Standard 67: Surgical and Specialty Clinics (Version 11)

Why it matters.

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).

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.

Why it matters.

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

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.

Why it matters.

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

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.

Why it matters.

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.

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.

Why it matters.

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

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.

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.

Sample. Observe 5 procedures on the day of assessment, or from the last month if none are running. For each, check the checklist record for all three pauses. Check the team’s spoken confirmation at the time-out.

1. The checklist is completed aloud at all three pauses.

Method. Observe the pauses for each of the 5 procedures and check the record.

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

Pass when. At least 90% of procedures show all three pauses completed aloud.

2. Identity is checked against the identification log.

Method. Check the patient identification log for each of the 5 procedures.

Evidence to show. Patient identification check log (ID-FRM-001).

Pass when. Every sampled procedure has an identity check recorded.

Immediate fail (any one means the criterion is not met). A procedure starts with no time-out, or the checklist is completed after the patient has left the theatre.

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.

Sample. Review 10 anaesthesia records from the last month, and check the machine check records for the last 30 days.

1. Anaesthesia follows a written protocol.

Method. Read the anaesthesia protocol and check its review date.

Evidence to show. Anaesthesia safety and monitoring (SRG-POL-002).

Pass when. The protocol is current and approved by the lead anaesthetist.

2. The patient is monitored continuously from induction to recovery.

Method. Check each of the 10 records for monitoring at the set interval through the case.

Evidence to show. Anaesthesia record and monitoring chart (SRG-FRM-002).

Pass when. At least 90% of records show continuous monitoring.

3. Anaesthetic equipment is checked before each list.

Method. Check the machine check record for each list in the last 30 days.

Evidence to show. Anaesthesia machine and equipment check (SRG-FRM-003).

Pass when. At least 90% of lists have a recorded check before the first case.

Immediate fail (any one means the criterion is not met). A patient is anaesthetised with no monitoring, or on equipment that has not been checked.

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.

Sample. Review the compliance record for the last 3 months, the surgical site infection register for the same period, and 10 procedures.

1. Each procedure follows the bundle.

Method. Check the bundle compliance record for each of the 10 procedures.

Evidence to show. Surgical site infection bundle compliance record (SRG-FRM-004).

Pass when. At least 90% of procedures have every part of the bundle recorded as done.

2. Surgical site infections are tracked and reviewed.

Method. Check the surveillance register and the review record for the period.

Evidence to show. Healthcare-associated infection surveillance register (HOS-REG-005).

Pass when. Every infection is recorded and reviewed within 7 days.

Immediate fail (any one means the criterion is not met). A procedure starts without the bundle, or a surgical site infection is found with no review.