Document Title Phlebotomy Policy… · 2020-03-31 · phlebotomy skill as this will be covered in all the Trust’s centralised Phlebotomy training sessions. 2 Purpose 2.1 This document

Document Title Phlebotomy Policy

Reference Number NTW(C)35

Lead Officer Executive Director of Nursing and Chief Operating

Officer

Author (name and designation)

Kevin Crompton Lead Trainer

Ratified by Business Delivery Group

Date ratified Jun 2018

Implementation date Jun 2018

Date of full implementation

Jun 2018

Review date Jun 2021

Version Number V04.2

Review and Amendment

Log

Version Type of change

Date Description of change

V04 Review Jun 18 Policy review

V04.1

Update

Jan 19

Updated Appendix 1a and Additional Appendix 1b- Phlebotomy Supervisor role extended to non-registered nurses at Section 9.13

V04.2 Update Nov 19 Governance Changes

This policy supersedes:

Reference Number Title

NTW(C)35 – V04.1 Phlebotomy Policy

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CNTW(C)35

Phlebotomy Policy

Section Contents Page No:

1 Introduction 1

2 Purpose 1

3 Aim 1

4 Abbreviations 1

5 Duties and responsibilities 1

6 Legal Issues 2

7 Consent 3

8 Individual’s religious faith or belief 4

9 Training 4

10 Assessment 7

11 Record keeping 8

12 Practice 8

13 Standardisation of Equipment 10

14 Monitoring and Reviewing 10

15 Identification of Stakeholders 10

16 Equality Impact Assessment 10

17 Implementation 11

18 Standard Key Performance Indicators 11

19 Fair Blame 11

20 Fraud Bribery and Corruption 11

21 Associated Documents 11

CNTW(C)35

Appendix A Equality Analysis Screening Tool 12

Appendix B Training Checklist and Needs Analysis 14

Appendix C Audit Monitoring Tool 17

Appendix D Policy Notification Record Sheet - click here

Appendices – listed separate to policy

Appendix No: Description

Appendix 1a NTW Training route

Appendix 1b NTW non-registered nurse phlebotomy supervisor framework

Appendix 2a NTW Assessment criteria

Appendix 2b Supervision Framework Phlebotomy Supervisor for non-registered nurse

Appendix 3 NTW Standardised equipment

Appendix 4 Tourniquet order details

Appendix 5 BD Order catalogue

Appendix 6 Unistix information card

Appendix 7 Unistix information leaflet

Appendix 8 Unistix order details

Appendix 8a Unistix product details

Appendix 9 BD Microtainer - Family of Products

Appendix 10 BD – Lab Notes

Appendix 11 Nitrex Non-sterile Medical Glove order codes

Appendix 12 Order of Draw- BD Vacutainer

https://www.cntw.nhs.uk/about/policies/appendix-d-policy-notification-record-sheet/

CNTW(C)35

Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(C) 35 – Phlebotomy Policy – V04.2- Iss Nov 19

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1 Introduction

1.1 This policy describes Cumbria Northumberland, Tyne and Wear NHS Foundation Trust (the Trust/CNTW) approach to Phlebotomy, the procedure for taking blood samples for the purpose of laboratory investigation and testing. For the purpose of this policy the term phlebotomy is used to describe the complete procedure from receiving the service user to the dispatch of the blood sample. The term venepuncture will be used in relation to the actual act of accessing venous blood. This policy will also identify standards in training, practice and equipment. It is not the purpose or scope of this policy to describe the procedure and acquisition of phlebotomy skill as this will be covered in all the Trust’s centralised Phlebotomy training sessions.

2 Purpose

2.1 This document provides the phlebotomy practice standards framework for all CNTW practitioners.

3 Aim

3.1 To ensure that all staff practice consistently and safely within their sphere of professional responsibility, reflecting Trust standards in order to provide the highest skill provision to meet the needs of our service users.

4 Abbreviations

BMA British Medical Association

DoH Department of Health

GMC General Medical Council

NMC Nursing and Midwifery Council

GPhC General Pharmaceutical Council

CNTW Cumbria Northumberland, Tyne and Wear NHS Foundation Trust

PHWG Physical Health and Wellbeing Group

MDAM Medical Devices Safety Management Group

5 Duties and Responsibilities

5.1 The Chief Executive on behalf of CNTW retains ultimate accountability for the health, safety and welfare of all service users, carers, staff and visitors; however key tasks and responsibilities will be delegated to individuals in accordance with the content of this policy.

5.2 Senior clinical lead for phlebotomy together with phlebotomy supervisors will review on-going standards and practice.

5.3 The Phlebotomy training lead will feedback and report to both the Physical Health and Wellbeing Group (PHWG) and Safety and Sustainability Medical Devices.

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5.4 The PHWG and will provide information as regards equipment and practice standards to the Safer Care Group (SCG) which in turn will provide information for the Trust Board.

5.5 The MDAM will work with the PHWG in order to meet national and local physical health screening and assessment needs of our service users.

5.6 Medical Director and Executive Director of Nursing Chief Operating Officer are required to:-

Ensure that all Medical and Nursing staff are aware of this policy and other policies and guidance which relate to this policy.

Ensure that adequate training is given to allow medical, nursing and specialist staff to implement this policy safely.

Ensure that all non qualified practitioners work within the structure as described in Section 9 - Training.

To inform Senior Mental Health Management if the policy is not being implemented appropriately.

5.7 All phlebotomy practitioners must read the phlebotomy policy and maintain clinical practice that reflects standards therein.

5.8 All phlebotomy practitioners can attend an annual update to maintain on-going competencies and reflect periods of non-practice.

6. Legal Issues

6.1 Practice will reflect guidance from the Nursing and Midwifery Council under the Code of Professional Practice and Scope of Professional Practice.

6.2 In 1992 the regulatory body for nurse in the UK, the ‘UK Central Council for Nursing, Midwifery and Health Visiting (UKCC), published ‘The Scope of Professional Practice’. This document aimed to develop standards in nurse practice with the proviso that the nurse acknowledge the require skills for the role they undertake.

6.2.1 In 2002 the Nursing and Midwifery Council (NMC) replaced the UKCC and launched ‘The Code of Professional Conduct’ which encouraged nurses to expand their practice, provided they had the knowledge and skills and accepted responsibility for their actions but also recognised the importance of involving service users in decision affecting their care.

6.3 Doctors will practice under guidance from the General Medical Council (GMC). The later organisation has a statutory role to promote standards and co-ordinate all aspects of medical education, which includes continuing professional development.

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6.4 All pharmacist or pharmacy technicians will reflect practice standards and regulation through the General Pharmaceutical Council.

6.5 In all cases practitioners have a responsibility to deliver evidence based care. Service users have the right to receive a uniformly high standard of care, regardless of whom they are and where they receive care. (Department of Health - DOH 2000).

7 Consent

7.1 The Department of Health states: “It is a general legal and ethical principle that valid consent must be obtained before starting treatment, physical investigation or providing personal care” (DOH 2000). All service users have a right to receive accurate information about their condition and intended treatment. It is the responsibility of the individual practitioner proposing to carry out the treatment to ensure that the service users understand what is proposed (NMC 2002).

7.2 This policy also reflects principles under the Human Rights Act 1998 with particular reference to:

Article 5: The right to liberty and security of person

Article 8: The right to privacy

Article 10:Confidentiality

7.3 The term “Consent” refers to the service user’s agreement for a health professional to provide care, or agreement to participate in education or research. Service users may indicate consent non-verbally, orally or in writing. For the consent to be valid the service user must be competent to take the particular decision. Also the service user must have sufficient information to make a decision and not be acting under duress.

7.4 In all cases where supervisors are involving the service user for the purpose of education and clinical supervision of staff member they will gain informed consent. This will relate both to the observation of the phlebotomy procedure and the actual act of gaining venous access by the member of staff being trained. Also it is the Phlebotomy supervisor’s responsibility in conjunction to an individual’s case holder or lead practitioner to ascertain whether the facilitation of supervised training is conducive and non-detrimental to the overall care of that individual.

7.5 For consent to be to be valid the service user must have capacity to make that particular decision. The Mental Capacity Act 2005 details assessment of capacity and best interest decision. The service user should first be assumed as having capacity to make decisions if the person’s capacity is in question an assessment must be carried out and documented. A person is unable to make a decision for themselves if they are unable to:

Understand the information relevant to the decision

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Retain that information

Use or weigh that information as part of the process of making the decision

Communicate their decision (whether by talking, using sign language or any other means)

7.6 If a person does not have the capacity to consent to this procedure a ‘best interest’ decision must be made by the person carrying out the procedure. This must consider any advanced decision or advanced statement made by the person. Any decision must be in the best interests of the service user and follow the principles of the least restrictive option possible. Best interest decision must also be documented. For further advice on consent/capacity please consult the Trust policy, CNTW(C)05- Consent to Examination or Treatment.

8 Individual’s religious faith or belief

8.1 At all times practitioners must demonstrate sensitivity to an individual’s religious belief or faith and how this could influence the phlebotomy procedure.

9 Training

9.1 All training will be delivered and directed centrally by the Workforce and Organisational Development department.

9.2 All staff require line management support to access phlebotomy training with the aim of developing local standards in care delivery to meet the service user’s needs.

9.3 It is not an acceptable reason for individual staff to undertake phlebotomy training for personal or professional reasons if it cannot be demonstrated that acquiring such skills aims to meet the needs of service users. Further it is not realistic for staff to access this training if there is no opportunity or requirement to use such skills in their clinical or care environment.

9.4 Staff will book training through the central Workforce and Organisational Development department.

9.5 All phlebotomy trainers delivering the underpinning theory and centralised training standards will have a recognised phlebotomy training and teaching qualification.

9.6 All phlebotomy trainers will be current phlebotomy practitioners and with either Registered Nurse or Medical qualification in order to provide a broader contextual appreciation of physical health.

9.7 The phlebotomy training programme will offer both new courses for practitioners with no previous experience and update courses for current practitioners. (See Appendix 1)

9.8 Staff undertaking new training will receive a training work-book prior to undertaking Part I ‘underpinning theory’ session. This work book will require staff to reflect on their care environment and specific needs of their service users. All

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pre-course work will be consolidated in their training and the work book will also follow them through the programme and act as a personal resource and to aid reflection. All participants will need to contact a supervisor prior to Part 1 to arrange Part II clinical supervised practice.

9.9 Staff undertaking Part I will be assessed in an on-going capacity and by way of a formal knowledge based assessment.

9.10 On successful completion of Part I staff will then access a suitable clinical environment where they will be practically assessed by a clinical supervisor.

9.11 On successful completion of Part I and Part II they will be able to clinical practice phlebotomy.

9.12 All staff that identify they would like to become Clinical Supervisors will meet the following criteria:

Qualified Nurse

Qualified Doctor

Qualified Pharmacist or Pharmacy Technician

Recognised phlebotomy practitioner

Attend an CNTW phlebotomy update session

Undertake a clinical review of their practice environment

Reflect all standardised phlebotomy equipment

Follow all CNTW training standards and assessment criteria

Work reflecting guidance from CNTW’s MDAM and PHW groups

Work within their professional bodies guidelines

Be able to assure informed consent from individual service users for their involvement in training CNTW staff within phlebotomy practice and that this would not be detrimental to their care provision

9.13 Non-registered nurses that identify they want to become Phlebotomy Supervisors must reflect the standards outlined by CNTW’s: ‘Supervision Framework’ document (Appendix1b) which outlines how individual non-registered nursing staff can undertake Phlebotomy Supervisor Training in Adult Services:

Receive clinical line management support

Identifies a registered nurse or medic that can act as a clinical point of contact

Receive CNTW in house training for phlebotomy

Be assessed through supervised practice as competent to perform phlebotomy and identified on CNTW phlebotomy database

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Completes phlebotomy update and supervisor role

Completed CNTW Capacity to consent training

Reflect the Consent to Examination & Treatment Policy CNTW (C) 05

In conjunction with named nurse or lead practitioner ascertains appropriateness and capacity to consent of individual service users participation within the phlebotomy training programme within their clinical setting

Can demonstrate and reflect all CNTW Phlebotomy practice standards and associated Infection Prevention and Control standards

Are ‘signed off’ for the role of Phlebotomy Supervisor by their ‘designated’ clinical line-manager in conjunction to their clinical supervision, reflecting local-clinical need

9.14 All practitioners successfully taking up role of supervisors will meet the following role requirements:

Identify a suitable environment for training with a significant number of phlebotomy opportunities

Responsibility for their immediate practice environment

Will reflect all CNTW safety policies and guideline/protocols and locate relevant policies in practice environment

Course attendees will independently contact supervisor for clinical supervision but the supervisor will negotiate dates/times based upon their workload.

Supervisors will maintain ongoing educational file

Follow training and assessment criteria all assessment sheets will be sent to Workforce Support for central record keeping

Attend ‘self-identified’ Phlebotomy Updates

Distribute all information cascaded PHW, MDAM and CAS Alert distribution

Independently maintain knowledge and skills

Work within their professional body guidelines

9.15 Supervisors will record their training using the CNTW training log provided.

9.16 CNTW will offer training to qualified and unqualified staff. Qualified staff will work within their professional scope of practice and be supported by their line manager. Non qualified staff will be supported through their line manager who will agree their ‘local’ role extension support framework.

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9.17 Following successful completion of CNTW phlebotomy training qualified staff can practice phlebotomy independently and will be expected to work within their professional body: Nursing and Midwifery Council, General Medical Council and General Pharmaceutical Council practice standards.

9.18 Following successful completion of CNTW phlebotomy training non qualified staff must practice in a designated clinical environment with competent qualified staff or have them as a point of contact.

9.19 Non-qualified staff that wishes to practice phlebotomy independently must be supported through their line manager. This person must take overall responsibility as the individual does not work within a professional body which governs clinical practice independently of the Trust. In this case the following pre-requisites must be met:

Support for role extension from line management within Knowledge Skills Framework and clinical supervision

Identify role remit e.g. practice environment and service provision

Identify point of contact (qualified nurse/doctor and a recognised phlebotomy

practitioner)

Successfully complete CNTW phlebotomy training

Demonstrate how they aim to maintain up to date practice in both underpinning knowledge and practice skills

Can attend phlebotomy update sessions to support practice

9.20 Phlebotomy practitioners will attend phlebotomy update training as required

through reflecting upon on-going individual clinical development responsibilities, clinical skills retention and service needs.

9.21 All medical staff, locums and junior doctors on rotation placements must practice

to CNTW phlebotomy standards. Practice standards and phlebotomy policy will be identified through CNTW Trust and local induction process. All medics can access phlebotomy training programme to support practice standards.

9.22 In all training sessions presentation will be delivered on Infection Prevention and Control, Health and Safety and Occupational Health Services.

10 Assessment

10.1 All new staff undertaking phlebotomy training will be assessed in the following way:

Complete accompanying course training booklet. This will be sent to each course participant prior to course and will follow them through their training programme.

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During underpinning theory (Part I) participants will complete a knowledge based assessment and on-going/practical assessment during training day.

Following successful completion of Part I participants will be clinical supervised (Part II) and assessed using the standardised CNTW criteria and signed off by the supervisor. (See appendix 2a and 2b).

10.2 On completion of part I course attendees have a period of three months to commence part II assessment. If three months expire course attendees must contact the course leader (clinical lead) to discuss circumstances and decide upon an appropriate individualised training route.

10.3 Following successful completion of part I and part II staff can then practice phlebotomy.

10.4 Staff undertaking the phlebotomy update will be assessed informally during session.

11 Record Keeping

11.1 All training will be booked through the Workforce and Organisational Development department.

11.2 Computer based record of all training booking and attendance will be kept centrally.

11.3 Hard copy records of Part I underpinning theory and Part II supervised clinical practice will be kept centrally.

12 Practice

12.1 All staff will follow Health and Safety and Infection Prevention and Control guidelines when handling sharps and body fluids. The National Institute for Clinical Excellence (NICE) have highlighted a number of issues that have a direct relevance as regards Infection control, use of personal protective equipment, sharps safety and waste disposal in phlebotomy practice.

12.2 The vacuum based, safer sharps systems will be used for all phlebotomy sampling to:

Reduce the risk of needle stick injury

Reduce the risk of cross infection

Reduce the risk of spillage

Improve the quality, consistency and accuracy of sampling

12.3 Staff will be trained in the use of vacuum based systems for venous access

of antecubital fossa/arm and metacarpal/hand sites

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12.4 Staff will be trained to use capillary device systems for both point of contact testing (Blood Glucose-BM) and for capillary sampling with Dry Blood Spot Testing DBST highlighted.

12.5 Staff must decontaminate hands immediately prior to and after each procedure following CNTW guidelines.

12.6 Staff have a responsibility to maintain their practice environment to prevent cross infection.

12.7 All staff will wear personal protective equipment (PPE) including gloves and disposable aprons as identified in the Trust’s CNTW(C)23, Infection, Prevention and Control Policy, where there is a risk of contamination/cross infection.

12.8 In preparation for actual venous access all sites will be cleaned with identified solutions unless contra indicated in which case infect ion prevention and control leads will be contacted for advice.

12.9 Practitioners will only use once only tourniquets.

12.10 Sharps must be discarded into designated sharps container located at the point of use by the practitioner and must not be overfilled or left on the floor.

12.11 Hypodermics must never be recapped, bent or disassembled at any point throughout the phlebotomy procedure.

12.12 The following documents will be covered in all trainings sessions and practitioners will be required to follow all the respective guidelines/protocols:

CNTW(C)05 - Consent to Examination and Treatment

CNTW(C)23 - Infection, Prevention and Control and practice guidance notes

o IPC-PGN-2.1- Standard precautions

o IPC-PGN-3.1- The safe use and disposal of sharps

o IPC-PGN-3.2 - Immediate management of percutaneous sharps injury

o IPC-PGN-4.1 – Hand Hygiene and use of alcohol rub

o IPC-PGN-7.1- The management of sharps and needlestick injuries and post exposure prophylaxis (PEP)

CNTW(C)46 – Inoculation Injury Policy

CNTW(O)01- Development and Management of Procedural Documents

Health and Safety COSHH Management of Clinical Waste

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13 Standards of Equipment

13.1 All equipment for venous sampling will be standardised across the Trust based upon the vacuum system.

13.2 All point of contact, capillary and venous sampling devices will incorporate ‘safer- sharps’ needle protection systems.

13.2 All equipment will be ‘signed off’ by the Medical Devices, Physical Health and Wellbeing and Prevention and Control of Infection with all information cascaded to all Departments. (See Appendix 4)

13.3 CNTW reflects all standards identified by European sharps directive 2010/32/EU and implementation of revised directive ‘Safer needle protection systems’ EU directive May 2013.

14 Monitoring Compliance

14.1 The PPF meets quarterly with the remit of continually reviewing standards and practice. Any recommendation from this group will be cascaded through the supervisors and relevant Trust groups.

14.3 The PPF will feedback and report to the MDAM.

14.3 The clinical lead for phlebotomy will provide the SSMDRG with all information on current developments, issue relating to safety and standards of practice. Also the group will receive information from the Health and Safety alert system.

14.4 The MDAM and PHW will monitor the implementation of NICE guidelines.

14.5 The clinical lead for phlebotomy will act as an ongoing point of contact for all phlebotomy enquiries.

14.6 The clinical lead for phlebotomy will maintain ongoing contact with leads in Health and Safety and Infection Control to maintain up to date advice to Trust groups as regards phlebotomy.

15 Identification of Stakeholders

15.1 The consultation of this policy has been carried out in line with the Trust’s policy, CNTW(O)01 – Development and Management of Procedural Documents. Due to only minor changes within the content of this policy, no Trust-wide consultation was necessary, therefore implementation of this policy will be immediate.

16 Equality and Diversity Assessment

16.1 In conjunction with the Trust’s Equality and Diversity Officer this policy has undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner.

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17 Implementation

17.1 This will be implemented immediately and monitored by the MDAM and PHWG during the review process. If at any stage there is an indication that the target date cannot be met and will consider the implementation of an action plan.

18 Standards / Key Performance Indicators

18.1 National standards that reflect Nice Guidelines, DOH and professional bodies such as British Medical Association, General Medical Council, Nursing and Midwifery Council and Mental Health Capacity Act.

19 Fair Blame

19.1 The Trust is committed to developing an open learning culture. It has endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken.

20 Fraud, Bribery and Corruption

20.1 In accordance with the Trust’s policy CNTW(O)23 – Fraud, Bribery and Corruption Policy, all suspected cases of fraud and corruption should be reported immediately to the Trust’s Local Counter Fraud Specialist or to the Executive Director of Finance.

21 Associated Documents

CNTW(C)05- Consent to Examination and Treatment Policy

CNTW(C)23 - Infection Prevention and Control Policy and PGNs:

IPC-PGN-02.1 - Standard Precautions PGN

IPC-PGN-03.2 - Immediate Management of Percutaneous Sharps Injury PGN

IPC-PGN-03.1 Safe Use-Disposal of Sharps

CNTW(C)46 - Inoculation Injury Policy

CNTW(O)01 – Development and Management of Procedural Documents

Health and Safety COSHH Management of Clinical Waste

Hand Hygiene and use of Alcohol Hand rub, Appendix 2

Single Use Medical Devices Equipment List

IPC-PGN 10 Disinfection and Decontamination Practice

Aseptic Non-Touch Technique - See Tissue Viability - CNTW(C)18 - TV-PGN- 03

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Appendix A

Equality Analysis Screening Toolkit

Names of Individuals involved in Review

Date of Initial Screening

Review Date Service Area / Locality

Christopher Rowlands May 2018 June 2021 Trust wide

Policy to be analysed Is this policy new or existing?

CNTW(C)35 – Phlebotomy Policy V04 Existing

What are the intended outcomes of this work? Include outline of objectives and function aims

This policy describes Cumbria Northumberland Tyne and Wear NHS Foundation Trust’s approach to Phlebotomy, the procedure for taking blood samples from a service user for the purpose of laboratory investigation and testing. For the purpose of this policy the term phlebotomy is used to describe the complete procedure from receiving the service user to the dispatch of the blood sample. The term venepuncture will be used for the actual act of accessing venous blood. The policy will reflect National and European recommendation/standards in practice and equipment.

Who will be affected? e.g. staff, service users, carers, wider public etc

Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them

Disability Potential need for reasonable adjustments for staff who may find it difficult to use the equipment

Sex Dignity issues are addressed in the policy

Race NA

Age NA

Gender reassignment

(including transgender)

Dignity issues are addressed in the policy

Sexual orientation

Religion or belief Ramadan health guide states clearly that giving any blood during a fast period is not acceptable unless the condition of the patient means that it is vital that it takes place at that time. Guidelines about exemptions to the fast need careful interpretation by both the patient and the health worker and this may be aided by a Muslim Leader (Imam or other representative from the relevant Mosque) or Chaplain.

Marriage and Civil Partnership

Pregnancy and maternity

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Carers

Other identified groups

How have you engaged stakeholders in gathering evidence or testing the evidence available?

Through policy process

How have you engaged stakeholders in testing the policy or programme proposals?

Through review of policy

For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:

Staff

Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life.

Low impact – religious needs however need to be observed

Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic

Eliminate discrimination, harassment and victimisation

NA

Advance equality of opportunity NA

Promote good relations between groups NA

What is the overall impact? NA

Addressing the impact on equalities NA

From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010?

If yes, has a Full Impact Assessment been recommended? If not, why not?

Manager’s signature: Chris Rowlands Date: May 2018

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Appendix B

Communication and Training Check list for policies

Key Questions for the accountable committees designing, reviewing or agreeing a new Trust policy

Is this a new policy with new training requirements or a change to an existing policy?

Existing Policy

If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below.

Standardisation of practice skills, training, recording and equipment use that reflects centralised Training and Development

Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice?

Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHS Resolutions etc.

Please identify the risks if training does not occur.

Training standards reflects local/regional Strategic Health Authority.

National standards that reflect Nice Guidelines, DOH and professional bodies such as British Medical Association, General Medical Council and Nursing and Midwifery Council, General Pharmaceutical Council and Mental Health Capacity Act.

Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training.

Specific staff groups or individual staff with line management support. Must demonstrate need to extend or maintain skill base to meet service user need.

Is there a staff group that should be prioritised for this training / awareness?

All staff that are current phlebotomy practitioners or future practitioners must reflect the policy standards to underpin practice and attend centralised CNTW training programme.

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Communication and Training Check list for policies ………..continued

Please outline how the training will be delivered. Include who will deliver it and by what method.

The following may be useful to consider:

Team brief/e bulletin of summary

Management cascade

Newsletter/leaflets/payslip attachment

Focus groups for those concerned

Local Induction Training

Awareness sessions for those affected by the new policy

Local demonstrations of techniques/equipment with reference documentation

Staff Handbook Summary for easy reference

Taught Session

E Learning

The acquisition of new skills is by way of underpinning knowledge and skills and clinical supervised practice. In both cases this is delivered across the Trust to meet local need.

Information is circulated via the Trust Intranet with the Training Prospectus. Areas that are unable to access intranet have access to hard copies or access information through the Training and Development Department.

CNTW has a Trust-wide Phlebotomy supervisor network that cascades information. This group also feeds into the Physical Health and Wellbeing, Infection Prevention and Control Group and Safety and Sustainability, Medical Devices

Information and developments can be promoted via such routes or managements cascade with Lead Nurse Group.

All staff receive a practice skills booklet that follows them throughout training and supports practice upon qualification.

Within Induction the specialist clinical training is highlighted.

Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc.

Kevin Crompton - Clinical Lead for Phlebotomy will communicate within Workforce and Organisational Development department.

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Appendix B – continued

Training Needs Analysis

Staff/Professional Group Type of training

Duration of

Training

Frequency of Training

Service Area – Potentially any service area including in-patient or community care environments that identify they require phlebotomy practitioners to meet the needs of service users.

Please see section 8 Training for specific details.

CNTW will provide both New training and update training.

Please see Appendix 1 for training routes.

Following initial training CNTW identify phlebotomy updates to meet service needs or ongoing individual practice development

Staff / Professional Groups - Both qualified and non-qualified nursing and medical staff. Other staff groups will be reviewed on an individual basis.

Please see Section 8 Training for specific details

Should any advice be required, please contact: - 0191 2456777 (internal 56777) Option 1

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Statement

Monitoring Tool

Appendix C

The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework.

Auditable Standard/Key Performance Indicators

Frequency/Method/ Person Responsible

Where results and any Associate Action Plan will be reported to, implemented and monitored; (this will usually be via the relevant Governance Group).

1 Phlebotomy practitioners undertake required training

Bi Annual Training report

Provided by Workforce and Organisational Development department.

Training Manager

Physical Health and Wellbeing Group

2 Training provided ensures that relevant staff are aware of the requirements of the Phlebotomy Policy

Including equipment standards (national and European) and practice standards

Training package reviewed when changes to policy by Senior Clinical Trainer and outcome reported to relevant governance group

Physical Health and Wellbeing Group

Safety and Sustainability, Medical Devices

3 Review of any associated Sharps/exposure incidents

Quarterly incident report by

Infection Prevention and Control Nurse

IPC Committee

The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out.