• Matthew Charles Mason, Rebecca Katie Griggs, Rachel Withecombe, Eunice Yun Xing, Charlotte Sandberg, and Matthew Keith Molyneux.
• Department of General Surgery, Weston General Hospital, Weston-super-Mare, UK.
• BMJ Open Qual. 2018 Jan 1; 7 (3): e000294.

AbstractNational Health Service England published the National Safety Standards for Invasive Procedures (NatSSIP) in 2015. They mandated that individual trusts produce Local Safety Standards for Invasive Procedures (LocSSIPs), a set of safety standards drawn from the NatSSIP that apply to a particular clinical situation in a given department, for all invasive procedures. The project goal was to design and implement the LocSSIP within the endoscopy department. A draft LocSSIP was produced, and a pilot study conducted to gain initial feedback on its use. Version 1 of the checklist was produced and after approval, rolled out for use within the endoscopy department at 'time out' and 'sign out'. A scoring system was developed that allowed the quality of the performance of LocSSIPs to be assessed and recorded as a 'compliance score'. After 2 months, an independent observer spent a week assessing use of the checklist, recording completion and a compliance score. Analysis of this data led to a number of changes in performing the checklist, wider multidisciplinary team education and integration of the checklist into existing documentation, before reassessing at 12 months. In 2016, 'time out' checks were completed in 100% of cases, but full completion was only observed in 68%. 'Sign out' checks were completed in 91% of cases, with full completion in 71%. In 2017, 'time out' checks were completed in 100% of cases, with full completion in 85%. 'Sign out' checks were completed in 100% of cases, with full completion in 91%. The composite score for compliance in 2016 was 57% increasing to 90% in 2017. In conclusion, stronger departmental leadership, broadening education and integration of the checklist into routine documentation to reduce duplication led to significant improvements in compliance with use of the checklist. Ongoing education and assessment is imperative to ensure that compliance is maintained to ensure patient safety.

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