This document sets out the organisation s process for meeting these requirements.

Transcription

1 Trust Policy and Procedure Diagnostic & Therapeutic Equipment Training Document ref. no: PP(16)26 For use in (clinical areas): For use by (staff groups): For use for (patients / treatments): Document owner: Status: All clinical areas All permanent, bank, agency, locum and contractual staff using Diagnostic & Therapeutic Equipment Reusable Electro Biomedical Diagnostic & Therapeutic Equipment Training Nursing & Governance Directorate Approved Purpose of this document: In order to ensure our staff are competent in operating diagnostic & therapeutic equipment the West Suffolk NHS Foundation Trust is required to have an approved documented process for ensuring that all permanent bank, agency, locum and contractual staff are trained to safely use diagnostic and therapeutic equipment appropriate to their role that is implemented and monitored. This document sets out the organisation s process for meeting these requirements. Contents Page 1. Definition of terms Process 2 3. Training 3 4. Roles and responsibilities Monitoring Policy development. 6 Appendices Appendix 1: Standard Operating Procedure Appendix 2: Competency declaration form 1. Definition of terms 1.1 Diagnostic and Therapeutic equipment are electrically operated devices (including battery operated) used for the treatment, diagnosing and monitoring of patients. It also includes dental and podiatry equipment, i.e. drills etc, and laboratory equipment, pressure-relieving mattresses, operating tables etc. Throughout this policy, the term equipment shall be taken to mean diagnostic and therapeutic equipment as defined above. Source: Drugs and Therapeutics Committee Issue date: February 216 Page 1 of 8

2 1.2 Competency to use equipment is defined as the individual s ability to demonstrate the knowledge of, and skills required to: Meet Health and Safety requirements related to individual items of equipment. Set up the individual item of equipment. Use the individual item of equipment. Clean and maintain the individual item of equipment. 1.3 Independent practitioners are senior permanent staff that work across several clinical areas such as Consultants, Registrars and Nurse Specialists. 2. Process The processes outlined are to be followed in order to ensure that all permanent staff have been trained to safely use equipment appropriate to their role. A more detailed description of these processes is outlined in the Standard Operating Procedure in Appendix Process for where ward / department managers have the responsibility for assessing the training needs of their staff Each ward or department are required to formulate an inventory of the equipment that is in use in that area The ward or department will determine which staff are required to utilise individual items of equipment on the inventory appropriate to their role Competency of staff to use each designated item of equipment will be assessed either by direct or self-assessment (Appendix 2) dependent on the experience of the user and a record made of their level of competency Staff that are assessed as competent are then authorised to use that item of equipment Where training needs are identified, training should be given and competency reassessed before the equipment is used by the individual A record of the inventory of equipment, a list of staff required to use these devices and their assessed level of competency will be entered onto the clinical areas competency matrix stored on the (//charlie) O drive in the Equipment Competencies folder The competency matrix will be updated, by the ward or department manager to account for new items of equipment on the inventory, new members of staff on that ward or department and any changes to levels of competency as a result of attending training. 2.2 Process for where independent practitioners have the responsibility for assessing their own training needs Independent practitioners are required to formulate an inventory of equipment that they are required to use across the clinical areas in which they are employed, appropriate to their role. Source: Drugs and Therapeutics Committee Issue date: February 216 Page 2 of 8

3 2.2.2 Independent practitioners will complete a self-assessment of their competency to use each item of equipment on their inventory, and record this information on the competency declaration form (Appendix 2) Where training needs are identified, it is the responsibility of the independent practitioner to access the appropriate training Updated competency declaration forms are only required to be resubmitted if the independent practitioner is required to use new items of equipment or their level of competency has changed. 2.3 Bank, agency, locum and contractual staff Bank, agency, locum and contractual staff members must not use a medical device if they are not competent do to so. They should be asked to demonstrate that they know how to use the relevant equipment. 3. Training 3.1 All new permanent staff joining the Trust will be required to complete training to use the equipment available to them in order to fulfil their role. 3.2 Training in health and safety requirements related to items of equipment and their maintenance and cleaning will be provided through the corporate induction processes. 3.3 Training in the setting up and use of equipment will be provided by the clinical areas as part of the local induction process. 3.4 Once competency is achieved to use each item of equipment, there is no requirement to repeat the training unless the user has concerns about their continuing competency due to infrequent use of the device. 3.5 Additional training may also be triggered through any clinical incident involving a member of staff and a specified piece of equipment, and/or if identified as an area of concern by the ward/department manager. 3.6 Training to use equipment can be provided by staff that have been assessed as having this additional training competency, or by staff that have a responsibility for equipment training defined within their role. 3.7 When new items of equipment are introduced to the organisation, provision of staff training is to be an integral part of the purchasing process. 3.8 User manuals for all equipment are to be available to staff in all clinical areas either in hard copy or as an electronic version which are available for viewing on the Trust Intranet. 4. Roles and responsibilities. 4.1 Individual users Individuals have a responsibility to undertake training and be assessed as competent before using an item of equipment without supervision, and to adhere to agreed policies and procedures in using equipment Individuals employed across a range of clinical areas such as Medical staff, Matrons, Nurse Specialists etc. have a responsibility to undertake self- Source: Drugs and Therapeutics Committee Issue date: February 216 Page 3 of 8

4 assessment against specified criteria set out in the SOP in order to make a declaration of competency Individuals must highlight any areas for further development or for additional training through the appraisal/pdp process Individuals are required to raise any concerns about personal competency and request refresher training if required. 4.2 Ward / Department managers Managers are responsible for collating and maintaining an inventory of the equipment used in their clinical area Managers are required to ensure that individuals, for whom they are accountable, receive the appropriate training and have been assessed as competent to use all of the equipment held in their clinical area following the described processes Managers are required to ensure that their local induction process includes training and competency assessment to use equipment for all new staff appropriate to their role Managers are required to ensure that all staff, that have identified equipment training needs, are afforded the opportunity to receive training Managers are responsible for ensuring that a record is kept of all staff competencies to utilise the equipment on their inventory. 4.3 Directorate of Nursing & Governance The Directorate of Nursing and Governance are required to ensure that a nominated individual from this department leads the completion of competency matrices and competency declaration forms across the Trust The same nominated individual is responsible for ensuring that compliance with this policy is monitored and that issues of non-compliance and significant training deficits are escalated to ward / departmental managers, matrons and service managers for action The Directorate of Nursing and Governance nominated individual will also report issues of non-compliance and significant training deficits to the Deputy Chief Nurse. 4.4 General and Service Managers General and Service Managers are responsible for ensuring that this policy is implemented in their Directorates. In particular they will: 4.5 Trust Board Manage any major cost or resource issue. Manage any concerns, which arise from line managers in relation to the implementation of the policy. Through health and safety responsibilities, the Trust has a duty of care to its employees to ensure that any person operating equipment has sufficient understanding of its use to do so in a safe and effective manner. 4.6 Chief Executive Source: Drugs and Therapeutics Committee Issue date: February 216 Page 4 of 8

5 The Chief Executive has overall responsibility for Health and Safety. Day to day accountability is through the Directors, General Managers, Service Managers and Line Managers. 5. Monitoring 5.1 Ward and departmental managers will monitor their clinical area s compliance with this policy and ensure that all staff are competent to use the equipment available. 6. Development of policy. 6.1 Other relevant documents PP()24 Management of Medical Equipment Policy PP()76 Induction Management Process and Guidelines PP()244 Policy and procedure for Mandatory and Statutory training PP()167 Point of Care Testing 6.2 Document configuration information Author(s): Other contributors: Clinical Practice & Education Co-ordinator Medical Equipment policy & procedure group members Approvals and endorsements: Drug & Therapeutics Committee February 216 Consultation: Issue no: 4 File name: Supersedes: Equality Assessed Implementation Monitoring: (give brief details how this will be done) Other relevant policies/documents & references: Additional Information: Nurse Education team PP(12)26 Diag Ther training.doc Yes This document will be widely circulated within the Trust, including all heads of department and ward managers and will be made availability on the Trust s Intranet and Internet sites. Relevant changes will be brought to the attention of staff during circulation. See section 5 See section 6.1 Source: Drugs and Therapeutics Committee Issue date: February 216 Page 5 of 8

6 APPENDIX 1 STANDARD OPERATING PROCEDURE FOR ASSESSING, RECORDING AND MONITORING EMPLOYEE S COMPETENCY 1 AND TRAINING REQUIREMENTS FOR DIAGNOSTIC & THERAPEUTIC EQUIPMENT. All individuals are assessed to determine their level of competency to utilise all items of Diagnostic & Therapeutic equipment deployed in their clinical area(s) that they would be expected to use according to their roles and responsibilities. Level of competency will be determined through a process of; direct assessment by line manager, self-assessment validated by line manager or selfdeclaration of competency. This process will determine the employees competency to use items of Diagnostic & Therapeutic equipment, the ability to train others in its use and identify training needs where they exist. Individuals that are deemed competent or competent and capable to train are authorised to use the items of Diagnostic & Therapeutic equipment. The records of competency will be kept by the individual and where applicable by the line manager. A further record of competency will be entered onto the Competencies Matrix Template on the (//charlie) O drive. This process will provide a record of competency for all employees against individual items of Diagnostic & Therapeutic equipment, and enable individuals, line managers and the organisation to identify specific training needs. Where training needs are identified, it is the individuals and/or line manager s responsibility to access the appropriate training to acquire competency. This should be incorporated into the appraisal/pdp process. Training updates on utilisation of Diagnostic & Therapeutic equipment are only required if the individuals competency has been affected by lack of experiential use. Where this is the case it is the responsibility of the individual or their line manager to access the appropriate training. 1 Competency defined as: The ability to demonstrate knowledge of, and skills required to: Meet Health and Safety requirements related to individual items of equipment. Set up the individual item of equipment. Use the individual item of equipment. Clean and maintain the individual item of equipment. Source: Drugs and Therapeutics Committee Issue date: February 216 Page 6 of 8

7 APPENDIX 1 STANDARD OPERATING PROCEDURE FOR ASSESSING, RECORDING AND MONITORING EMPLOYEE S COMPETENCY AND TRAINING REQUIREMENTS FOR DIAGNOSTIC & THERAPEUTIC EQUIPMENT. This process will ensure all employees are safe and effective to use all items of Diagnostic & Therapeutic equipment in their clinical area(s). Having accessed the appropriate training, a record of the level of competency acquired should be kept and recorded onto the Competencies Matrix Template on the (//charlie) O drive. All new members of staff will also be incorporated into this process and their competency recorded in a similar fashion. Individuals will also be required to undergo training and be assessed for competency for all new items of Diagnostic & Therapeutic equipment that come into use on their clinical area(s). New Diagnostic & Therapeutic equipment and an individual s competency to use this equipment will also be recorded onto the Competencies matrix template on the (//charlie) O drive. This process will ensure an ongoing record of competency is developed incorporating; training needs acquisition, new employees and new items of Diagnostic & Therapeutic equipment. Following the initial assessment of all individuals, the Directorate of Nursing & Governance will conduct annual audits to evaluate the process. This process will allow the Organisation to demonstrate a robust and effective policy to ensure its staff has the necessary knowledge and skills to safely utilise Diagnostic & Therapeutic equipment. Source: Drugs and Therapeutics Committee Issue date: February 216 Page 7 of 8

8 Appendix 2 Diagnostic & Therapeutic Equipment Competency Assessment Name. Role Clinical area.. Level of assessed competency (tick as appropriate). Not competent Competent to and requires use. Equipment type training Not required to use as part of current role Self assessment? Direct assessment? Where competency is required, but has not been achieved, staff are not authorised to use those items of equipment, without supervision, until deemed competent. If competency is required, staff should access appropriate training. Level of competency reassessed and recorded. Competencies agreed by: Staff name: Sign: Date: Manager's Name: Sign Date: Review date: If staff member is competent to use all equipment required, review should be annually at time of appraisal For staff that require training, review should take place every four months until all competencies are achieved. Source: Drugs and Therapeutics Committee Issue date: February 216 Page 8 of 8