Maximising success– marginal gains concept

Factors that influence effectiveness

Staff

Training

Knowledge

Skills

Facilities

Materials

Equipment

Procedures (SOP)

Patients

Suppliers

Satisfied Patients

PreventiveAction

Monitor, Measureanalyse

CorrectiveAction

Patients

Consistent

INPUTS OUTPUTSThe process

ProcessIUI,IVF,ICSI

Donor Programme

Feedback

Feedback

An RCN Education and Career Progression Framework for Fertility Nursing RCN Feb 2018

The role of the fertility nurse is to provide a holistic approach to fertility investigation, treatment and preconception and early pregnancy care, through compassionate, informed and evidence based practice.

…informed and evidence based practice

ALL new staff should have an orientation plan, held in HR file as evidence

Training plan in place combining• Knowledge – theoretical, courses, internal CPD - evidence• Skills with a plan in place to observe, to be supervised, assessed -

evidence• Competence – assessment by expert, internal or /and external –

evidence.

Nursing Staff

A Generic Log book must be completed throughout the training period recording observation, supervised practice and demonstration of competence in areas highlighted below :

Pelvic Ultrasound – Training courses should be undertaken as provided by the British Fertility Society Course (BFS) or any other academic institution that has an appropriate course. To ensure standard is met all staff must follow Pelvic Ultrasound Scans (OP-GN-0028) when undertaking a scan.

Intra-uterine Insemination (IUI) – Training courses should be undertaken in accordance with the Royal College of Nursing (RCN) and the Fertility Nurses Group guidelines. Followed by in house supervised practice with completion of generic logbook FM-TR-0014

Embryo Transfer (ET) – Training courses should be undertaken as provided by the British Fertility Society Course (BFS). To ensure standard is met all staff must perform ET’s in accordance with Embryo Transfer SOP (OP-AR-0001).

Early Pregnancy Ultrasound – Following completion of recognised course in pelvic ultrasound training will be provided in house by recognised BFS trainers with mentorship being provided by senior clinical staff. To ensure standard is met all staff must perform early pregnancy ultrasound in accordance with Early Pregnancy SOP (OP-GN-0014).

Training opportunities………examples

• RCN Fertility Nurses Annual Study day• British Fertility Society – study days and modules• British Fertility Society – annual meeting• European Society of Human Reproduction and Embryology (ESHRE) –

Certification course in reproductive health for nurses and midwives.• ESHRE Annual meeting• Senior Infertility Nurses Group (SING) – on line modules• SING Counselling course (compassionate practice)• Edgehill University, Liverpool – MSc Advanced Fertility Practice

MSc Advanced Fertility Practice

British Fertility Society

https://britishfertilitysociety.org.uk/

Fertility nurses must work within the limits of their competence in caring for patients and partners throughout the fertility journey by treating people as individuals, practice in line with best evidence available and uphold the reputation of the nursing profession.

An RCN Education and Career Progression Framework for Fertility Nursing RCN Feb 2018

Competencies

Whatever tasks nurses undertake they must have evidence of training and competence assessment e.g.:

• Fertility assessment including pre-conception care• Provision of information and consent• Medicines management• Infection prevention and control• Documentation and record keeping• Surgical pathway – IVF• Ovulation Induction• Intra-uterine insemination/Embryo Transfer (training)• Ultrasound scanning

Benner’s stages of clinical competence

Beginner(B) Advanced Beginner (AB) Competent (C) Proficient (P) E Expert (E)

Provide evidence to demonstrate the knowledge and skills required through: • independent assessment of competence• direct observation of practice• reflective report• care based discussion • clinical case review• feedback from colleagues and patients

Benner P (1984) From Novice to Expert, Excellence and Power in Clinical Nursing Practice, Menlo Park:Addison-Fertility Wesley

Competence AssessmentBeginner(B) Advanced Beginner (AB) Competent (C) Proficient (P) Expert (E)

Specific competences

Communication is key

Roles and Responsibilities

Centre Manager

Admin SupervisorLaboratory Manager

Admin StaffLaboratory Staff

Senior Nurse Quality Manager

Quality StaffNurses

Clinical Lead

Medical Team

Everybody, Somebody, Anybody and …………Nobody

There was an important job to be done and Everybody was sure that Somebody would do it.

Anybody could have done it, but Nobody did it.

Somebody got angry about that because it was Everybody's job.

Everybody thought that Anybody could do it, but Nobody realized that Everybody would not do it.

It ended up that Everybody blamed Somebody when Nobody did what Anybody could have done.

Team work

Together Everyone AchievesMore

To me…………….

Effectiveness/Success = Quality

Quality Standards

Quality management systems Requirements (ISO 9001:2015) -The quality management principles are:• — customer focus; (staff training etc.)• — leadership; (roles and responsibilities)• — engagement of people; (patients, suppliers, referrers)• — process approach; (SOP’s)• — improvement; (through audit and risk assessment)• — evidence-based decision making; (SOP’s, CPD)• — relationship management. (roles and responsibilities)

Medical laboratories — Requirements for quality and competence (ISO 15189:2012) This International Standard can be used by medical laboratories in developing their quality management systems and assessing their own competence. It can also be used for confirming or recognizing the competence of medical laboratories by laboratory customers, regulating authorities and accreditation bodies. United Kingdom Accreditation Service (UKAS) Andrology Diagnostic Semen Analysis.

Annual Plan of Risk Assessments

Risk is defined as the probability that an event or action may adversely affect the Centre. Internal Audit should be within Risk Management strategy; the more specific purpose of a risk assessment from an audit perspective is to • Prioritise audit projects by level of potential risk• Determine the nature, timing, and extent of internal audit procedures in

direct relation to the level of the risk• Develop a plan for performing internal audit projects in risk areas to

minimize the risk of loss• Use everyone’s time in an effective and efficient manner• The risk assessment process includes the review of existing

documentation such as Prior Audit Findings, the Centre’s Strategic Plan, and interviewing managers and process owners with a focus on “what can go wrong” scenarios.

Why Internal Audit is Important

1. Provides Objective Insight – trained internal auditor (Quality Manager) who can provide an independent and unbiased view.

2. Improves Efficiency of Operations – Continuous monitoring and review of processes and procedures

3. Evaluates Risks and Protects Assets – Risk assessments, equipment & supplier control

4. Assesses Controls – SOP’s are they validated and being followed

5. Ensure Compliance with Laws and Regulations – ISO 9001:2015, ISO15189:2012, HFEA

Areas of compliance – Audit Plan

Audit programme

Validation for ovarian stimulation SOP

Document Description Notes/CommentsCochrane Database of Systematic Reviews 2011, Issue 8. Art. No.: CD006919. DOI: 10.1002/14651858.CD006919.pub3.

Maheshwari A, Gibreel A, Siristatidis CS, Bhattacharya S Gonadotrophin-releasing hormone agonist protocols for pituitary suppression in assisted reproduction

Cochrane Database of Systematic Reviews 2011, Issue 5. Art. No.:CD001750. DOI: 10.1002/14651858.CD001750.pub3.

Al-Inany HG, Youssef MAFM, Aboulghar M, Broekmans FJ,Sterrenburg MD, Smit JG, Abou-Setta AM.Gonadotrophin releasing hormone antagonists for assistedreproductive technology.

Cochrane Database of Systematic Reviews2010, Issue 11. Art. No.: CD008571. DOI:10.1002/14651858.CD008571.pub2.

Benschop L, Farquhar C, van der Poel N, Heineman MJ. Interventions for women with endometrioma prior to assisted reproductive technology.

Cochrane Database of Systematic Reviews2006, Issue 1. Art. No.: CD004635. DOI:10.1002/14651858.CD004635.pub2.

Sallam HN, Garcia-Velasco JA, Dias S, Arici A, Abou-Setta AM.Long-term pituitary down-regulation before in vitro fertilization(IVF) for women with endometriosis.

RCOG Guidance

British Fertility Society Policy and Practice Committee: Prevention of Ovarian Hyperstimulation Syndrome

Human Fertility, 2014; 17(4): 257-268 © 2014 The British Fertility Society

Embed external standards into SOP’s

Each Audit/Risk Assessment/RCA

Factors that could influence effectiveness

• Ineffective training • Inadequate supervision• High work load• Poor working environment • Ineffective communication• Inadequate resources• Uncertainties in roles and responsibilities…………………

All these areas should be explored when undertaking a Root Cause Analysis (RCA)

RCA investigation

RCA Outcome

• Confirm the root cause and effects on the process

• Generate potential solution/ recommendations

• Implement changes and re-audit

Factors that influence effectiveness

Staff

Training

Knowledge

Skills

Facilities

Materials

Equipment

Procedures (SOP)

Patients

Suppliers

Satisfied Patients

PreventiveAction

Monitor, Measureanalyse

CorrectiveAction

Patients

Consistent

INPUTS OUTPUTSThe process

ProcessIUI,IVF,ICSI

Donor Programme

Feedback

Feedback

Compassionate care - a patient’s voice…..

• This may be a normal day at work for you ….. But it’s a big day in my life

• I may only be here for four days but I will remember you the rest of my life

• Remember I’m not usually this needy or scared• I am here because I trust you, help me to stay confident• I may only be here for four days but I will remember you

the rest of my life

Marginal gains

• Nursing staff consistently provide evidence based care based on SOP’s• By undertaking training and competence assessments ensure standards

are maintained • Effective communication ensure patient care is seamless and individual• Nursing team consists of staff with a range of skills (Band 2 – Band 7/8)

each with specific job description• Initiate and participate in Risk assessments• Initiate and participate in Audit practice