Theatre Operational Policy

Policy Type Clinical

Directorate Medical Directorate

Policy Owner Medical Director

Policy Author Theatre Matron

Next Author Review Date 1 November 2025

Approving Body Theatre User Group

Clinical Standards Group
Version No. 2.0

Policy Valid from date 1 April 2023

Policy Valid to date: 30 April 2026

This policy will be reviewed in line with the Document Control Policy, please read the
policy in conjunction with any updates provided by National Guidance.

Theatre Operational Policy

Version No.2.0 Page 1 of 39
DOCUMENT HISTORY
(Procedural document version numbering convention will follow the following format. Whole numbers for approved versions, e.g. 1.0,
2.0, 3.0 etc. With decimals being used to represent the current working draft version, e.g. 1.1, 1.2, 1.3, 1.4 etc. For example, when writing
a procedural document for the first time – the initial draft will be version 0.1)

Date of Issue Version Date Director Responsible Nature of Change Ratification /

No. Approved for Change Approval
14/06/18 0.1 Medical Director New policy draft
21/06/18 0.2 Medical Director Enhancement
28/06/18 0.3 Medical Director Draft revision and
consultation
14/08/18 0.4 Medical Director Policy review Policy Management
Recommendations Sub Committee
10/09/18 0.5 Medical Director Enhancement
13/09/18 0.6 Medical Director Final Validation
13/12/18 0.6 Medical Director Endorsement at Theatre Steering
Group
11/10/18 0.7 Medical Director Post Policy review
finalisation
9/10/18 1.0 9/10/18 Medical Director Approved at Policy Management
Sub Committee
23/10/18 1.1 Medical Director Enhancement
16/01/19 1.1 09/10/2018 Medical Director WHO Checklist Policy Management
added as an Sub Committee
appendix as noted
at
29/01/21 1.1 09/10/2018 Medical Director 12 month blanket Quality & Performance
policy extension Committee
due to covid 19
applied with author
review date set 6
Months prior to
Valid to Date.
22/05/21 1.1 09/10/2018 Medical Director Extended policy Corporate Governance
uploaded and
linked back with
new cover sheet
07.10.22 1.1 Planned management Draft
representatives
11.01.23 1.2 Theatre User group Final Draft

31/03/23 2 31 Clinical Standards Approval Clinical Standards

Group Group

NB This policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust

Theatre Operational Policy

Version No.2.0 Page 2 of 39
Contents

1 Executive Summary ....................................................................................................... 4

2 Introduction .................................................................................................................... 4
3 Definitions ...................................................................................................................... 4
4 Scope ............................................................................................................................ 8
5 Purpose ......................................................................................................................... 8
6 Roles and Responsibilities ............................................................................................. 9
7 Policy detail/Course of Action....................................................................................... 11
8 Service Principles ........................................................................................................ 11
9 General Principles........................................................................................................ 14
10 Ordering of supplies and consumables ..................................................................... 24
11 Conditions of service ................................................................................................ 26
12 Consultation ............................................................................................................. 26
13 Training .................................................................................................................... 27
14 18 References .......................................................................................................... 31
15 19 Appendices.......................................................................................................... 31

Theatre Operational Policy

Version No.2.0 Page 3 of 39
1 Executive Summary
This is the Theatre Operational Policy for the Isle of Wight NHS Trust.

The policy provides guidance and outlines the rules for the management of all
activity occurring in the Main Theatres, Day Theatres, Eye care theatre to ensure
patient safety is always maintained. This policy also acts as an operational guide for
those staff involved in the management of all scheduled theatre sessions i.e.,
elective, trauma and emergency within the theatre suites at Isle of Wight NHS Trust.
It sets out the roles and responsibilities, processes to be followed and establishes
good practice guidelines to assist staff to provide safe and efficient care to our
patients within a Theatre setting.

2 Introduction
The Trust is committed to ensuring optimal use of operating theatre capacity and
resources, maximising operating theatre performance, and avoiding cancelled
operations in order to provide high quality health care to patients admitted for
surgery. The theatre services at the Isle of Wight Trust consists of Three areas, main
theatres with a recovery area, day surgery theatre with a recovery area leading to
the day surgery ward, Eye care centre theatre with recovery area and ward area. All
professional staff must always abide by standards of professional bodies to ensure
patient safety.

3 Definitions
By default, all elective theatre sessions will be 3.5or 7 hours in duration to reflect
consultant contracts, with an additional 30-minute lunch break for an all-day session.
The only exceptions to this will be by formal agreement in the job planning process,
signed off by the Clinical Director and reviewed on a six-monthly basis. Theatreman
is the theatre management system in use within all theatres in the scope of this
policy.
Start time of session: As recorded within Theatreman determined by outcome of job
planning.

Theatre Operational Policy

Version No.2.0 Page 4 of 39
Finish time of session: As recorded within Theatre man determined by outcome of
job planning
Theatres used for elective purposes will undertake two elective sessions per day.
(Mon-Fri) and this will be reflected in the safer staffing levels and rostered shifts for
theatre workforce as outlined by the National Association of Peri–Operative
Practitioners (AfPP) and the Consultant Contract for unsocial hours working. The
theatre establishment has been developed utilising the AfPP national guidance and
staff are allocated based on theatre schedule.
Main Theatres
The WHO safer surgery Pre brief starts 10 minutes before the start time of the list
and the start time of the list is defined as first contact with the patient i.e., needle to
skin). List finish time is defined as the time the patient left the operating theatre.

o 08:30 – 12:00 AM sessions

o 13:30 – 17.00 PM sessions
o 08:30 – 16:00 All day session (including a 30-minute lunch break)
o 08.30-12.45 AM Session Orthopaedic and Colorectal Elective
o 13.15-17.30 PM Session Orthopaedic and Colorectal Elective
o 08.30-17.30 All day session (including a 30-minute lunch break) Session
Orthopaedic and Colorectal Elective

Day Surgery Theatres

The WHO safer surgery Pre brief will start 10 minutes before the start time of the list
and the start time of the list is defined as first contact with the patient ie. needle to
skin. List finish time is defined as the time the patient left the operating theatre.

o 08:30 – 12:00 AM sessions

o 13:30 – 17:00 PM sessions

Eye care unit

The WHO safer surgery Pre brief will start 10 minutes before the start time of the list
and the start time of the list is defined as first contact with the patient i.e., needle to
skin. List finish time is defined as the time the patient left the operating theatre

Theatre Operational Policy

Version No.2.0 Page 5 of 39
o 08.30-12.00 AM Session
o 13.00-17.00 PM Session

Utilisation
Utilisation will be calculated as the sum of minutes spent anaesthetising and
operating within the scheduled start and finish time of the session, divided by the
total number of session minutes available, As defined by Audit commission.
Reports will be produced monthly and will include:

o Utilisation by consultant, specialty and theatre

o Cancellations on the day of admission or day of surgery
o Cancelled sessions
o Re-allocated sessions
o This information will be displayed electronically within main theatres
o Weekly utilisation information will be displayed outside individual theatres
o Return to Theatre for additional surgery relating to their listed surgery

Detailed bespoke reports can be requested via the Senior data analyst for theatres.
The Theatre User Group meeting will review the previous month’s performance as
stated in the key performance indicators (targets) and ensure these are within
agreed parameters. Deviation from these parameters will be investigated and
challenged by the relevant directorate manager and clinical leads.
The key performance indicators are:

Key Performance Indicators

• Total number of cancelled operations

• Total number of same day cancellations

• Number of same day cancellations requiring rebooking within 28

days

Theatre Operational Policy

Version No.2.0 Page 6 of 39
 Cancelled • % Same day cancellations requiring rebooking within 28 days
operations
• Number of operations cancelled by the hospital on the day of
surgery for non-clinical reasons.

• Number of operations cancelled by the hospital on the day of

surgery for clinical reasons

• Number of day cases as % of all operations performed by

Day surgery speciality

• Number of Day Cases requiring in patient admission

• Number of patients admitted on same day of surgery as a

Elective theatre percentage
performance
• Theatre utilisation (Capped)

• Theatre Productivity i.e., number of cases per session by

speciality

• % Uptake of planned sessions

% Late Starts i.e., > 15 mins after planned start time

• Emergency Theatre Session Utilisation (capped)
Emergency
• Trauma Theatre Session Utilisation (capped)
theatre
performance
• Number of operations in categories NCEPOD 2, 3 & 4 between
Emergency 10pm and 8am.
operations out
• Out of hours theatre utilisation outside of planned sessions
of hours
• % Compliance with Team Briefing & Debriefs
Clinical
• % Compliance with WHO checklists
Governance
measures • Number of patient complaints

• Number of incident reports

Theatre Operational Policy

Version No.2.0 Page 7 of 39
 • Patient Experience Metrics

4 Scope
This policy applies to all staff working within theatres including medical and non-
medical staff groups, as well as substantive and temporary staff, including those
working on an agency and locum basis. It is the responsibility of the employing CBU
to ensure locums working in theatres with responsibility for lists are provided with a
copy of this policy. The policy covers main theatres, day theatres and eye care unit.
The dedicated Maternity theatre and endoscopy suite are excluded.

5 Purpose
The purpose of this policy is to facilitate the appropriate surgical intervention for all
patients who require an elective or emergency procedure on a 24-hour, 365-day
basis. Facilitation will include the provision of, an appropriate environment, staff with
the required skills / knowledge and the availability of equipment that is fit for purpose
to ensure patient safety is paramount.
This will be achieved by:
Being responsive to the individual needs of the patient. This will be supported by
appropriate and robust theatre list planning to ensure the appropriately skilled
personnel and suitable equipment is available on a patient-by-patient basis. This will
be monitored using theatre specific software.
Maximum utilisation of theatre time.
A professional and efficient Patient pathway throughout the pre- and post-operative
care episode. This will include timely booking of patients to reflect session length.
Patients will be booked onto a theatre operating schedule 2-6 weeks prior to the date
of surgery (see patient planning and scheduling)
For standard procedures on all lists, patient sequencing will be fixed 24 hours prior to
surgery, unless a clinical justification case is made to the Theatre Coordinator or
other member of the senior theatre management team (this will support the patient-
by-patient allocation of resources). No changes are to be made to the order without
this agreement. All Changes must be communicated to, operating surgeon, list
anaesthetist, ward, and theatre team.

Theatre Operational Policy

Version No.2.0 Page 8 of 39
Delivering a high standard of patient care whilst retaining the ability to respond
quickly to changing service needs and commissioners’ requirements.
Ensuring an efficient service is achieved through multidisciplinary co-operation and
the appropriate utilisation of available resources. For emergency and trauma cases,
session planning to prioritise patients in terms of acuity will be carried out every
morning at 08:00 with key personnel. All additional emergency/trauma cases booked
after this huddle will be booked via theatre Co-ordinator
Promoting an environment that is conducive to learning and development for all
grades of staff
Recognising audit as the ‘key’ to the maintenance and development of all standards
within the department. The benchmark standard will be set and monitored against
national standards using all forms of technology available to provide robust data and
will be reviewed annually.

6 Roles and Responsibilities

Theatre Co-ordinator:
Be responsible for co-ordinating the daily staff rotas, information on delays, start time
and late finishes, minimising wasted resources in relation to staffing and equipment.
Escalating to the Theatre Matron where safe rotas cannot be achieved
Co-ordinate the booking of emergency surgery and ensure the details are accurately
entered into Theatreman.
Communicate with Consultant Surgeons and Anaesthetists to reduce delays and
avoid problems. Where problems occur, the Theatre Co-ordinator will liaise with the
Clinical Director or Consultant Anaesthetist on duty/call and agree a decision which
she/he will then communicate to those involved.
Be responsible for overseeing the timely booking of equipment in advance of
sessions.
Ensure Theatre policies and procedures are relevant and up-to-date, and all staff
comply with agreed policies to maintain best practice.
Escalate any potential cancellations via the route set out in the policy. Be actively
involved in theatre planning and work collaboratively to ensure all risks of on the day
cancellations are mitigated against.

Theatre Operational Policy

Version No.2.0 Page 9 of 39
Team Leaders: Team Leaders for Scrub, Anaesthetics and Recovery are
responsible for leading by example, supporting, and ensuring their teams comply
with the policy.
Leading the team in their designated area of practise.
Ensuring Equipment, instrumentation, prothesis and sundry items are available in 24
hours in advance of list and escalating to co-ordinator any issues

Senior data analyst: Provide reports on all KPI’s, systems administrator for theatre
man, provide regular reports and bespoke reports, when requested.

The Surgeon is responsible for attending and leading the Team Brief. They have
responsibility for completion of the “Time Out” and “Sign Out” sections of the WHO
checklist although they may delegate the signing to another practitioner on their
behalf as they are often scrubbed at this point on the process. The surgeon is
responsible for having approved their list, including the operating order in compliance
with the timescales outlined in this policy.
The Anaesthetist: is responsible for attending and participating in the Team Brief
and the completion of the “Sign In” section of the WHO checklist although they may
delegate the signing of this section to another practitioner on their behalf Clinical
responsibility remains with the Surgeon and Anaesthetist who are either involved
with, or directly or indirectly supervising the care of the patient.
Surgeons and Anaesthetist to have enough time in their job plans for pre-op
assessment and to be available to commence WHO pre-brief 10 minutes before
planned list start time.
The Associate Director of Operations/Operational Managers: are responsible
for communicating and ensuring compliance with the policy by the operational and
non-medical clinical teams i.e., radiographers.
Clinical Lead: is responsible for communication and ensuring compliance with the
policy by surgical and anaesthetic clinical teams
Training and development lead is responsible for ensuing staff are receiving role
specific training, completion of role specific competency documents, co-ordinating
student placements. Identifying and planning future training needs.

Theatre Operational Policy

Version No.2.0 Page 10 of 39
7 Policy detail/Course of Action
To provide high quality efficient and safe surgical care to all patients in a safe and
professional environment. The Operating Theatre service aims to reflect the Trust
values listed below:
Compassion
Accountability
Responsibility
Everyone counts

8 Service Principles
Theatres will provide safe staffing level in line with the AfPP (Association for
Perioperative Practice) guidelines for all surgical activity. This includes 2 x Scrub
practitioners, 1x Circulator, 1 x Anaesthetic practitioner and a recovery practitioner
for each session where general anaesthetic is delivered. By prior agreement with the
Theatre Co-ordinator, the staffing of some lists maybe substituted by specialty
departmental staff with equivalent generic skills and training and specialty skills for
the procedures on the list. Where this occurs, it is the responsibility of the
surgeon/operator to ensure staff are adequately trained. This arrangement can be
terminated by the Theatre Co-ordinator at any point should suitable evidence of
training not be available.
Several scrub staff have the advanced qualification to act as surgical first assistants,
1st assistant cover is not provided from theatres established staffing. When 1 st
assistant cover is needed, the requesting operations manager must arrange the as
an additional duty, funded by the speciality. If a first assistant cannot be arranged an
alternative must be found from medical staffing, theatre staffing cannot assure cover.
All healthcare professionals have a duty to set a standard by which to practice. With
a focus on clinical effectiveness and evidence-based care, theatre staff must be able
to demonstrate the ability to audit nursing and theatre practice. The care that is
delivered and improvements in practice must be based on evidence and best
practice.

Theatre Operational Policy

Version No.2.0 Page 11 of 39
All staff working in the operating department will follow the WHO guidelines for safer
surgery and WHO surgical safety checklist

8.1 Pre-operatively
All patients are seen immediately prior to surgery by the anaesthetic and surgical
medical staff either in the ward or Pre-operative Waiting Area. It is not acceptable to
do this in the theatre reception area unless the patient is an emergency.
All patients have consent for their operation discussed and signed before they are
prepared for theatre in line with the Trust’s Consent to examination or treatment
policy. A copy of the signed consent form will be given to the patient.
No patient will be accepted into theatre without a signed consent form and pre-
operative check list. Should the planned procedure the surgeon wishes to carry out,
vary from that the patient has been consented for, the consent form must be
amended, re-signed and a copy provided to the patient.
Patients will walk to theatre accompanied by a member of staff, unless clinical needs
dictates transfer on a trolley or a bed accompanied by both a member of staff and a
porter, according to the standard operating procedure for patients being transported
to theatres.
In main theatres, the first, ‘Golden Patient’, on the operating list will automatically be
sent for before the team brief, to ensure no delays to list start.
In Main theatres, after the first patient, staff will utilise the pre-operative waiting
lounge for the remainder of the patients, in accordance with the SOP for the area.
A team brief will be conducted and documented before each theatre list.
Theatre staff must ensure relevant equipment is available, for elective lists, the team
leader will review the list the day before and all equipment will be made ready. If any
equipment is not available, the surgeon will be informed as soon as possible. For
emergency/trauma surgery all equipment needed will be discussed at WHO team
brief and team leader will ensure all equipment is available before anaesthesia
commences.
Patients must not be left unattended in the Anaesthetic Room.
All patients will undergo a “sign in” from the Surgical Safety Checklist completed and
documented electronically, as part of their Peri-operative care provision.

Theatre Operational Policy

Version No.2.0 Page 12 of 39
8.2 Intra-operatively
All patients will undergo a “time out” and “sign out” from the Surgical Safety Checklist
completed and documented electronically, as part of their Peri-operative care
provision.
All staff must always practice the principals of ANTT.
All staff must follow Trust policies and procedures for assessing, managing, and
reporting risks, ensuring that any incidents are dealt with swiftly and effectively and
reported to the Team Leader or Coordinator, in order that further action can be taken
where necessary.
Patients and instrument trays are tracked within Theatre and HSDU. It is the
responsibility of the surgeon/operator to ensure that the theatre practitioner verifies
that the instruments & swabs counts are correct, including items such as finger
tourniquets and throat packs, and that sharps have been correctly disposed of, as
per safe handling and disposal of sharps policy.
Specimens will be dealt with according to departmental SOP’s and Pathology user
handbook

8.3 Post-operatively
The operating surgeon will lead the debrief, the debrief will be performed and
documented at the end of every list
All patients that require post anaesthetic care will be recovered by a trained
Recovery practitioner.
The anaesthetic team will give a clearly documented handover that will include
patient identification, the operation performed, any patient alerts or allergies and
specific post op instructions.
When the patient is ready for transfer back to the ward, the recovery team will give a
clear handover to the nurse accompanying the patient during transfer. This handover
will include identification, local anaesthetic, any medication given, operation
performed, wound closure, drains as appropriate and dressings.
The recovery team will assess the patient’s condition to meet the unit’s discharge
criteria as set out in the patient pathway. For day case surgery, criteria led discharge
will be the default practice.

Theatre Operational Policy

Version No.2.0 Page 13 of 39
9 General Principles
All day sessions using the same theatre team, including surgeon and anaesthetist
are particularly efficient. Wherever possible, weekly half day sessions should be
consolidated into fortnightly full day lists. There should be provision for meal and
comfort breaks however, and overall scheduled operating time should not be booked
in excess of the planned session time.

9.1 Booking of elective cases

When planning elective theatre sessions, it is the responsibility of the Consultant to
whom the session belongs to ensure that, as far as is reasonably practicable,
allocated operating session times are not exceeded, to effectively utilise theatre
resources. The admissions team will use informed booking time to fill lists to their
allocated session length.

The admission team will fill lists first based on indicated clinical priority and thereafter
in waiting list date order. They will be responsible for ensuring across the operating
day that there is an appropriate gender mix, given the constraints of the day surgery
and orthopaedic elective wards, and that total day surgery unit or inpatient ward
capacity is not exceeded, or same sex guidance breached.
Realistic scheduling of procedures can assist in avoiding cancellation of operations
due to lack of theatre time or impact on other theatre users. Consultants are
responsible for checking their theatre lists prior to final submission. Consultants are
also responsible for ensuring that any requirements, for example, loan equipment,
are communicated in advance of the list with sufficient time for equipment to be
sourced externally, as per SOP for the
Efficient use of theatre capacity, time and resources relies upon effective
communication and co-ordination of theatre cases. This will be achieved by
implementing procedures for notifying theatres of forthcoming cases with as much
notice as possible which also allows for planning skill mix and required equipment, or
planning for special circumstances i.e., allergies, infections. To be reviewed weekly
by Theatre management team at 6-4-2 meeting.
6-4-2 Planning Process

Theatre Operational Policy

Version No.2.0 Page 14 of 39
9.1.1 Six weeks from list date
Surgeons who plan not to utilise their operating list due to annual leave or study time
are to ensure that they have notified theatres six weeks prior to the list date to
ensure a theatre and anaesthetic team can be reallocated. The cancellation of the
list will need to be confirmed by the Operational Manager for the speciality who will
have counter-signed leave applications. A list is not to be stood down without this
second confirmation. This list will then be listed as out to offer, and options for cover
explored within the speciality.
Direct instructions to the admissions team to cancel lists or to not fill them with less
than six weeks’ notice will need authorisation from the Associate Director of
Operations.

9.1.2 Four weeks from list date

Theatre Operational Policy

Version No.2.0 Page 15 of 39
Four weeks prior to planned elective list date, if a vacated session has not been filled
by the speciality listed, the session will be offered to other surgical specialities as a
funded session that is available for utilisation.

9.1.3 Two weeks from list date

All elective lists will be booked to 85% within Theatreman two weeks prior to planned
date for surgery. Specialist or limited items must be identified at the time of listing to
enable theatres and other services to plan resource availability and identify conflicts
with equipment or equipment availability as they arise.
Examples of these resources may be:
• Anaesthetic cover
• Radiography
• Critical care/ HDU/ITU bed
• Loan Equipment
• Implants
• Surgical first assistant

(This list is not exhaustive)

Equipment booking requests must be emailed to the theatre team and HSDU
The following details must be recorded: -
• Consultant
• Date and time of planned procedure
• Procedure to be performed
• Time and date when booking made
• Company representative to attend to train surgeon/scrub staff

Where specialist or limited resource requirements are not identified at the two-week
time frame access to that resource cannot be guaranteed. Theatre team leads will
escalate to theatre co-ordinator when loan equipment is expected and confirm with
Two weeks in advance of the planned list, if vacant lists have been held and not
confirmed or populated with patients, the list will be considered vacant, all supporting
resource will be reallocated, and the list cancelled.

Theatre Operational Policy

Version No.2.0 Page 16 of 39
Any lists ‘out to offer’ at two weeks will be closed and listed as cancelled, as per 6-4-
Re-opening of a theatre list can only occur with agreement of theatre matron, theatre
co-ordinator and the Associate Director of Operations.

9.1.4 One week from list date

One week prior to the planned list date the theatre list for elective lists will be locked
and no further patients will be added unless a sound clinical justification for late
addition is made to the Theatre Management Team. The only exception is for lists
that do not need to meet the two week access requirement for cancer fast track
patients.

9.1.5 Three days from list date

Seventy-two hours prior to surgery all cases must be listed and locked on Theatre
man. The Consultant/operating surgeon should have ordered the list and staggered
the admission times where appropriate and signed off the list. The operator/surgeon
and anaesthetist are responsible for ensuring that patients have been correctly listed
as either day cases or inpatients. Failure to do so, risks on the day cancellations to
surgery.

9.1.6 One day from list date

There will be a daily theatre operational meeting at 11.30 am, reviewing previous day
incidents, utilisation, on the day cancelations and elective case booked for following
day. At this meeting will be representees from all theatre areas, operation managers,
bookings, HSDU, stores and preassessment. All lists will be locked in order of
content and theatres will send for the patient at the top of the operating schedule at
08.05hrs on the day of the list, the ‘golden patient’. Theatre team leads will check
equipment is available and theatre co-ordinator will review theatre staff allocation for
the list. Any issues will be escalated via theatre management team. Changes to the
list on the day should only be for clinical reasons and must be agreed by the Theatre
Co-ordinator.

Theatre Operational Policy

Version No.2.0 Page 17 of 39
9.2 Short notice Cancelation Process
The Trust is committed to ensuring optimal use of operating theatre capacity and
resources, maximising operating theatre performance, and avoiding cancelled
operations to provide high quality health care to patients admitted for surgery.
The purpose of this process for escalating cancellations is to ensure that:
Cancellations are minimised through mitigating action:
No cancellation on the day for non-clinical reasons takes place without appropriate
escalation and all reasonable steps being taken to prevent the cancellation

Ensure that there is continued learning to reduce the rate of cancellations on

the day of surgery:
Cancellations on the day due to clinical reasons are reviewed to ensure that our pre-
operative pathway is fit for purpose in minimising cancellations on the day
Patient initiated cancellations on the day due to patient decision not to proceed are
reviewed by speciality operations managers, bookings and pre-assesment, to ensure
that our pre-operative pathway is fit for purpose in minimising cancellations on the
day
All on the day cancellations are to be reported on Datix for governance and further
learning

9.2.1 Clinical Cancellation

A patient may have their operation cancelled at short notice for clinical reasons at
various stages of the admission process:
• During Pre-Assessment by the anaesthetist, the surgeon or Pre-Assessment
Nurse (Day Case Patients) as per pre-assessment unit SOP’s
• Preadmission by patient due to acute illness
• Following admission or on arrival for admission to hospital the surgeon or
anaesthetist.

The surgeon/anaesthetist, who identifies, the patient needs cancelling for a clinical
reason is responsible for advising the patient that their operation has been cancelled.

Theatre Operational Policy

Version No.2.0 Page 18 of 39
Any decision to cancel a patient must be recorded in the patient notes by the person
making the decision with the reason for cancellation clearly identified.
The cancellation on the day form, on E-Carelogic needs to be completed by the
person making the decision to cancel.
The Patient notes are to be sent to pre-assessment unit. All clinical cancellations are
to be reviewed by the Pre-assessment nursing team, to ensure patients are
aprropiately reviewed and optimised before being re-booked.
If the cancellation occurs prior to theatre, the ward staff must be informed and should
escalate immediately to the Theatre Coordinator. The patient will then be cancelled
from the theatreman scheduler.

Surgical emergencies with higher clinical priority are a clinical cancellation. The
CEPOD theatre should always be utilised if possible before interrupting an elective
list. If a list needs interrupting, the surgeon/anaesthetist must liaise with theatre
coordinator/theatre Matron, who will risk assess the most appropriate list to be
interrupted. Matron of the Day and Associate Director of Ops for Planned Care will
be informed and if an elective patient needs to be cancelled the Theatre
Matron/Matron of the day will inform the patient/s and the speciality ops manager will
liaise with the Admissions team to seek a replacement date, or confirmation they will
be contacted if this is not possible on the day

9.2.2 Non-Clinical Cancellation

There are a number of non-clinical reasons why an operation may be cancelled
Cancellation due to no bed
Where possible when there is a risk to availability of beds for elective surgery the
following day then patients should be cancelled in advance the day before. The
decision must be agreed in advance by the Associate Director of Operations for
Planned Care.
Should this be identified out of hours and concerns raised by the Site Co-ordinator
Team, the decision to cancel must be agreed by the Senior Manager on Call with
agreement from the Executive On call.
If the decision is on the day, then the ward Manager must liaise directly with the
Matron of the day, bleep 171, to support identification of potential options and liaise

Theatre Operational Policy

Version No.2.0 Page 19 of 39
as necessary with the bed management team. If no solution can be found this
should be escalated to the Associate Director of Operations for planned care to
confirm the decision to cancel. The speciality operations manager will inform the
patient, liaise with the admission team to seek a replacement date if possible, or
confirmation they will be contacted if this is not possible on the day. In the absence
of an operations manager the responsibility falls to the theatre Matron

Theatre staff shortages

Before a decision to cancel a patient(s) is made, the Theatre Matron or theatre
coordinator on the day, must contact the Associate Director of Ops for Planned Care
or Associate Director of Nursing, to discuss whether any options other than
cancellation are possible, and whether other cases of less priority need to be
considered and theatre teams skill mix assessed to support any decision.
Please see appendix theatre staff RAG rating
List over runs
There will be occasions when it is necessary to cancel patients due to shortage of
theatre time or due to lists being interrupted/cases being more complex than
anticipated. If this happens escalation must occur via bleep 171, Matron of the day to
escalate via Associate Director of Operations for Planned Care to ensure all possible
options are explored before the patient is cancelled. This should include feasibility of
postponing the procedure until the next day if beds and theatre time allow. Once
cancellation has been confirmed the theatre co-ordinator will inform the nurse in
charge of the patients allocated ward, to inform the patient/s. The theatre co-
ordinator will inform the Admissions team to arrange another date for surgery. It is
important that lists are reviewed regularly during the day by the Theatre Coordinator
to ensure that any potential overruns are identified and escalated as early as
possible to facilitate mitigation and so patients can be informed and not left until end
of list.

Equipment Unavailability
If there is an issue with the availability or sterility of equipment and instruments, the
Surgeon and theatre matron/theatre coordinator of the day must be informed, and
the issues escalated to Associate Director of Operations for Planned Care. For a
sterility issue HSDU will be informed, to scope re-sterilisation and possible list

Theatre Operational Policy

Version No.2.0 Page 20 of 39
changes. Theatre procurement team will be informed if equipment is unavailable, a
solution may be found within the wider partnership. If no alternative can be sourced
the Theatre Matron/Theatre co-ordinator will inform the patient and liaise with the
Admissions team to seek a replacement date if possible, or confirmation they will be
contacted if this is not possible on the day. When theatre matron/theatre co-ordinator
unavailable responsibility will fall to speciality operations manager.

9.2.3 Priority Criteria for Cancellation

Any cancellation decision will consider the following criteria, where the option is to
decide which patient should be cancelled:
1. Priority must be given to all fast-track cancer cases in the first instance. This
will involve the bed management team and the ward team ensuring that beds
are available to accommodate fast track patients if they are scheduled to
arrive later than other routine patients.
2. When all cancer fast track patients are accommodated, priority should be
given to urgent cases, and again the Bed Management team and ward team
must ensure that beds are available should these patients be arriving later
than routine patients
3. Consideration then should be given to patients who have ceased specific
medication/have complex care package in situ before routine patients are
cancelled.
4. Those patients who have been cancelled previously and are scheduled as a
28-day rebook should be given the next priority. (28-day rebooks are patients
cancelled on the day of their surgery and must be rebooked within 28 days).
This information should be on the theatre scheduler to alert the bed
management team
5. Following information on the theatre scheduler for admissions will highlight
reasons such as long waiters and any previous cancellations. Priority should
then be given to the longest waiter, as identified by Associate Director of
Operations for Planned Care.
6. Consideration should also be given to whether expensive equipment has
been hired for the procedure.

Theatre Operational Policy

Version No.2.0 Page 21 of 39
If cancellations are to go ahead, these should be the shortest waiter with minimal
risks i.e., no patients with critical medication stopped pre op or patients with complex
care packages which it may not be possible to reinstate

9.2.4 Authority to cancel

Non-Clinical Cancellation
In hours, the authorisation to cancel lies with the Director or Associate Director of
Operations.
Out of hours the authority lies with Senior manager on call with agreement from
Executive Director on-call

Clinical Cancellation
The surgeon or anaesthetist with agreement from consultant anaesthetist on call,
062 bleep holder.

9.3 Planned changes to start/finish times

Where it is anticipated in advance, that the complexity of the procedure(s) or the
nature of the operative case(s) will result in a longer than scheduled operating time it
is the responsibility of both the Consultant surgeon and Anaesthetist to liaise with the
Theatre Co-ordinator to discuss the potential for an early start/late finish and the
organisation of appropriate resources
If patients are brought forward on the list and require an inpatient bed, the Surgical
Matron of the Day, bleep 171, must be informed prior to anaesthetic commencing to
ensure the patient can be accommodated at an earlier time and to avoid delays in
recovery.
Where theatre sessions are planned and scheduled to reflect appropriate planned
utilisation (85 – 92%) and the session overruns due to clinical complication or
complexity of surgery, theatres will make every effort to support the list to its
conclusion
Theatre session utilisation will be reviewed continually, with monthly oversite at
Theatre User Group

Theatre Operational Policy

Version No.2.0 Page 22 of 39
9.4 Emergency surgery

The use of emergency operating time will be co-ordinated by the Theatre Co-
ordinator or, out of hours, a designated senior member of theatre staff. Case mix and
priority of patients on lists will be decided based on the clinical needs of patients and
NCEPOD (National Confidential Enquiry into Patient Outcomes and Death)
recommendations. There is a daily meeting at 5pm, between speciality surgeons,
anaesthetist on-call and theatre co-ordinator, to identify a ‘golden patient’ for the
following day.
Patients requiring emergency surgery will be called to theatre in order of clinical
priority which will be identified collaboratively by the operating surgeon, attending
anaesthetist and theatre co-ordinator or deputy.

When a patient requires emergency or trauma surgery, the speciality surgical team
will book the patient using the forms in emergency booking folder and inform theatre
Co-ordinator. The patient can then be booked onto theatreman by:

i) Trust staff who have appropriate access following training, and who abide by
the access policy.
NOTE: where access guidelines are not adhered to, access rights will be removed
until a period of retraining has been completed.
ii) The Theatre Co-ordinator will be responsible for ensuring a member of
Theatres staff enters patient information into Theatre man and the list will be ordered
by clinical priority as outlined below.

All patients requiring emergency surgery must have a management plan to reflect
fitness for emergency surgery at time of listing and availability of a surgeon to carry
out the procedure as soon as a slot becomes available. It is the responsibility of the
surgeon listing the patient to ensure appropriate instructions regarding fasting and
VTE prophylaxis are given to the ward to ensure patient safety.
.
If no post operative bed has been allocated to an emergency patient pre-operatively,
the matron of the day will be contacted (08.00-16.00 weekdays) or the site team

Theatre Operational Policy

Version No.2.0 Page 23 of 39
(16.00-08.00 or weekends) to obtain a post operative ward bed. Emergency surgery
MUST NOT be delayed whilst waiting for a bed to be allocated.

9.4.1 Cases for scheduled Trauma sessions

It is acknowledged that there is less control over planning of scheduled Trauma
sessions when compared to elective sessions. However effective communication
and co-ordination of Trauma cases is still required and therefore when planning
scheduled Trauma sessions, it is the responsibility of the Consultant on-call to
ensure that, as far as is reasonably practicable, allocated operating session times
are not exceeded.
Orthopaedic trauma will have one image intensifier and radiographer allocated every
afternoon without the requirement of booking.
Extra trauma session can only be arranged if there is a second radiographer, image
intensifier (if needed), theatre staff and a free theatre.

10 Ordering of supplies and consumables

It is imperative that the adequate volumes of stock are held so that surgical efficiency
is not compromised by item unavailability, while maintaining a cost-effective level of
stock on hand. The theatre matron approves any orders of stock/equipment, with
oversight from head of Nursing. Theatre stores are managed NHS South of England
Procurement Services with a stock management system, Atticus.

10.1 Ordering for routine planned operating lists

Sets of sterile instruments, drapes and gown packs will be stored in the departmental
stores and individual theatre prep rooms.
On receiving the operating list, the Team Leader will check the availability of the
required numbers of instrument sets, drapes and gowns plus any special
requirements. This will be done a day in advance of the planned operating list
ensuring any issues with equipment are escalated to theatre team lead/theatre Co-
ordinator.
Requests to stores and HSDU for extra equipment will be made directly to the
Department, giving as much notice as possible.

Theatre Operational Policy

Version No.2.0 Page 24 of 39
10.2 Specialist Instruments
Orders for the sterilisation of trays and instruments on loan or hired to support
specialist surgery will be notified to Hospital Sterilisation and Decontamination Unit,
giving as much notice as possible prior to the date of the planned surgery. Ideally 48
houirs before the day of procedure.

10.3 Orders for sterile equipment for emergency surgery

Orders for sterile equipment for emergency surgery will be checked as described in
8.1 and 8.2 above. In addition to the above, trolleys containing sterile equipment for
each specialty and/or surgeon will be kept in the theatre department.
Theatre staff will be responsible for restocking and replacing equipment used from
specialist trolleys; these will be checked on a daily basis and escalated if essential
equipment is missing.
Specialty trolleys will be located in the theatre prep rooms appropriate to the
particular specialty but will follow the surgeon if he/she operates in a different area,
e.g. emergency theatre, or day surgery theatre.

10.4 Return of contaminated instrument trays and equipment to HSDU

In order to ensure equipment is promptly decontaminated and available for use, at
the end of a case all instrument trays and used overwrapped instruments will be
loaded on to a trolley and taken immediately to one of the dirty HSDU caddies
located in the dirty hold in main theatres, back corridor in DSU theatres and in the
theatre sluice in Eye care unit theatre.
It is the responsibility of the operator/surgeon to ensure any defective equipment is
identified and therefore placed in the quarantine process. Theatre staff will identify
the fault on the paper copy of the theatre check list and return the list with the
instruments to HSDU. The HSDU production manager manager will provide a
monthly update of quarantined instrument to theatre speciality leads, theatre co-
ordinator and theatre matron. Speciality leads will meet monthly with HSDU team to
ensure instrument sets are out of the quarantine process in a timely manner.

Theatre Operational Policy

Version No.2.0 Page 25 of 39
11 Conditions of service
All staff and users will always adhere to Trust Policies and department Standard
operating procedures (SOP’s). All staff and users will adhere to local theatre policies
to promote the provision of a seamless service and the achievement of utilisation
target and ensure patient safety.
Where clinically appropriate all elective day cases will be scheduled through the Day
Surgery Unit.
If there is any change in practice that will have equipment (instrumentation, critical
resource or consumable) implications that may have influence reference costs this
must be supported by a business case that has gone through the correct approval
process and identifies the funding stream for capital or revenue expenditure. The
business plan must also identify the lead time for equipment acquisition and training
that informs the planned implementation date.
The introduction of new surgical techniques, procedures or equipment must go
through the Clinical Effectiveness Committee and Theatre user group. Such
techniques or equipment once authorised will not be approved for use until the
Theatre Co-ordinator has confirmed that all theatre staff are suitably trained and
competent to support.

12 Consultation
All documents including major revisions of existing policies will require consultation;
policies should describe the level of consultation undertaken in relation to new, or
revised, documentation and will be dependent upon:
• The type of document.
• The impact that its introduction will have.

NB the document should include the most recent consultation not consultation on
previous versions.

Any significant dissent against a Policy that is flagged during the Consultation
process should be highlighted to the Lead Director and documented in the meeting’s
minutes.

Theatre Operational Policy

Version No.2.0 Page 26 of 39
13 Training
The objectives of the theatre training are:
To ensure that a standard of care is delivered to each individual that is equitable and
fair and safe.
To identify the standards of care to be delivered to patients through all the areas
within the operating theatres i.e., Anaesthetic room, Operating Theatres and the
Recovery Unit.
Where practice needs additional clarity, a Standard Operating Procedure will be
written. Staff will sign to say they have read and are familiar with these.
To enable auditing of professional practice through all areas.
To ensure all staff are aware of standards of care to be delivered to patients whilst in
the Operating Theatre Department.
To provide information to all staff.
The 4 weekly anaesthetic audit afternoons will be protected training time for theatre
staff. The only agreed list run during this time will be NCEPOD/trauma.
All theatre staff will be working on or have completed competency documents
relevant to their role, training record held by department
All staff will have a training record to use the equipment used in the relevant theatre
environments and a record of the training held by the department.
All staff working in operating theatre will be expected to be mandatory training
compliant.
The Annual appraisal will be provided for all staff is designed to support the training
and development of the individual and support staff health and wellbeing. Annual
appraisal will be in line with the local appraisal policy.
The training and development Lead will co-ordinate all training for theatre staff and
will oversight of all courses booked by theatre staff.
All new staff will have a supernumerary induction period with an assigned
buddy/mentor. There will be a six-month probational period in which all new staff will
be expected to complete their role specific competency document. If this is not
completed staff will be performance managed in accordance with the Capability
policy.

Theatre Operational Policy

Version No.2.0 Page 27 of 39
14. Quality and Audit
The Quality Risk and Safety for the Planned Care Group meeting provides a forum
for ensuring safety and quality standards in clinical practice.
Clinical incidents will be processed and reviewed in DATIX in line with Trust policy.
The WHO (World Health Organisation) and NatSSips/LocSSIPs checklists will be
audited in accordance with the NPSA (National Patient Safety Agency).
Health and Safety and COSHH standards will be managed in line with trust policy.
Infection Prevention and Control are in line with Trust Policy, Clean Hospital and
Saving Lives. There are identified Infection Control Link Nurses.

14.1 Theatre User Group (TUG)

15. Support services

Theatres interface with a range of support services and co-operative working
relationships and effective communication is essential to maintain safety and quality
standards and meet the expectations of staff and users of the service.

15.1 HSDU
A routine two hourly collection and delivery service is in place to maintain throughput
and flow of equipment, during the hours 07.00 and 20.00 Monday to Friday.
Emergency provisions are supplied within agreed timescales in line with service level
agreement.

15.2 Laundry
A daily delivery of theatre scrubs and linen will be provided on a receive and return
basis

15.3 Pathology
Collection of specimens will be twice daily at 13:00 and 16:30 approximately. Urgent
specimens will be sent immediately following operation. Specimens from Eye care
unit will be taken to pathology by the theatre team and documented, in an

Theatre Operational Policy

Version No.2.0 Page 28 of 39
accompanying book. There are specific arrangements for Breast Specimens, details
can be found in folder of information located on specialised breast trolley.
Specimen containers will be routinely ordered, and additional stock can be requested
daily at the specimen collection point.
Any large formalin containers are stored with specimen containers and associated
spill kits. Replacements will be provided upon request. Any spillage must be reported
to health and safety team in line with
The blood fridge is located in Pathology, access will be given to staff collecting blood
with mandatory training in line with Policy
Please refer to the Pathology User Guide, available via intranet, for further
information.

15.4 Pharmacy

Pharmacy ordering and deliveries will be daily or as required for Eye care centre.
Flammable items will be stored as per departmental COSHH risk assessments as
per COSHH policy, available on the intranet.
Anaesthetic volatile agents will be stored in locked cupboards in the anaesthetic
rooms.
Pharmacy items will be stored in the appropriate manner in Anaesthetic Rooms in
locked cupboards or in the Recovery Omnicell.
There are lockable fridges in each Anaesthetic Room and Recovery for drugs which
need to be stored at lower temperatures.
All medicines must be managed in line with the medicines policy, available on the
intranet.

15.5 Radiography
There is both an in hours and out of hours radiology service. Advance notice should
be given to radiology to avoid delays

15.6 Security
Digital or swipe security locks are provided on all external doors.

Theatre Operational Policy

Version No.2.0 Page 29 of 39
15.7 Domestic Services
Domestic services are supplied via Service Level Agreement
Soiled linen and clinical waste will be removed as required from the disposal rooms
by the Portering Service.
All waste will be managed in line with the Waste management Policy, available on
the intranet.

16 Monitoring Compliance and Effectiveness

The Trust will maintain a full reporting suite against the theatre utilisation targets.
These will be displayed on the intranet and in the department. The electronic
information will be real-time and populated from information entered onto Theatre
man.
Quality and compliance with the WHO checklist will be monitored through
observational audits on monthly cycles. The information will go to the Theatre user
Group.
17 Links to other Organisational Documents

Include all relevant documents that should be read in conjunction with the document
e.g., legal, guidelines etc.

• Who Safety Check List

• Infection Control Policies
• Capability Policy
• Waste management Policy
• Pathology User Handbook
• Medicines Policy
• CoSHH Policy
• Dress Code and Uniform Policy
• Departmental SOPs
• Departement CoSHH risk assessments
• NatSSips/LocSSIPs

Theatre Operational Policy

Version No.2.0 Page 30 of 39
14 References

Audit Commission Operating Department Review of National Findings. Available at:

[Link]
[Link]/SiteCollectionDocuments/AuditCommissionReports/NationalStud
ies/[Link]
WHO safer surgery guidelines and checklist are available at
[Link]
surgery

15 Appendices

Appendix A - WHO Surgical Safety Checklist, paper copy.

Appendix B Cancellation flow chart
Appendix C Staff RAG rating
Appendix D – Financial and Resourcing Impact Assessment on Policy
Implementation
Appendix E - Equality Impact Assessment (EIA) Screening Tool

Theatre Staffing Escalation Guide

Theatre Operational Policy

Version No.2.0 Page 31 of 39
Each theatre has a funded budget that allows for the minimum number of staff per
list in accordance with AfPP guidance
RAG Rating System for Staffing Levels in Theatres;
AfPP Minimum Guidelines
One Anaesthetic Practitioner
Two Scrub Practitioners
One Theatre Support Workers
One Recovery Practitioner per list
Additional staff required for simultaneous procedures on same patient/high volume
lists

Operating List
STATUS DESCRIPTOR
GREEN List is staffed to AfPP Guidelines
Staff are able to safely deliver all aspects of patient care
AMBER List is staffed below AfPP Guidelines however it is deemed within safe
levels by the Lead Nurse / Deputy using professional judgement,
acuity, skill mix and activity.
Minor delays in patient care may occur but will not be detrimental to
their overall care and safety
RED List is staffed below AfPP Guidelines to a point that the Lead
Nurse/Deputy have concerns regarding safety which could result in
detrimental impact on patient care.
Escalation process is being followed to mitigate and resolve the
situation

Recovery
STATUS DESCRIPTOR
GREEN Recovery is staffed to AfPP Guidelines
Staff are able to deliver all aspects of patient care without any delays
AMBER Recvery is staffed below AfPP Guidelines, however it is deemed
within safe levels by the Lead Nurse / Recovery Specialist Lead using
professional judgement, acuity, dependency, skill mix and activity.
Minor delays in patient care may occur but will not be detrimental to
their overall care and safety

RED Recovery is staffed below AfPP Guidelines to a point that the Lead
Nurse/ Recovery Senior Practitioner have concerns regarding safety
which could result in detrimental impact on patient care.
Escalation process is being followed to mitigate and resolve the
situation

Assessment: Co-ordinator of the day

Theatre Operational Policy

Version No.2.0 Page 32 of 39
 In-Hours
Ask yourself the following of each planned list, morning and afternoon….

1. Is staffing below AfPP Guidelines?

2. With the planned procedures, is the skill mix inadequate?
3. Do you have concerns about being able to provide safe care for patients with
the current level of staffing?
Assessment -
Green, Amber If you answer yes to any of these questions then escalate your concerns
or Red as detailed below

RED - IMMEDIATE ACTIONS:

1. Review activity on all lists
2. Contact all other theatre departments to check whether they have any spare
staff
3. Review roster, call own staff, offer additional shifts move from future shifts.
4. Initiate WhatsApp message on shifts group
5. Review any staff rostered for non-clinical working and allocate to list
6. Escalate at 08:15 staffing huddle.
7. Agree plan i.e. combine lists, cancel lists
8. If no resolution escalate to the Theatre Matron/matron of the day
9. If a list is to be cancelled, escalate to Speciality Manager to confirm which list
is to be stood down.
10. Submit a Datix

Assessment: Senior Theatre Practitioner

Weekends / Out
of Hours Ask yourself the following….

1. Is staffing below AfPP Guidelines?

2. Is the skill mix inadequate?
3. Do you have concerns about being able to provide safe care for patients
with the current level of staffing?

Assessment If you answer yes to any of these questions then escalate your concerns
Green/Amber/Red as detailed below

RED - IMMEDIATE ACTIONS:

1. Inform Site Management Team. If required, ask for support to ring off-duty
staff. Liaise with emergency anaesthetist & clinicians.
2. Review skill mix of staff on-duty i.e. dual skilled staff
3. Contact off-duty staff, pull staff forward from future planned shifts, initiate
WhatsApp message
4. Ensure Site Team are aware and have informed Senior Manager On-call
5. Submit a Datix

Theatre Operational Policy

Version No.2.0 Page 33 of 39
 On the day cancellation
(Out of Hours, Contact Senior manager on-call, see policy)

Inform Theatre Co-ordinator

Non Clinical
Clinical Cancellation
Cancellation

Contact Matron of the Contact On-call

Escalate to Director of consultant anaesthetist
day operation or deputy
Bleep 171 Director of operations Bleep 062

Communicate outcome to Theatre co-ordinator

Theatre Co-ordinator will ring Ward and Admissions team

Inform ward and theatre team of outcome. Admissions team will arrange
another date for surgery
Arrange Nurse in charge of ward/surgeon/anaesthetist to inform patient

If required Theatre Matron/Matron of the day or speciality operations

manager will speak to patient

Complete a incident form (Datix)

Ensure patient has been cancelled on
theatre man

Theatre Operational Policy

Version No.2.0 Page 34 of 39
Theatre Operational Policy
Version No.2.0 Page 1 of 39
 Appendix A

Financial and Resourcing Impact Assessment on Policy Implementation

NB this form must be completed where the introduction of this policy will have either a
positive or negative impact on resources. Therefore this form should not be completed
where the resources are already deployed and the introduction of this policy will have no
further resourcing impact.

Document
Theatre Operational Policy
title

Totals WTE Recurring Non

£ Recurring £
Manpower Costs £0
Training Staff £0
Equipment & Provision of resources £0

Summary of Impact:

Risk Management Issues: Nil

Benefits / Savings to the organisation:

More efficient use of theatre time with clear operational guidelines for all satff

Equality Impact Assessment

▪ Has this been appropriately carried out? YES

▪ Are there any reported equality issues? NO

If “YES” please specify:

Use additional sheets if necessary.

Please include all associated costs where an impact on implementing this policy has been
considered. A checklist is included for guidance but is not comprehensive so please ensure
you have thought through the impact on staffing, training and equipment carefully and that
ALL aspects are covered.
Manpower WTE Recurring £ Non-Recurring £
Operational running costs £0

Totals:

Staff Training Impact Recurring £ Non-Recurring £

£0

Theatre Operational Policy

Version No.2.0 Page 1 of 39
 Totals:

Equipment and Provision of Resources Recurring £ * Non-Recurring £

*
Accommodation / facilities needed £0
Building alterations (extensions/new)
IT Hardware / software / licences
Medical equipment
Stationery / publicity
Travel costs
Utilities e.g. telephones
Process change
Rolling replacement of equipment
Equipment maintenance
Marketing – booklets/posters/handouts, etc

Totals: £0

• Capital implications £5,000 with life expectancy of more than one year.

Funding /costs checked & agreed by finance:

Signature & date of financial accountant:
Funding / costs have been agreed and are in place:
Signature of appropriate Executive or Associate Director:

Theatre Operational Policy

Version No.2.0 Page 2 of 39
 Appendix B
Equality Impact Assessment

This Equality Analysis is a written record that demonstrates that you have shown due regard to the
need to eliminate unlawful discrimination, advance equality of opportunity and foster good
relations with respect to the characteristics protected by the Equality Act 2010.

Name of policy/procedure Theatre Operational Policy

Date of assessment: 11.01.23
Responsible department: Theatres
EIA Author: Sarah Insley
Intended equality
outcomes:

Who was involved in the consultation of this document?

Date Forum
07.10.23 Planned care management team
11.01.23 Theatre user group
31.03.23 Clinical Standards Group

Please describe the positive and any potential negative impact of the policy on service users
or staff.

In the case of negative impact, please indicate any actions to mitigate against this by
completing stage 2. Supporting Information can be found be following the link:
[Link]/ukpga/2010/15/contents

Protected Equality Analysis EIA Impact

Characteristic (Positive/Negative)
Age No Issues Positive
Disability No Issues Positive
Gender reassignment No Issues Positive
Marriage & civil No Issues Positive
partnership
Pregnancy & maternity No Issues Positive
Race No Issues Positive
Religion/Belief No Issues Positive
Sex No Issues Positive
Sexual orientation No Issues Positive

Stage 2: Full impact assessment

What is the impact? Mitigating actions Monitoring of actions

Theatre Operational Policy

Version No.2.0 Page 3 of 39
Theatre Operational Policy
Version No.2.0 Page 4 of 39