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3. IQIPS Accreditation – Safety

By Andrew Pellew-Nabbs (Warrington and Halton Hospitals NHS Foundation Trust) and Alison Charig (Portsmouth Hospitals NHS Trust).

IQIPS Accreditation – Safety

(The SA Domain)

This is article number 4 in the series on IQIPS accreditation, and we turn our attention now to the Safety domain. As ever, we aim to give some practical advice on how to evidence the areas of patient and staff safety, and monitoring of risk. Also how to cover the difficult (and hopefully rare) situations such as violence and aggression.

The IQIPS standards describe the purpose of this domain as to “provide the highest level of safety for patients, staff and others who come into contact with the service”

This is a relatively small domain, and it seeks to fulfil this purpose through 5 sub-domains, covering:

  • Managing the risk of infection
  • Monitoring risk associated with hazardous substances
  • Safe moving and handling
  • Managing violence and aggression
  • General health and safety of patients, staff; visitors and others

With a lot of cross-over with Trust level and CQC requirements, most departments will hopefully have robust policies and procedures to provide ample evidence for these areas. As always though, the emphasis for UKAS, is on continuous improvement of systems – so where we have good systems in place, audit and monitoring are the finishing touches needed.

Where do we start with fulfilling IQIPS requirements?

Please take a look back at the Spring 2018 Newsletter for detailed information as this was covered in our first article, but a good place to start is in:

  • checking your organisational and departmental policies are up to date
  • writing any local policies that are required
  • considering how you might monitor your systems so that you can identify those things that are working well and where improvement might be needed


Some examples of monitoring methods for SA:

As with the other domains, such as Facilities, Resource and Workforce – SA is a domain that lends itself to site visits. Due to the physical nature of some of the areas it focusses on, such as ensuring safety; equipment and storage of hazardous substances, UKAS assessors may find it easiest to simply see some of these in action.

Of course, this doesn’t mean that we can’t evidence good practice through the web-based assessment. Whether you comply or not is quite a ‘black and white’ decision so a useful and straight forward way to evidence systems might simply be through photographs which you can upload to the document box on the web assessment tool. 

We can also readily demonstrate robust monitoring systems through existing logs and documents.

Here is a more detailed look at each of the 5 sub-domains for Safety:

SA1 – Implementing and monitoring systems to manage the risk of infection

Infection control is a mainstay of everything that we do, and fundamental to the safety of ourselves and our patients.

As such, this is a nice introduction to this domain because it should be relatively easy for us to provide evidence.

As we might expect from the domains we are already familiar with  – we will be required to show that we have defined roles and responsibilities for infection control (do you have a named staff member responsible for infection control? Do they attend regular Trust updates sessions?); and also, to outline what systems we have to manage infection control.

Some questions that we might ask ourselves are:

  • Do you check your ultrasound machines are clean each day? And how do you record that you have checked? Would a daily checklist for each clinical room satisfy this requirement?
  • Where do I record decontamination procedures?
  • Do we know which in-patients have infections?
  • Do we have a policy outlining how we would manage an infected patient differently?
  • How would you know how many incidents related to infection control we have had in the last 12 months?
  • Who makes a decision to scan or not to scan a particular patient? Are the referrals vetted for this?

So firstly you need to design systems and start recording compliance.  Do you have clinic checklists? Are your checklists completed? Whose job is it to check this? Do you report results back to the rest of the team? Does this improve things? These are the sort of questions that assessors will be asking as they look through your evidence and it is useful to follow their train of thought as you design and adapt your own departmental systems.

When thinking about the key objective of the IQIPS process: “to show continuous monitoring and improvement”, we can see that the monitoring can be straight forward. Showing improvement sometimes appears to be trickier – but as we’ve mentioned in previous articles, sometimes this situation can be reverse-engineered. It may be difficult to construct a system to show that we have improved a decontamination regime for example, but it might be possible to show a decline in the number of infection-related incidents logged as evidence for improved decontamination practice.


SA2 – Managing the risks associated with hazardous substances and materials

This covers all of the usual suspects – accountability, roles and responsibilities, incident reporting etc. but also covers the safe storage, handling and disposal of hazardous substances and how we decontaminate people as well as equipment.

As with SA1, we can evidence policies relating to COSHH and lines of responsibility – but we can also think about using those photographs of storage cupboards and signage over different types of bins for disposal for easy evidence.

This section asks us questions around things such as:

  • Do we have the appropriate Personal Protective Equipment (PPE) and is it used appropriately? Have all staff had training?
  • Do we do a daily check that we have gloves etc in clinic rooms?
  • Who orders PPE to ensure we don’t run out?
  • How would we decontaminate a member of staff or a patient if a spillage occurred? Do we have a quick reference guide or a laminated poster in the scan room for example?
  • Is there clear signage on each of the bins to outline how to dispose of different types of material?
  • Can I show purchase orders for the appropriate decontamination wipes?
  • How do I know that staff are using the correct wipes/solutions for different types of cleaning – e.g. scanner; hard surfaces or blood on the floor?

This is one of those areas where assessors will probably glean a great deal of information from being on-site, but simple photographs and examples of posters etc. will go a long way to provide evidence.

SA3 - Implementing and monitoring systems to manage safe moving & handling

The idea of undertaking moving and handling training often fills staff with dread – and plans to try to be the volunteer patient so that you don’t have to do any heavy lifting quickly start to formulate in our minds as training approaches…

But of course, it is of critical importance for the safety of our patients and to staff. We’ve probably all heard horror stories (real or imagined) of staff who gave themselves long-term injuries through patient moves or falls. And in an industry where musculo-skeletal integrity underpins the longevity of our careers, it’s an important consideration.

As we might expect, this section covers safe moving and handling and the use of moving/lifting aids which will always raise the question of appropriate training. It also extends to the safe transport of patients and the restraint of patients, including children and vulnerable adults.

Training records and maintenance logs for any equipment involved in moving patients will be a given here, as will incident reporting. We can use examples of resolved incidents to highlight improvement in practice – but also, any examples of positive feedback from patients or relatives about how a patient’s time in the department was enhanced through good moving and handling practice will also be great evidence.

Questions that can help us with this section might include:

  • Who is trained to use a hoist? What is our policy for scanning bed-bound or wheelchair-bound patients?
  • How do we know the transfer status of a patient? Is it a question on our referrals for clinicians to indicate?
  • Can outpatients make special arrangements ahead of their appointment for moving and handling provision? What information is included in our appointment letters about the level of movement or removal of clothing required for their scan.
  • How do we monitor patient satisfaction with the provision, use and quality of movement aids?

The notion of restraint may not be applicable or relevant to most departments – but if you work within a larger Radiology department for example, there may be a policy for the restraint of patients. If this doesn’t apply to your department, it’s acceptable to simply state this in the web-assessment tool. These domains are wide-reaching and must cover all bases – not all will be applicable to your department and UKAS only expect us to provide evidence where a system is actually in place or should be in place.

SA4 – Systems to manage violence & aggression

Again, staff training and your associated records of completion are required for this standard. Most Trusts will provide conflict resolution training as a minimum for clinical and support staff.

Whilst it may be rare for patients or staff to experience violence, you need to demonstrate that you have a system in place to provide support in case an incident were to occur. Some questions that you may want to ask of your service:

  • Do you have panic alarms in your clinic rooms, and who would respond to them going off? Do you test them? Do they ring where you thought they would?
  • Do you mention risk of violence and aggression in your departmental and clinic room risk assessments?
  • If a patient was shouting at your Receptionist, would anyone hear?, what would you do?
  • When you have had incidents, do you record and learn from them?

SA5 – Ensuring the general health & safety of patients, staff & others

There is a whole raft of legislation which is applicable here, so you need to ensure that any local policies take account of your wider Trust policies and procedures.  You will also need to ensure that you have policies for any specific risks related to your service and that staff are aware of these policies and how to access them. Risk assessments (with regular review and updating) will be the key to many of the requirements of this standard.

As ever, we have some questions to get you started:

  • Do you have risk assessments, and do you include vascular specific risks (e.g. WRULD, provision of manual handling aids for amputees)?
  • Have you discussed your risk assessment with your Trust Health & Safety team?
  • Are your staff aware of your risk assessments and what they are required to do to minimise risk?
  • Do you have access to a crash trolley? Who checks this? Do staff know where it is?
  • Do you have a Back Care team in your Trust? Could they come and watch each Vascular Scientist scan and provide a report with some learning points? Could you include discussion of WRULD in annual appraisals? Does your Trust have a system for rapid access referral to Occupational Health? If not, and you have staff on sick leave with WRULD, could you exert pressure for this to be put in place?
  • Do you consider ergonomics when you purchase new ultrasound machines? Do you include your ‘un-ergonomic’ machines in your Divisional risk register (to ensure you have a good chance of funding for replacements)?
  • Do you check that your fire extinguishers are “in date” and have been checked?
  • Could you ask the Trust Fire Officer to do a drill in your department?

Documentation to evidence any of these processes will provide excellent evidence that you meet this standard.


We hope that this article has been helpful and, as ever, we would be very pleased to receive feedback and suggestions for the future articles. In the next one we will cover the 4th and final domain, Clinical.


IQIPS = Improving Quality in Physiological Services

UKAS = United Kingdom Accreditation Service

WRULD = Work related upper limb disorder