Assessment Criteria
The survey combines both objective and subjective components to provide a comprehensive assessment of the performance of the Centre.
The following terminology is used.
Fully Met
  • This is when the assessment criteria are achieved to the level of 80-100%.
Partially Met
  • This is when the assessment criteria are achieved to the level of 50-79%.
Not Met
  • This is when the assessment criteria are achieved to the level of 0-49%.

1. Hospital Organisation

The Centre will introduce the organization of the hospital including the Obstetrics and Gynaecology department. The presentation must include the following:

  • Head of MIS
  • MIS Doctors/Trainees
  • MIS Staff
  • Anaesthetic Team
  • Operating Theatre Staff
  • Nursing Staff

1.1 Head of MIS

The Assessors will conduct a panel interview with the Head of MIS.

  • Appointment Process
  • The Head of MIS must be Fellow of APAGE or in the process of applying for accreditation as a surgeon
  • Role of Head of MIS within department/hospital
  • MIS Teaching, Training, Research
  • Vision for MIS Department

1.2 Facilities

The Assessors will conduct a hospital tour. The hospital tour should occur on a normal working day and include the following key areas:

  • Outpatient Clinics
  • Outpatient Hysteroscopy Suite
  • Day Surgery
  • Major Operating Theatres
  • Post Anaesthesia Recovery Area
  • High Dependency Unit, Intensive Care Unit
  • Inpatient Wards
  • Skills Lab

1.3 Equipment and Instruments

This will be assessed during the hospital tour. There centre should also provide, if available and applicable, an updated service log of equipment.

1.4 On Call Coverage for Complications/Emergencies

The Centre must demonstrate a system of referral. Applicants must submit:

a. On Call Roster:

  • 24 hours qualified ACLS Physician
  • 24 hours Gynaecologist On Call

b. Referral Pathway to Other Specialties: Pre, Intra and Post Operative

  • General Surgeons
  • Urologists
  • Vascular Surgeons
  • Radiologists

c.List of personnel with BLS/ACLS qualification

2. Qualifying Procedures

The Centre must submit a case logbook in the 12 months preceding the date of application. Please use the following format as an example


Hospital Patient ID

Date of Procedure

Name of Procedure














A separate logbook must be submitted for a. laparoscopic procedures b. hysteroscopic procedures and c. vaginal procedures. Only qualifying procedures need to be included in the logbook. Please refer to Appendix A for a list of qualifying procedures.

 3. Informed Consent

The Centre will introduce the hospital’s policy on Informed Consent. This criterion will be further assessed by inspection of medical records/consent forms. The Applicant must prepare 5 medical records for each individual assessor i.e. total:

15 Medical Records for inspection. The applicant may need to provide an English translator if necessary.

Medical Records should reflect the following:

  • A sample period across 12 months
  • Different surgeons obtaining consent
  • Only MIS procedures

3.1   Supporting Documents

The centre may also include patient information leaflets or any activity that improves patient education that the hospital provides.

4. Clinical Pathways

The Centre should submit existing clinical pathways that are implemented by the hospital. They should ideally include all of the following:

  • Intraoperative anaesthesia, including monitoring and airway management
  • Perioperative care, including monitoring, pain management and airway management
  • DVT prevention and management
  • Instructions for the management of perioperative and postoperative complication warning signs such as tachycardia, fever or haemorrhage
  • Evaluation and plan of action for patients at high risk for malignancy including when a malignancy is detected
  • Fluid management in hysteroscopy
  • Preoperative patient preparation checklist, including education, consent and instruction

If available, the Centre can submit audit data to demonstrate adherence to these hospital’s protocols. Assessors will also assess adherence through medical records. These can be the same records as those used for assessing Informed Consent.

5. Training

a. Courses/Training Programme

The Centre must demonstrate relevant personnel (surgeons/nursing staff) undergo MIS training. The training curriculum should be submitted. This may be in-house accreditation process and may include:

  • Basic Laparoscopy/Hysteroscopy Course
  • Advanced Laparoscopy/Hysteroscopy Course
  • Others: Case Discussion, Topic Presentation

A list of personnel with relevant qualifications should be submitted.

The Assessors will also conduct a panel interview with 2 selected Trainees regarding their MIS training: 1 Junior and 1 Senior. If the centre offers MIS fellowship, then this interview should also include 1 MIS Fellow.

b. Fellowship Programme

The Centre should submit a Training Programme for Fellows, if applicable.

4.3 Training Facilities

The Centre should have a Skills Lab where clinicians can have hands-on skills. The Assessors will inspect this during the hospital tour.

6. Continuous Quality Assessment

The Centre must demonstrate an active audit process to evaluate outcomes on MIGS procedures.

  • Regular Audit Meetings
  • Audit Data on Outcomes in the preceding 12 months.
  • Patient outomes or safety meaures

7. Patient Satisfaction

The surveyors will select from a list of patients provided by the centre to interview. This can range from 6-10 patients.

A validated patient satisfaction questionnaire will be used.

Please download: ACMIG Accreditation Appendix A