Theatre Audit & Accreditation

Audit Visit

This is a bespoke visit where a hospital needs assistance with undertaking our Perioperative Audit Tool. We usually offer two days to get a team started with the toolkit, a follow up visit to review findings and action plans to support improvements following the full audit.

A formal report of findings may not be necessary as the audit tool provides the basis for feedback. If issues of poor practice that could put patient safety at risk are observed, then these would be fed back either at the time of observing or at the end of the review. In this situation, a formal confirmation of issues would be provided via a report.


Accreditation/Audit Visit

The accreditation process is designed to assess the quality of the processes followed by healthcare providers. They allow users to recognise the highest quality care and to continually raise standards in the longer term.

A ‘kite mark’ is provided to theatres that meet the required standards. The accreditation lasts for two years, after which we return to gain assurance that the hospital team is continuing to maintain the high standards of care.
We conduct an initial two day visit to get a team started with the Perioperative Audit Tool. During the two days we work with the team to undertake, in detail, three elements of the audit tool, two set and one of the team’s choice. Following this, the hospital continues going through the audit tool, using other theatres/hospitals within their group/Trust to provide peer review opportunities.

An initial report is provided to the hospital to assist with action and improvements identified in the first visit. A follow up meeting is then undertaken where practices and action plans are reviewed. At the end of the process a follow up report is produced. This details findings and provides recommendations as to whether the hospital should be accredited with meeting the required standards.

Perioperative Peer Review

This is an observational exercise. It’s undertaken when a hospital asks us to review practice within their theatre environment, often following poor CQC feedback; incidents of poor practice or similar. Hospitals generally want reassurance that measures they have put in place as a result are satisfactory. Sometimes we’re asked to review practices with a view to making suggestions for improvement.