POLICY FOR APPLICATION OF THE WHO SURGICAL SAFETY CHECKLIST

POLICY FOR APPLICATION OF THE WHO SURGICAL SAFETY CHECKLIST Department / Service: Theatres, Ambulatory Care, Critical Care & Outpatients Surgery Originators: Andy Fryer, Training Facilitator Theatres Sally Pickard, Training Facilitator Theatres Dan Nash, Clinical Theatre Manager Alexandra/Kidderminster Ann Digby, Matron Theatres WRH/ECH Lucy Young, Band 6 Anaesthetics Accountable Director: Dr Julian Berlet / Mr Graham James Approved by: Trust Management Committee Date of approval: 18 th June 2014 First Revision Due: 18 th June 2016 Target Organisation(s) Worcestershire Acute Hospitals NHS Trust Target Departments Operating theatres, cardiac catheter labs, intervention rooms and obstetrics Target staff categories Consultants / Theatre professionals Policy Overview: The Worcestershire Acute NHS Trust adopted the WHO (World Health Organisation) Surgical Safety (SS) Checklist to improve patient safety in the perioperative environment. This document sets out the Trust s Policy and Procedures for compliance with these checks. The WHO Surgical Safety Checklist is designed to reduce the number of errors and complications resulting from surgical procedures by improving team communication and by verifying and checking essential perioperative care interventions. Effective teamwork and optimum communications are crucial to assuring safe and effective care and are an acknowledged bi-product of completing the WHO checklists. Pre-operative briefs and postoperative de-briefs will be included as part of this process. The principles of the SS Checklist include: Team Brief to discuss plans for surgery / procedure and anticipated safety concerns Sign In prior to the induction of anaesthesia Time Out prior to the start of the procedure e.g. skin incision Sign Out before any key team member leaves the operating theatre (or equivalent) Team debrief to discuss how the session went/if anything could be improved/ lessons learnt. Key amendments to this Document: Date Amendment By: Jan 2013 Minor amendment to role of surgeon on page 5 Nick Hickey June 2014 Document reviewed and strengthened throughout WAHT-CG-751 Page 1 of 11 Version 2

Contents page: 1. Introduction 2. Purpose of this policy/procedure 3. Scope of this document 4. Definitions/Glossary 5. Roles and Responsibility 6. Standards and Practice 7. Dissemination and Implementation 8. Monitoring and compliance 9. Policy review 10. References 11. Background 11.1 Equality requirements 11.2 Financial Risk Assessment 11.3 Consultation Process 11.4 Approval Process Supporting Documents Supporting Document 1 Supporting Document 2 Equality Impact Assessment Financial Risk Assessment WAHT-CG-751 Page 2 of 11 Version 2

Policy for application of the Who surgical safety checklist 1. Introduction Patient safety is an essential element of effective, quality patient care in the perioperative environment and all healthcare staff have a duty of care to prevent harm to the patient. The Worcestershire Acute NHS Trust has adopted the WHO Surgical Safety (SS) Checklist to improve patient safety in the perioperative environment. This document sets out the Trust s Policy and Procedures for compliance with these checks. The WHO Surgical Safety Checklist is designed to reduce the number of errors and complications resulting from surgical procedures by improving team communication and by verifying and checking essential perioperative care interventions. Effective teamwork and optimum communication are crucial to assuring safe and effective care. Pre-operative briefs and post-operative debriefs will be included as part of this process. These checks mitigate the risks and harm associated with surgical procedures where patient safety is a key element of maintaining professional registration for registered practitioners (HCPC 2008, NMC 2008). It is an essential element of clinical governance frameworks and risk management processes. The principles of the SS Checklist include: Team Brief to discuss plans for surgery/procedure and anticipated safety concerns Sign In prior to the induction of anaesthesia Time Out prior to the start of the procedure eg skin incision Sign Out before any key team member leaves the operating theatre (or equivalent) Team debrief to discuss how the session went / if anything could be improved / lessons learnt. 2. Purpose of this Policy/Procedure The purpose of the document is to improve patient safety and set out the procedure for all staff to follow with respect to the use of the WHO Surgical Safety Checklist. 3. Scope These guidelines apply to all staff, regardless of grade or profession who work in Worcestershire Acute Hospitals NHS Trust and are involved in a patient surgical care pathway where use of the WHO Surgical Safety Checklist is required. This policy is intended for all patients attending hospital for a procedure where the use of the WHO Surgical Safety Checklist is required. For example: operating theatres, cardiac catheter labs, intervention rooms and obstetrics. This list is not exhaustive as other areas performing invasive procedures may wish or be required to adopt WHO Safety Checks by the Trust. 4. Definitions/Glossary WHO - World Health Organisation. Surgeon clinician performing the surgical/interventional procedure, regardless of designation. Peri-operative environment Theatre suite or intervention room where the procedure is performed. WAHT-CG-751 Page 3 of 11 Version 2

5. Roles and Responsibilities 5.1. Role of the senior operating surgeon/clinician The senior operating surgeon/clinician retains overall accountability to ensure that the WHO Surgical Safety Checklist is fully completed. 5.2. Role of the Divisional Managers & Divisional Directors of Nursing To assume overall responsibility for compliance with this policy within their areas. This includes ensuring that Senior Managers have agreed and instigated a structure that ensures all staff have been informed, educated and trained appropriately in the utilisation of the WHO Surgical Safety Checklist in any environment where interventional procedures are taking place, and that they remain competent to do so. To monitor the dissemination, training, competency and compliance of the procedures set out in the WHO Surgical Safety Checklist Policy, for all clinicians at Worcestershire Acute NHS Trust. To receive and monitor monthly results of the WHO audits and provide compliance information to Trust committees. 5.3. Role of the Theatre/Departmental Managers To assume day-to-day responsibility for the implementation of this policy. To ensure the health, safety and risk management standards are met and maintained, and any risks minimised during the use and safe application of the WHO Surgical Safety Checklist. To ensure training records reflect that each staff member has been assessed as competent in the use of the WHO Surgical Safety checklist and/or is working toward that competency, and records the name of the person performing the assessment. To ensure new members of staff have an induction package to assess competence in the Application of the WHO Surgical Safety Checklist procedure. To monitor information provided from the Bluespier system on a daily basis, and by the Information Department on a weekly and monthly basis, for validation. 5.4. Role of Individual Staff The Trust expects all staff, including temporary staff working in the Trust and those working in the Trust from other organisations, to adhere to the principles of the WHO Surgical Safety Checklist in environments where interventional procedures are taking place. 6. Standards and Practice 6.1 Legal and Professional Obligations The operating surgeon retains overall accountability to ensure that the WHO Surgical Safety Checklist is fully completed. Registered Practitioners: Nurses, Midwives, Allied Health Professionals and Operating Department Practitioners (ODPs), have a professional obligation to provide a duty of care to their patients (NMC, 2008, HPC, 2008). Registered Practitioners will maintain overall responsibility for completion of the WHO Surgical Safety Checklist but may choose to delegate any part of the tasks related to its application to non-registered staff, other than the required registered practitioner s signature. The registered practitioner retains professional accountability for the appropriateness of the delegation of any task. WAHT-CG-751 Page 4 of 11 Version 2

Prior to the commencement of the operating list participation by the full theatre team allocated to the operating list is required: Staff must introduce themselves to each other by name and role. This information will be recorded electronically. Any changes to the published theatre list must be agreed and a new list created. Any issues related to the organization of the list must be discussed e.g. staffing, wards, recovery, beds, radiology, manual handling, instrumentation or equipment. 6.2 Sign In Before Induction of anaesthesia The team will verbally confirm all points detailed on the sign in section of the WHO Surgical Safety Checklist. Discretion may be used for questions relating to airway/aspiration risk and blood loss. The registered practitioner/delegated person will record the checklist in the appropriate place on Bluespier. It is acknowledged that in certain circumstances i.e. obstetric emergencies it may not be possible to complete the WHO. Every effort must be made to confirm identity, consent and correct side of surgery as a minimum requirement. The WHO checklist must be completed at the earliest available moment. If there is a failure of I.T. systems within an area then contingency measures must be evoked and a paper copy of the WHO checklist must be completed and the electronic WHO completed retrospectively. 6.3 Time Out Before start of the procedure To be completed by the whole team including surgeons and anaesthetists. A registered practitioner/delegated person will confirm all team members are present and initiate the checklist by reading out loud all points contained in the timeout section of the checklist. Discretion may be used for questions relating to blood loss if the patient has a local or regional anaesthetic. If, at any point during completion of the checklist, a member of the team is required to leave the theatre the checklist must be suspended and recommenced when all are present. If, at any point during completion of the checklist, the team is interrupted by an individual external to the team, the checklist must be suspended and recommenced when all team members can pay full attention to the process. Any concerns or queries raised by any team member must be resolved before the procedure commences. The registered practitioner/delegated person will clearly mark the checklist in the appropriate place in Bluespier. Any concerns/problems/issues raised during the checking procedure must be documented on Bluespier. If, at any point during the procedure, a member of the team is replaced or a further member of staff joins the team, they will be introduced by name and designation and be briefed on the procedure, given any necessary information and have sight of the consent form. It is acknowledged that in certain circumstances i.e. obstetric emergencies it may not be possible to complete the WHO at that time. Every effort must be made to confirm identity, WAHT-CG-751 Page 5 of 11 Version 2

consent and correct side of surgery as a minimum requirement. The WHO checklist must be completed at the earliest available moment. If there is a failure of I.T. systems within an area then contingency measures must be evoked and a paper copy of the WHO checklist must be completed and the electronic WHO completed retrospectively. 6.4 Sign out - after completion of the final swab and instrument count and prior to any staff member leaving the operating theatre To be completed by the whole team including surgeon and anaesthetists. A registered practitioner/delegated person will confirm all team members are present and initiate the checklist by reading out loud all points contained in the sign out section of the checklist. Any concerns/problems/issues raised during the sign out procedure must be documented on Bluespier. Any concerns or issues that have arisen during the procedure must be reported as an incident on Datix where necessary. The team must formally acknowledge any concerns for recovery and postoperative management of the patient. If there is a failure of I.T. systems within an area then contingency measures must be evoked and a paper copy of the WHO checklist must be completed and the electronic WHO completed retrospectively. 6.5 List Debriefing The whole team including surgeon(s) and anaesthetist(s) must debrief at a suitable interval to review the procedures undertaken on the operating schedule. The whole team must acknowledge: What did we expect to happen? What actually happened? Why was there a difference? What have we learned? 7. Dissemination and Implementation 7.1 New Staff. The WHO Surgical Safety Checklist policy will be provided as induction pre-reading material for all new members of staff who are involved in the surgical care pathway. 7.2 Existing Staff The WHO Surgical Safety Checklist policy will be stored on the electronic Document Library. 7.3 Training An introduction to the WHO Surgical Safety Checklist must be included in the local induction/orientation programme for all new staff. Documentary evidence of this must be available. All staff must receive instruction in how to implement the WHO Surgical Safety Checklist. Documentary evidence of this must be available. WAHT-CG-751 Page 6 of 11 Version 2

8. Monitoring compliance and effectiveness Monitoring of the WHO Surgical Safety Checklist will be performed daily through Bluespier reports and weekly and monthly reports through reports provided by the Information Department. Results of the audits provided by the Information Department will be reviewed and any shortfall acted upon by the Divisional Management Team. The results are included in a monthly report provided by the Information Department to the Trust Board. Page/ Section of Key Document Key control: Checks to be carried out to confirm compliance with the policy: How often the check will be carried out: Responsible for carrying out the check: Results of check reported to: (Responsible for also ensuring actions are developed to address any areas of non-compliance) Frequency of reporting: WHAT? HOW? WHEN? WHO? WHERE? WHEN? All elements of the WHO checklist have been fully completed and electronically submitted Daily, weekly and monthly reports checked by theatre leads and all non-compliance challenged. Directorate, divisional and Trust managers and committees. Monthly Other techniques to consider are audits, spot-checks, analysis of incident trends, monitoring of attendance at training. Daily at departmental level, 52 times per year at directorate level and 12 times per year at divisional level. Information Department provide data for all checks. Daily checks - Department Managers. Weekly checks to Department and Directorate Managers. Monthly checks directorate and divisional checks. WAHT-CG-751 Page 7 of 11 Version 2

9. Updating and Review 9.1 This Policy with be reviewed every two years. 9.2 Revisions can be made ahead of the review date when the procedural document requires updating. Where the revisions are significant and the overall policy is changed, the author must ensure the revised document is taken through the standard consultation, approval and dissemination processes. 10. References WHO Guidelines for Safe Surgery 2009 WHO Surgical Safety Checklist Implementation Manual 2009 NPSA Alert 2009 WHO Surgical Safety Checklist Code: NPSA/2009/ PSA002/U1 11. Background 11.1 Consultation This document has been circulated to the following individuals for comment/approval. Key individuals involved in developing the document Name Andy Fryer Ann Digby Sally Pickard Lucy Young Dan Nash Designation Training Facilitator - Theatres Matron Theatres WRH/ECH Training Facilitator - Theatres Band 6 Anaesthetics Clinical Theatre Manager Alexandra/Kidderminster Hospitals Heads of Department Name Designation Julian Berlet Divisional Medical Director Theatres, Ambulatory Care, Critical Care & Outpatients (TACO) Inese Robotham Divisional Director of Operations TACO Carole Brooks Divisional Director of Nursing TACO Amanda Moore Interim Divisional Director of Nursing TACO Graham James Divisional Medical Director - Surgery Sarah King Divisional Director of Nursing - Surgery Andrew Short Divisional Medical Director Women & Children Patti Paine Divisional Medical Director Women & Children Tony Scriven Divisional Medical Director - Medicine Ann Carey Divisional Director of Nursing - Medicine Nick Hickey Clinical Director Theatres/Pre-op Stephen Lake Clinical Director Endoscopy Tarun Sharma Clinical Director Ophthalmology Umesh Udeshi Clinical Director - Radiology Michelle Mullan Clinical Director Breast Anthony Perry Clinical Director Upper GI Steve Pandey Clinical Director Lower GI Richard Downing Clinical Director - Vascular Paul Rajjayabun Clinical Director Urology Steve Lewis Clinical Director ENT/Audiology WAHT-CG-751 Page 8 of 11 Version 2

Kieron McVeigh Charles Docker Melwyn Pereira Sam Agwu Nick Hudson Steve Randle Tracey Baldwin Dawn Robins Rachel Carter Alison Talbot Rachel Duckett Swati Ghosh Judi Barratt Lucy Waldock Tracey Jones Clinical Director Maxillofacial/Oral Surgery Clinical Director Trauma Clinical Director Orthopaedics/Hands Service Clinical Director Obstetrics/Gynaecology Clinical Director Medicine including Cardiology Directorate Manager Theatres, Anaesthetics & Pre-op Matron Ambulatory Care Matron Endoscopy/Bowel Screening Matron Maternity Inpatients WRH Matron Maternity Inpatients Alexandra Hospital Consultant Obstetrician Obstetric guidelines lead Consultant Obstetrician Obstetric guidelines lead Clinical Midwife Specialist Obstetric guidelines lead Sister Ophthalmology Sister - Ophthalmology 11.2 Approval process This document has been submitted to the following committees for approval. Name Rabia Imtiaz Sue Aston Julian Berlet Committee / group Obstetric Governance Committee CG Committee Surgery Division TACO Management meeting 11.3 Equality requirements See Supporting Document 1 11.4 Financial risk assessment See Supporting Document 2 WAHT-CG-751 Page 9 of 11 Version 2

Supporting Document 1 - Equality Impact Assessment Tool To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Yes/ Comments Age 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? - 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? - - - If you have identified a potential discriminatory impact of this key document, please refer it to Assistant Manager of Human Resources, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact Assistant Manager of Human Resources. WAHT-CG-751 Page 10 of 11 Version 2

Policy Supporting Document 2 Financial Impact Assessment To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. Title of document: 1. Does the implementation of this document require any additional Capital resources 2. Does the implementation of this document require additional revenue 3. Does the implementation of this document require additional manpower 4. Does the implementation of this document release any manpower costs through a change in practice 5. Are there additional staff training costs associated with implementing this document which cannot be delivered through current training programmes or allocated training times for staff Other comments: Yes/ If the response to any of the above is yes, please complete a business case and which is signed by your Finance Manager and Directorate Manager for consideration by the Accountable Director before progressing to the relevant committee for approval WAHT-CG-751 Page 11 of 11 Version 2