Standard 54: Dermatology and Skin Clinics

Sample. Review skin lesion records and referrals for a sample of patients in the last 6 months, including every biopsy taken.

1. Every skin lesion is examined by a documented method.

Method. Check each sampled record for the examination features recorded.

Evidence to show. Skin lesion examination and urgent referral (DRM-SOP-001); skin lesion examination and referral record (DRM-FRM-001).

Pass when. Every sampled lesion has its features recorded.

2. A lesion suspicious for malignancy is referred urgently.

Method. Check each sampled suspicious lesion for the referral date against the time set.

Evidence to show. Skin lesion examination and referral record (DRM-FRM-001).

Pass when. Every sampled suspicious lesion was referred within the set time.

3. Each biopsy is tracked to a pathology result.

Method. Check each sampled biopsy for the pathology result and the date the patient was told.

Evidence to show. Aftercare and pathology follow-up record (DRM-FRM-003).

Pass when. Every sampled biopsy has a recorded result and the patient was told it.

Immediate fail (any one means the criterion is not met)

• A changing pigmented lesion is recorded as benign and not referred, and is later found to be melanoma.

Sample. Observe minor skin procedures on several days and audit the records for the sample period.

1. Minor skin procedures are carried out with sterile technique.

Method. Observe a sample of procedures and check each against the technique steps.

Evidence to show. Sterile technique for minor skin procedures (DRM-SOP-002); sterile technique audit record (PRO-FRM-005, existing, reused).

Pass when. Every observed procedure follows sterile technique.

2. Hand hygiene is done before each procedure.

Method. Observe the hand hygiene before each observed procedure.

Evidence to show. Hand hygiene at the point of care (HH-SOP-001, existing, reused).

Pass when. Hand hygiene is done before every observed procedure.

3. Instruments are single-use or sterilised, and sharps are disposed of at once.

Method. Check the instrument records and the sharps disposal on each sampled day.

Evidence to show. Sterile technique and infection control in procedures (PRO-SOP-005, existing, reused).

Pass when. Every sampled instrument is single-use or sterilised, and sharps are disposed of at once.

Immediate fail (any one means the criterion is not met)

• A biopsy instrument is reused without sterilisation, and the patient develops a wound infection.

Sample. Review the device log and operator sign-off records for all laser and light devices in the last 12 months.

1. Each device is operated only by staff signed off for it.

Method. Compare each logged use with the operator sign-off list.

Evidence to show. Laser and light device safety (DRM-POL-001); device use log (DRM-REG-002).

Pass when. Every logged use was by a signed-off operator.

2. Skin type, settings and contraindications are checked before each treatment.

Method. Check each logged treatment for the check entries.

Evidence to show. Laser and light device use log (DRM-REG-002).

Pass when. Every logged treatment has the checks recorded.

3. Eye protection is used during treatment.

Method. Check each logged treatment for the eye protection entry.

Evidence to show. Laser and light device use log (DRM-REG-002).

Pass when. Every logged treatment records eye protection.

Immediate fail (any one means the criterion is not met)

• A laser is used on the face without eye protection, and a patient suffers an eye injury.

Sample. Review the records of patients on systemic dermatology drugs with monitoring needs in the last 12 months.

1. Systemic drugs with monitoring needs are prescribed under the written protocol.

Method. Check each sampled prescription against the protocol.

Evidence to show. Systemic dermatology drug monitoring (DRM-SOP-003); medicines management policy (HOS-POL-001, existing, reused).

Pass when. Every sampled prescription follows the protocol.

2. Pregnancy prevention and the required tests are set before the first dose.

Method. Check each sampled patient for the baseline tests and the pregnancy prevention plan before the first dose.

Evidence to show. Systemic drug monitoring and pregnancy prevention record (DRM-FRM-002).

Pass when. Every sampled patient has both recorded before the first dose.

3. Results are repeated at the interval and acted on.

Method. Check the monitoring dates against the interval and the action taken for each out-of-limit result.

Evidence to show. Systemic drug monitoring and pregnancy prevention record (DRM-FRM-002).

Pass when. Every test was repeated on time, and each out-of-limit result has a recorded action.

Immediate fail (any one means the criterion is not met)

• A patient on a systemic drug has no blood test for a year, and an abnormal result is missed.

Sample. Review discharge records for a sample of procedures and biopsies in the last 6 months.

1. Each patient who has a procedure receives written aftercare at discharge.

Method. Check each sampled procedure record for the aftercare sheet given.

Evidence to show. Written aftercare and pathology follow-up (DRM-SOP-004); aftercare and pathology follow-up record (DRM-FRM-003).

Pass when. Every sampled procedure has written aftercare recorded as given.

2. A pathology follow-up is booked before the patient leaves.

Method. Check each sampled biopsy for the booked follow-up date before discharge.

Evidence to show. Follow-up booking before discharge (AFT-FRM-001, existing, reused).

Pass when. Every sampled biopsy has a follow-up booked before discharge.

3. Patients who do not attend are contacted.

Method. Check each sampled non-attendance for the contact record.

Evidence to show. Aftercare and pathology follow-up record (DRM-FRM-003).

Pass when. Every sampled non-attendance has a recorded contact.

Immediate fail (any one means the criterion is not met)

• A patient with a biopsy leaves with no appointment, and the malignant result is never delivered.