Standards › ASF Health Standards v10 › Module 3B · Surgical and Procedural Safety

Module 3B · Surgical and Procedural Safety

3 criteria · ASF Health Standards v10 · Draft for review

Each criterion below shows what the surveyor checks, the evidence to show, and what counts as met, partly met or not met.

Colour key: Red = Essential, required in every setting. Green = Recommended. Amber = Standard.

3B.1 The Surgical Safety Checklist Is Used

Non-negotiable

WHO's Surgical Safety Checklist is completed, out loud, as a team pause for every procedure — not filed as paperwork after the fact — and includes explicit verification of correct patient, correct procedure, and correct body site, with the site physically marked before the patient enters theatre.

Questions the surveyor asks

1. Is the checklist completed out loud, as a team, before induction, before incision, and before the patient leaves theatre? All three checkpoints, spoken, not just the pre-induction one done and the rest skipped.
2. Does every team member participate, not just the most senior person present? A checklist read by one person to a silent room misses its purpose — catching what any team member might notice.
3. Is there evidence the checklist has changed a decision or caught an issue, not just been completed? A checklist that never catches anything over time is worth questioning, not simply checking for completion.
4. For any procedure involving laterality, multiple structures, or multiple levels, is the surgical site physically marked by the operating clinician before the patient enters theatre, and is that mark visible and verified during the time-out? Explicit site marking and verification, not an assumption that confirming the procedure name alone rules out wrong-site error.

Why it matters. The surgical safety checklist works only when the team says it out loud, together, at each pause. A checklist filed after the operation protects no one.

Evidence to show. Checklist (current) and an observation record for 10 procedures showing the three pauses.

Good

• checklist completed out loud at each pause, with the whole team taking part.

Failure

• checklist signed after the operation with no pause.

Partly met when

• Team not joining: The checklist is said out loud but not every team member joins.
• Completed after: The checklist is completed after the operation.

How to implement

• Week 1: Print the checklist and place it in each theatre.
• Week 2: Train the team to run the pauses out loud.
• Monthly: Observe the pauses and record the result.

What the surveyor does

• What the surveyor sees: Watches the process at the point of care and reads a sample of the records for the last 3 months.
• What the surveyor asks: Ask the nurse: where in the operation do you do the safety checklist, and who speaks?
• What is uploaded: Checklist (current) and an observation record for 10 procedures showing the three pauses.

E-learning. Ophthalmology and Day Surgery Safety

3B.2 Anaesthesia Is Delivered Safely

Non-negotiable

Anaesthesia follows defined safety protocols with continuous monitoring throughout the procedure, appropriate to the level of anaesthesia and the patient's specific risk profile.

Questions the surveyor asks

1. Is continuous monitoring maintained throughout the entire procedure, not just at induction and emergence? Gaps in monitoring during the middle of a long procedure are a documented risk pattern.
2. Is the monitoring equipment appropriate to the level of anaesthesia and functioning, not just present? Equipment that is present but not properly calibrated or maintained provides false reassurance.
3. Is there a defined escalation protocol for anaesthesia-related complications? A protocol for the routine case is not the same as a protocol for when something goes wrong.

Why it matters. Anaesthesia is the highest-risk part of the day for many patients. Continuous monitoring through the whole procedure, matched to the level of anaesthesia, is the standard that finds the problem early.

Evidence to show. Anaesthesia monitoring standard (current) and the anaesthesia record for 10 procedures (anonymised).

Good

• continuous monitoring from induction to emergence; equipment matched to the level; a written response to complications.

Failure

• monitoring stopped during the procedure.

Partly met when

• Gaps in monitoring: Monitoring is done at induction and emergence only.
• Alarms silenced: Alarms are silenced and not reset.

How to implement

• Week 1: Set the monitoring standard for each level of anaesthesia.
• Week 2: Record monitoring throughout each procedure.
• Monthly: Audit anaesthesia records.

What the surveyor does

• What the surveyor sees: Watches the process at the point of care and reads a sample of the records for the last 3 months.
• What the surveyor asks: Ask the anaesthetist: what do you monitor during the procedure, and what do you do when an alarm sounds?
• What is uploaded: Anaesthesia monitoring standard (current) and the anaesthesia record for 10 procedures (anonymised).

E-learning. Anaesthesia Delivery and Monitoring

3B.3 Surgical Site Infection Is Actively Prevented

Non-negotiable

A defined surgical site infection prevention bundle is followed for every procedure — a specific, checkable set of practices, not general good intentions about cleanliness.

Questions the surveyor asks

1. Is a specific, defined SSI prevention bundle followed for every procedure, not general practice? "We're careful about infection" is not the same as a specific, checkable bundle of practices.
2. Is the facility's own SSI rate measured and tracked? Improvement is not possible against a rate nobody is measuring.
3. Is bundle compliance checked per procedure, not assumed from general training? General training does not guarantee the bundle was followed on any specific occasion.

Why it matters. Infections after surgery are preventable with a set of checkable practices. A bundle, followed for every procedure and measured, is what makes prevention real.

Evidence to show. SSI bundle (current), the compliance audit (last 3 months) and the facility's own infection rate.

Good

• a written SSI bundle, followed for every procedure, with compliance checked and the facility's own rate tracked.

Failure

• no bundle; general practice only.

Partly met when

• Compliance not checked: The bundle is written but compliance is not checked for every procedure.
• Rate not tracked: The facility's own rate is not measured.

How to implement

• Week 1: Write the SSI prevention bundle.
• Week 2: Add the bundle to the checklist and train the team.
• Monthly: Measure compliance and the infection rate.

What the surveyor does

• What the surveyor sees: Watches the process at the point of care and reads a sample of the records for the last 3 months.
• What the surveyor asks: Ask the surgical team: what is in your infection bundle, and how do you check it is followed?
• What is uploaded: SSI bundle (current), the compliance audit (last 3 months) and the facility's own infection rate.

E-learning. Hand Hygiene and Standard Precautions