Standard 60: Surgical and Specialty Clinics

Sample. Review the operating lists and the privileges register for every session in the last 3 months, including any procedure added at short notice.

1. Each surgeon has documented privileges for the procedures they perform.

Method. Compare each surgeon on the sampled lists with the privileges register.

Evidence to show. Surgeon privileges register (SSC-REG-001); qualification and scope register (SPM-REG-002, existing, reused); staff qualification register (FW-REG-001, existing, reused).

Pass when. Every sampled surgeon has privileges recorded for the procedure.

2. The operating list is checked against privileges before each session.

Method. Check each sampled list for the privileges check and its date.

Evidence to show. Surgeon privileges and operating list check (SSC-SOP-001).

Pass when. Every sampled list has a privileges check dated before the session.

3. No procedure is done outside privileges, including short-notice additions.

Method. Check each short-notice addition for the privileges check and approval.

Evidence to show. Surgeon privileges and operating list check (SSC-SOP-001).

Pass when. Every short-notice addition has a privileges check and approval recorded.

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

• A general surgeon performs a vascular procedure added at short notice without privileges, and the patient has a major bleed.

Sample. Observe a sample of operations on several days and audit the checklist records for every operation in the last 3 months.

1. The checklist is completed at sign-in, time-out and sign-out for every operation.

Method. Check each sampled operation for the three checklist entries.

Evidence to show. Surgical safety checklist procedure (SRG-SOP-001, existing, reused); surgical safety checklist record (SRG-FRM-001, existing, reused).

Pass when. Every sampled operation has all three checklist stages recorded.

2. The operation site is marked and confirmed with the patient.

Method. Observe the site marking and the confirmation for each observed operation.

Evidence to show. Surgical safety checklist procedure (SRG-SOP-001, existing, reused).

Pass when. Every observed operation has the site marked and confirmed.

3. The checklist is completed before the first incision.

Method. Check the time of the time-out against the time of incision for each sampled operation.

Evidence to show. Surgical safety checklist record (SRG-FRM-001, existing, reused).

Pass when. Every sampled time-out was completed before incision.

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

• An operation proceeds on the wrong side because the site was not marked and the time-out was skipped.

Sample. Review anaesthesia and sedation records and the emergency equipment checks for every procedure with sedation or anaesthesia in the last 6 months.

1. Anaesthesia and sedation are given by credentialed clinicians.

Method. Compare the clinician for each sampled procedure with the credential register.

Evidence to show. Sedation credential register (DAY-REG-001, existing, reused); clinician qualification and scope register (SPM-REG-002, existing, reused).

Pass when. Every sampled clinician has a current credential at the time of the procedure.

2. Monitoring is continuous throughout the procedure and recovery.

Method. Check each sampled monitoring record for the entries across the procedure.

Evidence to show. Sedation and anaesthesia safety (AES-SOP-003, existing, reused); sedation and anaesthesia monitoring record (AES-FRM-003, existing, reused).

Pass when. Every sampled record has continuous monitoring recorded.

3. The emergency equipment is checked and a recovery area is ready.

Method. Inspect the emergency equipment and recovery area on the sampled days.

Evidence to show. Resuscitation area readiness (ED-POL-002, existing, reused); equipment inventory and service log (EQP-REG-001, existing, reused).

Pass when. The equipment and recovery area are ready on every sampled day.

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

• A sedated patient desaturates in recovery, and the suction and oxygen are not checked or ready.

Sample. Review the infection bundle and VTE records for every operation in the last 6 months, and the hand hygiene audit for the operating area.

1. The surgical site infection bundle is applied to each patient.

Method. Check the bundle compliance record for each sampled operation.

Evidence to show. Surgical site infection prevention bundle (SRG-SOP-003, existing, reused); surgical site infection bundle compliance record (SRG-FRM-004, existing, reused).

Pass when. Every sampled operation has the bundle recorded as applied.

2. The VTE assessment is done and prophylaxis is given as indicated.

Method. Check each sampled operation for the VTE assessment and any prophylaxis.

Evidence to show. VTE risk assessment and prophylaxis (CLN-SOP-005, existing, reused); VTE risk assessment record (CLN-FRM-007, existing, reused).

Pass when. Every sampled operation has a VTE assessment and prophylaxis as indicated.

3. Hand hygiene and sterile technique are followed in the operating area.

Method. Observe hand hygiene and sterile technique in the operating area on the sampled days.

Evidence to show. Hand hygiene at the point of care (HH-SOP-001, existing, reused); sterile technique and infection control in procedures (PRO-SOP-005, existing, reused).

Pass when. Every observed step follows the standard.

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

• An operation is done without a VTE assessment, and the patient has a pulmonary embolism on day three.

Sample. Review discharge and follow-up records for every operation in the last 6 months, including patients who had a complication.

1. Each patient recovers under monitoring until the discharge criteria are met.

Method. Check each sampled recovery record for the discharge criteria and the time of discharge.

Evidence to show. Recovery monitoring and discharge criteria (DAY-SOP-001, existing, reused); discharge and escort record (DAY-FRM-002, existing, reused).

Pass when. Every sampled discharge meets the criteria recorded.

2. Each patient leaves with an escort and written advice, and a follow-up booked before discharge.

Method. Check each sampled discharge for the escort, the written advice and the booked follow-up.

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

Pass when. Every sampled discharge has the escort, advice and booked follow-up recorded.

3. Complications are followed through the set pathway and recorded.

Method. Check each sampled complication for the pathway steps and the record.

Evidence to show. Complications pathway and named contact (PRO-SOP-003, existing, reused); adverse reaction record (PRO-FRM-006, existing, reused).

Pass when. Every sampled complication has the pathway followed and recorded.

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

• A patient with a wound complication after a day procedure is discharged with no named contact and presents late with sepsis.