EQUIPMENT TRAINING POLICY AND PROCEDURE

Issued: Next Review:

November 2008 November 2009

Equipment use Policy and Procedure for Training

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Document control
Name Version File location\ Document name Date of this version Produced by Equipment Training Policy and Procedure First W: Corporate Development/ November 2008 Andy Peck, Head of Estates & Risk Management

Approved by Publication date To be distributed to

IGC Nov. 2008

Trust Board members; all staff (through publication on Harbourlights and PCT Website and cascading by managers to staff

Date distribution completed Due for review Enquiries to

** 2008 No later than: October 2009 Diane Collier, Head of Corporate Development Andy Peck, Head of Estates and Risk Management

Equipment use Policy and Procedure for Training

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1.0

Introduction The Trust requires every member of staff, both clinical and non-clinical, to be trained to use the equipment necessary to carry out their duties at work. Training programmes are established for certain types of equipment, the bulk of equipment training occurs within departments. It is the individuals responsibility not to use equipment before they have received training and not to use it unsupervised until they have been assessed as competent to do so. Once assessed as competent to use a piece of equipment there should be a programme to record and evidence continued competency on a regular basis. As a general rule, the need and frequency for training is based on the risk assessment of the equipment and the job role of the member of staff. All records of training and competency assessments must be recorded on the organisations training database.

2.0

Purpose An essential part Patient Safety relates to staff being authorised and assessed as competent to use equipment in a safe and effective manner. External agencies such as the NHS Litigation Authority require documentary evidence of training programmes, training records and competency assessments related to diagnostic and therapeutic equipment. Scope This document refers specifically to all types of diagnostic and therapeutic equipment used within the organisation (this policy can be extended to form the principles and basis for the training requirements to cover non-clinical equipment). The policy is pertinent to all staff employed within the organisation and will include temporary, agency, locum staff and contractors. Responsibilities It is the responsibility of all managers and line managers, to ensure that the staff they are responsible for are authorised and trained in the use of the equipment as identified in that persons job role before using it unsupervised. The need and frequency for training is based on the risk assessment of the equipment and the job role of the member of staff. Managers must assess staff for competency to use the equipment as part of local induction (refer to Corporate Induction policy). Also assessment will form part of the Personal Development Plan (PDP) process which must be performed at least on an annual basis. Managers must ensure that staff receive regular update training as required and to provide documented evidence accordingly. Staff must not be allowed to use any equipment unsupervised until they have been assessed as competent to do so by an assessor deemed competent by the department (see section 9.0). It is the responsibility of all staff within the organisation to ensure that they have been authorised by their line manager to use any equipment and that they are trained before using such equipment. Staff must ensure that they are updated regularly according to the organisations and Department policy in the use of equipment in consultation with their line manager. The list of equipment that a member of staff is expected to be competent to use will be produced as a result of discussion and agreement between that member of staff and their line manager and be based on the persons specific equipment needs and the risk assessment for that piece of equipment. Staff must not use equipment that is faulty or potentially faulty and must report such to the Medical Engineering Department at the James Paget University Hospital.

3.0

4.0

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5.0

New equipment All diagnostic and therapeutic equipment used in any area of the Trust, new to the Trust (i.e. not replacement) must be notified to the Assistant Director of Corporate Business Performance. Staff should only use equipment that has been approved for use in the Trust. All new equipment must be checked before use by the Estates / Electronic and Biomedical Engineering Department (EBME) for electrical safety and to ensure that the equipment meets or exceeds the required safety compliance standards.

6.0 6.1.1

Training Equipment for which training is required Equipment training is linked to local induction and the PDP process (refer to section 4.0 above). It is essential for all staff to be trained and assessed as competent to use all the equipment required as part of their job role. As part of a continuing assessment process, to make this policy workable it is necessary to decide which equipment staff require training for (and competency assessed and recorded) as part of their job role. As guidance the following list is supplied to indicate which training must be provided to staff: A high level of risk, or potential for causing any form of harm to staff, contractors, patients or visitors (i.e. physical injury, a potential risk to, or reduction in patient care such as the production of inaccurate diagnostic results). A high level of risk that could occur if the machine were incorrectly used and caused damage to that machine or environment. Equipment which is new to the user or has been significantly modified since the last training update. Adverse incident reports indicate the need for training (i.e. patient safety incidents have been reported and are associated with the misuse / lack of knowledge relating to the safe or correct use of a piece of equipment). Equipment which is rarely used and frequent refresher training is required. The user, supervisor or manager identifies a training need. The same category of equipment exists but in different types / models (i.e. variations of infusion pumps supplied by different manufacturers). Local / Professional rules may apply and require training on certain types of equipment (i.e. lasers).

6.1.2

Local policies Based upon the guidance contained in 6.1.1 above: Local policies must be agreed in conjunction with Department Heads / Professional Leads of Services and approved by the Assistant Director of Corporate Business Performance.

The policies must contain details of all equipment and training / competency arrangements applicable to all users of designated equipment within the Division. The policies must include a detailed rationale to ensure continued competency for equipment that does not require any additional training (i.e. equipment that does not fall into the category listed in section 6.1.1). Such policies must include reference to the method of recording, retention and documentation relating to all training and the assessment of competency. Copies of Divisional policies MUST be sent to the Risk Management and Governance Department (in Trust format). A copy of the policy should appear on the Trust intranet as a source of reference for staff.
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6.2

General Training must be accessible for all types of equipment used in the Trust and this will include new equipment or equipment on loan (an equipment inventory is held in the Medical Engineering Department and on the PDP system). The level and frequency of training required will depend upon the type of equipment, the job role and required skill level for the staff who will use that equipment (see Statutory Training Policy). A training needs analysis and training programme must be produced by the Division or department introducing the equipment into the Trust. If new equipment is introduced to be used across the Trust, the Medical Devices Group will be responsible for producing a training needs analysis and developing a programme for training. Equipment training and discussions relating to competencies to use equipment is a continual process which is formally reviewed as part of the Personal Development Plan (PDP process). Frequency of training is Some staff have specific training responsibilities, for example; Medical device training will be initiated by department managers and will be supported for certain devices through the statutory training programme within the Trust. Blood gas analysers and near patient testing devices will be the responsibility of the Point of Care Testing Officer in Pathology. The Supplier will be responsible for training key staff to an agreed level of competency. Further staff training may be cascaded or continued through a programme agreed with the supplier.

7.0

Training programmes Training to use equipment should form part of every member of staffs local (department) induction programme See Appendix 2, Induction Checklist. This programme should be arranged and monitored by the member of staffs line manager. A copy of the completed form is sent to the Corporate Training Database Administrator and the original is kept in the member of staffs personal file. Some corporate equipment training is provided by the Trust at statutory training sessions and will include selected medical devices (such as oxygen, suction pumps, feeding pumps and epidural pumps). Notification of available training programmes will be sent to wards and departments and will be available on the Intranet. A list of approved equipment trainers can be found in the equipment folder found in Wards and appropriate Departments. More specific training is the responsibility of individual departments and is arranged, provided and assessed at department level.

New staff Equipment training is performed as part of local induction for new staff within their department. The line manager in consultation with the post holder will identify what equipment training is required for that member of staff and indicate on the induction form the appropriate equipment and expected timescales for completion of training. Completed Medical Devices Diagnostic and Therapeutic Equipment forms (refer to above hyperlink) are placed in the equipment folder found in the Ward / Department. Copies of the completed induction forms are returned to the Corporate Training Database Administrator to be entered into the training database and a copy stored in the personnel file of the member of staff. Copies of the completed forms will act as evidence to demonstrate compliance with the equipment policy and will also act as evidence when the Trust is assessed by external agencies. If within one month of commencing in post the member of staff has not returned the completed induction form to the Training Administrator notification of non-compliance will be sent to the appropriate Manager.
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Existing staff All staff using equipment must be assessed on a regular basis (at least once in three years) by a designated competent assessor. For Medical Devices a completed Diagnostic and Therapeutic Equipment form is required to evidence that competency has been assessed and documented. Existing staff that move between departments should be treated as New Staff for the purposes of Induction.

8.0

Training records Attendance at corporate training sessions is recorded by staff signing the attendance sheets. The information is stored on the Corporate Training Database where it is updated accordingly. Annual training attendance records will be produced by the corporate training database administrator or other designated person. Department training records will be kept by the Divisional secretariat, head of department or the line manager, and a copy will be kept in the personal files of the member of staff. The Medical Devices Diagnostic and Therapeutic Equipment forms will act as evidence of training and should be reviewed to ensure that competency to use equipment is current and recorded as part of the annual PDP review. All training records must be sent to the Training and Education Administrator to be recorded on the training database. For junior medical staff the record should be kept in their log book and be reviewed with their Educational Supervisor, a copy of which should be sent to HR to be held in their personal file.

9.0

Assessing competency Medical Devices, Diagnostic and Therapeutic Equipment forms will be used as part of discussions with the member of staff at PDP / appraisal to confirm that the member of staff is authorised and still safe and competent to use equipment in that Ward / Dept and that the member of staff and line manager sign accordingly. Any training requirements are then agreed between the line manager and the member of staff and booked via PDP system. All staff using equipment must be assessed on a regular basis (at least once in three years) by a designated competent assessor. The assessor will be a person who has been agreed by the head of department to have had sufficient training and has the appropriate knowledge, skills and ability to perform that role (assessment may be observational or may require written evidence of competency). Where a supervisor / manager is aware that a member of staff does not have the knowledge and skills to safely operate a piece of equipment, they must ensure that the person ceases to use the equipment until appropriate training has been received. See Appendix 1, Assessment of Competence.

All competency assessments must be recorded and copied to the Training Administrator. The records must as a minimum contain dates of assessment, staff involved, list the equipment, type and model and contain signatures of the assessor and the assessee. The records must be stored safely and be available to act as proof in case of claims for potential litigation, health and safety issues and to act as evidence for use by external assessing bodies. Departments may keep there own records provided that a) the records contain the information required as above and b) the records are regularly copied to the Corporate Training Database Administrator for entry into the training database. There must be a process whereby the assessors competency is determined in order that they are deemed appropriately trained to provide training and assessment to others. Such an assessment may (for example) be provided by the supplier of the equipment through a formal recognised programme. Such competency assessments should be performed on a regular basis (at least once in three years) and be fully recorded and evidenced.
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10.0

Hazard Warnings The Medicines and Healthcare products Regulatory Agency (MHRA) issue safety warnings about equipment which are distributed throughout the organisation by the Risk Management and Governance Department. It is essential that every ward and department has a process to ensure that all members of staff are made aware of these warnings, particularly when equipment identified is in use within the Trust and to take the relevant action. Staff have a responsibility to notify defective equipment to the Electronic and Biomedical Engineering Department at the James Paget University Hospital and to act appropriately to warning notices. Process for Monitoring and Review This policy will be reviewed annually. All training records for diagnostic and therapeutic equipment must be stored on the Trust Training Database. Training records for equipment specific to a department will be kept by the department (and copies sent to the Training Administrator). Equipment training and competency will be reviewed as part of the PDP process. A training needs analysis will be performed to determine which staff require training and the frequency of training based on the risk assessment for that piece of equipment.

11.0

12.0

Related policies Refer to the; Corporate induction policy Medical Devices Strategy Induction Policy

13.0 References: MHRA Safe Use and Operation Guidance NPSA Seven Steps to Patient Safety

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Appendix 1

Assessment of Competence

Guidance for Managers: Workplace equipment includes a wide variety of equipment, particular attention is required when managing diagnostic and therapeutic equipment in a clinical environment although the same principles can be applied to all work equipment. Where a variety of equipment could be used to fulfil a similar function within a clinical environment, competencies are agreed as an assessment of ability to obtain accurate diagnosis or correct use rather than on an individual device basis. It is important that when staff are judged against these standards that they are familiar with the device being used in your specific ward/area/department. When staff move to a different ward/area/department managers must ensure staff are safe and competent to use the equipment, no assumption should be made about staff ability or knowledge. Safe and Competent use of equipment can be assessed by judging ability related to the following criteria: If the staff member has received training to use this piece of equipment and can demonstrate an understanding that ensures safe operation. If the staff member through experience is considered safe and competent to use the equipment and can demonstrate this despite the fact that they may not have received formal training. Training is recognised as a need by the staff member and is organised by the ward/department manager or educational supervisor following which the individual is assessed and deemed safe and competent to use the equipment by the manager. In some instances further training or assessments may be required before the individual is deemed safe and competent.

When ensuring competence managers should ensure staff fully understand: purpose of the device principles of how it operates device specifications setting up the device safety features and the rationale for them reliance to be placed on the device reliance to be placed on results obtained from the device reliance to be placed on the safety features of the device importance of double checking by observing the patient and device use of any relevant alarms difficulties in the use of the specific device and any likely causes of failure monitoring and checking of device recognising when the device has failed common faults in the use of the device importance of the user consulting the manufacturers instructions their responsibilities related to cleaning and decontamination

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Appendix 2
Employee: Manager:

INDUCTION CHECK-LIST NEW EMPLOYEES ................................................................................................................ ................................................................................................................

To ensure the employee receives a comprehensive and effective induction programme, please read the induction policy prior to completion of these tables.

Table 1 (to be completed on the new employees first day)

Introduction to colleagues and tour of work area - kitchen, facilities and toilets Information on building/environment and facilities - layout including access and exit points (including door codes) - canteen facilities/where to eat/rest room - no smoking policy General health and safety including: - first-aider (who, how contacted, where located) - accident/incident reporting procedure (what to report, location of Accident Book) - show how to operate fire alarm, location of equipment, fire escape, evacuation procedure, assembly point - departmental health and safety issues specific to work environment including how to use equipment, medical devices, adverse incident reporting, identified hazards and safe systems of work - information regarding manual handling procedures as applicable - information on the date, time and venue of the next Fire Training Information on operational procedures - working hours (flexi-time scheme if applicable) and breaks Work Equipment/Medical Devices - Ensure staff are aware of and know how to use equipment safely and in accordance with manufacturers instructions E mail/memo sent to inform other staff of employees arrival and their role etc

Completed

Table 2 (to be completed within 2 weeks of employees commencement)

Information relating to the job, procedures and standards - specific duties and standards to be maintained including those relating to confidentiality and Caldicott requirements, dignity and respect, harassment policies, race and disability awareness, fraud issues - office procedures including an overview of PALS and employees role Overview of the Trust - internal and external customers and their needs - how the Trust fits in with rest of NHS

Completed

Appointments with key people for explanation of their role

Arrangements for IDR meeting made

I verify that these issues have been brought to the attention of the above member of staff. Signature .......................................................(Manager) Date ............................................... I confirm that these issues have been brought to my attention and that I understand them. Signature .......................................................... (New employee) Date .................................................

Please return this form to Human Resources within three weeks of commencement
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Appendix 3 Equality and Diversity: Impact Assessment Tool Name of Policy/Procedure/Service Manager Leading the Assessment Date of Review Equipment Training Policy and Procedure Andy Peck October 2008

Stages of Assessment identify the aims of the policy/procedure/service consider the available data/research that would demonstrate any likely impact (could result from work at a national level) assess any likely impact consider the alternatives consult formally decide whether to adopt the policy make monitoring arrangements publish assessment results (undertaken by the Head of Corporate Development) Please state briefly the aims of the policy/procedure/service under review:
The purpose of this policy is to advise staff of the training requirements related to the safe use of equipment. It is based upon an assessment of the risks that staff may face whilst using equipment at work. Many potential accidents or incidents can be avoided, the straightforward and relatively simple measures outlined in this policy will significantly improve staff and patient safety.

Is there a known public concern regarding this policy/procedure/service? Describe how these concerns have been identified:
None

Describe how this policy/procedure/service is likely to affect any vulnerable groups:

No direct impact

Describe the information or data available to show the impact of this policy/procedure/service:
Adverse Incident Reports, Risk Assessment Forms, Risk Management data, trend analysis & statistical data

Describe the results of any internal consultation on this issue, including details of consultation mechanisms:
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Describe how the views of any external consultative and community groups have been obtained (letters; meetings; interviews; focus groups; questionnaires; workshops; conferences; other):
N/A

Explain in detail the views of the relevant consultative and community groups:
Expert opinion gained related to statutory compliance

Describe the result/outcome of any external consultation and the way in which the views expressed have influenced the development of the policy/procedure/service:
Policy considered compliant with NHS Litigation Authority and HCC standards

Analysis and Decision-Making Using all of the information recorded above, please show below those groups for whom an adverse impact has been identified. Adverse Impact Identified? Age Disability Gender Race/Ethnic Origin Religion/Belief Sexual Orientation No No No No No No

* Delete as applicable and summarise the impact this policy/procedure/service has on the particular community minority group, considering the following points: can this adverse impact be justified? can the policy/procedure be changed to remove the adverse impact?

If your assessment is likely to have an adverse impact, is there an alternative way of achieving the organisations aim, objective or outcome
N/A

What changes, if any, need to be made in order to minimise unjustifiable adverse impact?
None

Do you recommend that the PCT adopts this policy/procedure/service? YES

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