Perioperative practice
l Identification of gaps and support to close them.
l Celebration of good practice. l Confidence that services are prepared for regulatory inspection by CQC.
The Accreditation Journey: a step-by-step process AfPP Accreditation follows a clear structure designed to support hospitals at every stage: 1. Initial Visit - Typically two days (or longer for hospitals with more than six theatres). Experienced AfPP auditors will visit the hospital, observing practices, engaging with staff, and reviewing evidence.
2. Embedding continuous improvement - The AfPP Audit Tool is an essential part of the Accreditation process and forms the basis of the audit. The hospital must complete the full audit tool before Accreditation can be awarded. Regular use of the tool helps identify areas for improvement in advance and supports the ongoing maintenance of high standards once Accreditation has been achieved.
3. Follow-up Visit - Two AfPP consultants return to the operating department to review any changes and provide any further guidance.
4. Final Report & Accreditation - If standards are met, the hospital receives Accreditation, valid for two years, demonstrating the department’s achievements and areas of excellence, as well as confirming that it has met recognised safety and quality standards.
5. Reaccreditation - A revisit after two years to support continuous improvement, reinforce
AfPP Accreditation at a glance
What is it? A structured process to assess and improve perioperative care, providing independent assurance that theatres are safe, effective, and compliant with national standards.
How it works: l Initial Visit: Full review and introduction of the AfPP Audit Tool.
l Independent Work: Hospital teams embed peer review and address gaps.
l Follow-up Visit: AfPP checks progress and provides further support.
l Final Report & Accreditation: Valid for 2 years. l Reaccreditation Visit: Extends Accreditation for another two years.
What it covers: Observations will cover a range of perioperative
good practice, and help embed a culture of reflective learning.
AfPP Accreditation is a mark of excellence, it sets your service apart. It demonstrates to all stakeholders that your theatre is committed to the highest standards of perioperative care.
Circle Health Group: a national case study When Circle Health Group began its journey with
practice areas, including: l Compliance with NatSSIPs2 l Management and Human Resources Practices
l Accountable Items Management l Documentation & Policy Compliance l Culture & Teamwork
Benefits for hospitals: l Assurance of compliance l Regulatory readiness l Celebration of good practice l Constructive, supportive process l Action plans for improvement
Additional AfPP services: l Policy Reviews l Staffing Reviews l Perioperative Peer Reviews l Bespoke Audit Visits
AfPP in 2020, its goal was ambitious: to put the 49 of its 54 hospitals with operating theatres through the Audit Accreditation process. Four years later, in 2025, and with a break in the process due to COVID, that ambition became a reality. The final hospital to achieve Accreditation
was The Ridgeway Hospital in Wroughton, completing what has become AfPP’s largest and most comprehensive roll-out of Audit and Accreditation services to date. Matt Ashman, National Lead for Theatre
& Recovery Services at Circle Health Group, described the impact: “We saw Accreditation as a quality improvement journey. Having AfPP experts come in to give us a third-party view was invaluable. It wasn’t a rubber-stamping exercise - it was supportive, thorough, and all about conversations. Our teams learned, reflected, and improved.” Matt added: “What really stood out to me
Vicky Jones - Circle Group Director of Clinical Practice and Specialist Services; Matt Ashman - Circle Group National Lead Theatres & Recovery Services; Alex Duke - AfPP CEO; and Adam Busby - Circle Group Chief Clinical and Quality Officer
was how much our teams grew through the process. Accreditation gave them confidence in their practice and a sense of pride in their achievements. It has strengthened teamwork, built resilience, and reinforced our shared commitment to safe, high-quality care. “The Accreditation process has been a unifying experience for Circle Health Group. It created consistency across all 49 hospitals while still recognising the individuality of each theatre team. That balance of structure and flexibility has been key to embedding real, sustainable improvement.”
He said at the heart of the process were patients: “AfPP Accreditation has given us
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