey of three visits in two years has been very productive and useful for our service and staff. The AfPP Team has also been very supportive in addressing any queries we have had, always responding professionally and on time. AfPP Nurse Consultant’s feedback and responses has helped us enhance the quality of our audits and consultancy services.
Like AfPP, the Priory Hospital is dedicated in providing effective practice within our theatres that is safe for both our patients and our staff. Working with AfPP has been a really rewarding experience and has enabled us to gain the assurance that we are providing care of the highest standard. The AfPP Team were kind and supportive during their visit and took the time to get to know the theatre team, listening to them and providing further advice and guidance where we could improve. We are incredibly proud to have been awarded AfPP accreditation and will welcome a return visit when it’s time for renewal.
Sue and Max, AfPP Nurse Consultants, visited for reasons associated with AfPP’s Re-Accreditation. They were at the same time professional and friendly. They ensured that the theatre personnel felt comfortable during their visit, and they conducted their observations and checks with the utmost discretion. The staff received highly favourable verbal feedback at the conclusion of the lists. A discussion followed between one of them and me in my office at a later time. In general, the entire visit was extremely positive and Sue and Max deserve a 5-Star review.
