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Shared learning database

South Tees Hospitals NHS Trust
Published date:
September 2008

This submission demonstrates how Clinical Audit was used to support the implementation of, and show compliance with NICE guidance IPG 196.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The Trust adopted a proactive approach to the implementation of the NICE interventional procedure 196. A working group was formed and three audit cycles were completed to ensure the guidance had been fully implemented. 1. To raise the awareness of clinical teams of NICE Interventional Procedure 196 requirements 2. To embed changes in practice to meet and sustain compliance with IP196 3. To audit practice to confirm standards are being met.

Reasons for implementing your project

This guidance is a high priority for the organisation as scores were low for the original National Decontamination Survey. The Trust had started to introduce a number of measures related to decontamination and equipment marking to improve practice. The Medical Director took particular note of this guidance and asked for a multi-disciplinary working group to be established to support implementation. The group chaired by the Senior Nurse Anaesthetics & Theatres, included consultants and senior theatre managers for Ophthalmology, Neurology, Central Sterile Stores Department (CSSD), Head of Governance and Clinical Audit Team. Theatre staff were involved in a base line audit in August 2007 and actions plans were implemented to improve practice. This included marking supplementary instruments, working with manufacturers to design and develop high quality single use instruments, setting up boxes of equipment for children born after 1/1/1997. A second audit in February 2008 showed improvement and areas of non-compliance were discussed. Staff members attended a stakeholder event in March 2008 organised by NICE and were encouraged when comparing progress with other trusts. A third audit cycle in July 2008 demonstrated 100% compliance with standards in IP196.

How did you implement the project

1. Audit raised awareness of requirements of the guidance demonstrated through involvement with the project, the theatre staff involvement and ownership of the audit and the work with manufacturers to achieve compliance. 2. The use of Clinical Audit helped to highlight the areas for improvement throughout the implementation process and demonstrated that the necessary changes had been implemented in order to fully comply with NICE IPG196 3. The main audit standard was "If supplementary instruments are used they should be single use or traceable." The Audit findings demonstrated 100% compliance.

Key findings

An audit tool was devised for use in Neurosurgical and Ophthalmic theatres to capture data on high risk procedures. It looked specifically at supplementary instruments to identify if they were single use or traceable. Data collection took place at 3 points between August 2007 and July 2008. Staff in theatres were involved in design of the audit tool and were trained in how to complete the audit proformas by the Audit Team who then analysed and reported results back to staff. Theatre staff from both disciplines took ownership of the audit and were diligent in ensuring its accuracy.

Key learning points

1. Although a multi disciplinary team approach was adopted there were still some problems with the development of the audit proforma. This was particularly around interpretation of the questions on the proforma. This was resolved with additional training of staff using the proforma and the introduction of a step by step guide for staff to refer to. The need to pilot even simple looking proformas was highlighted through this project. 2. Involvement of senior Theatre staff who were actively involved in the purchase of equipment and had access to representatives to design single use equipment was a major factor in achieving the standards. 3. Multidisciplinary team involvement with strong support and encouragement from the Medical Director gave this patient safety project a high profile and encouraged active support across several teams.

Contact details

Emma Carter
Clinical Audit Manager
South Tees Hospitals NHS Trust

Secondary care
Is the example industry-sponsored in any way?