What does PAC mean to you?
In October last year the North West Dialysis Service (NWDS) policy and procedure committee undertook an audit of the revised policies relating to CVC procedures to determine policy compliance. The result of the audit demonstrated inconsistency in the procedure across the service. Compliance with this policy was poor in some areas (54%) whilst other areas were good (97%).
Staff identified in areas of non-compliances was interviewed post audit to establish reasons for nonconformity. Responses indicated that staff lacked awareness of policy changes and/or failed to appreciate the implications of not adhering to unit policy.
The policy and procedure committee reviewed reasons for staff not adhering to revised unit policy. This was examined in relation to CVC procedures, with respect to:
· Audit results emailed to all clinical staff
· Education of staff re policy changes
· Provide staff with rationale and evidence for policy changes
· Discuss policy releases at unit meetings
· Email sent to all staff regarding the importance of following Melbourne Health (MH) and NWDS policies
· Audit tool reviewed, no improvements or changes were required and the same tool will be used for next audit.
A repeat audit of CVC procedures was conducted in April 2006. The audit showed an increased consistency in the procedure across the service with compliance ranging from 89.5% in one area to 100% in all other areas.