A look at bringing verification ‘in house’

While ventilation is used in many areas of a hospital to provide a safe and comfortable environment for patients, staff, and visitors, some clinical areas – such as operating theatres, have additional requirements. We are fortunate that guidance is available from NHS England and NHS Improvement on specialist ventilation for healthcare premises in the form of HTM 03-01,^1,2 the most recent version having been published in 2021. This guidance comes in two parts: Part A¹ deals with the concept, design, specification, installation, and acceptance testing, of healthcare ventilation systems, while Part B² addresses the management, operation, maintenance, and routine testing, of existing healthcare ventilation systems. This article will therefore draw primarily on information in Part B, the focus of which is the routine testing of existing healthcare ventilation systems. 

A definition from the HTM

Starting with a definition, and according to the HTM: “…specialised ventilation is provided to help reduce airborne infection risks in areas such as operating departments, critical care facilities, isolation rooms and primary patient treatment areas”.¹ (2021a, p.1). Hospitals use air-handling units (AHUs) and a labyrinth of ducting to provide and deliver filtered air to air terminal devices (ATDs) at a flow rate and pressure suitable for the clinical setting. All critical ventilation systems require annual verification and performance testing. In many instances this is outsourced to companies that specialise in performing this work. The cost of this work therefore has to be borne by already overburdened NHS budgets. This is surprising at first glance, as all hospitals with air-handling units will have engineering staff appointed as Competent Persons for Ventilation (CP(V)). These CP(V) engineers will have been trained in the necessary audit skills and measurement techniques, and have gained the underpinning knowledge to undertake verification of critical ventilation systems. The CP(V)s will be supported in most instances by an on-site Appointed Person (AP(V)), who will have more in-depth knowledge. This paper will explore the benefits and opportunities for cost savings by moving verification ‘in house’, along with the associated risks.

Critical systems and verification

A Critical Healthcare Ventilation (CHV) system, according to HTM 03-01 (2021a, p.14),¹ is defined as follows: “Certain clinical and non-clinical areas within a healthcare establishment are considered critical to its ability to provide healthcare. Typically, ventilation systems serving the following are considered critical… [e.g. Operating theatres, isolation facilities, Critical Care, Pharmacy aseptic preparation areas, MRI, CT…]” All critical ventilation systems require annual verification and performance testing in accordance with HTM 03-01 (2021). In an acute NHS hospital Trust, there may be upwards of 50 CHV systems (in some Trusts there may be over 100), all requiring an such testing. As part of this requirement, the inspection also demonstrates compliance with the Workplace (Health, Safety & Welfare) Regulations (1992)3 and Building Regulations (2010).⁴ Furthermore, performance verification is an annual requirement to comply with the provisions of the Health Act (2009).⁵ 

Advanced CHV systems, such as Ultra Clean Ventilation (UCV) systems for orthopaedic operating theatres, require specialist measurement techniques, including entrainment testing, along with specialist particle counting equipment.  Furthermore, Local Extract Ventilation (LEV) systems require inspection by a Competent Person (P601 Certified), and  are therefore perhaps out of the scope, at least initially, for the CP(V). However, hospital CP(V)s can perform all the tests necessary for annual validation for a wide range of critical ventilation systems, opening up opportunities for significant financial savings. 

What are the risks and benefits?

There are increased risks to health if NHS Trusts do not ensure that their ventilation systems maintain the required standards. There is a well-established link between surgical site infections and the quality of the air in the operating theatre. This was identified by a renowned orthopaedic surgeon and innovator, Sir John Charnley, in the 1960s, as well as in studies by Lidwell and others. Many NHS Trusts outsource verification because they believe they are transferring the risk to an external contractor. The patient safety risk and duty of care will still, however, remain with the NHS Trust. While Trusts may see transferring or sharing the risk as justified, it could also be argued that by doing so they are putting the reputation of the NHS Trust in other people’s hands. Loss of reputation for an NHS Trust can impact via reduced activity, resulting in elevated financial and business continuity risks.

Bringing the work in house can provide the opportunity to ensure that  the quality of the work is at the desired level. Competent Persons – Ventilation CP(V) are trained to perform the necessary checks and measurements,  and it is within the scope of their role, as set out in the HTM: “The CP(V) is defined as a person designated by Management to carry out maintenance and periodic testing of ventilation systems.” (2021b, p.9)2 The Trust will have demonstrated that they have confidence in their CP(V)s, as the HTM goes on to say, “All post-holders should be appointed in writing…” (2021b, p. 9).²

The CP(V)s will have an intimate knowledge of the CHV systems, their locations, routes to access inspection hatches and test points, and any problems or concerns. Taking measurements such as differential pressures between rooms, or air flow measurements with a balometer, will be skills that CP(V) engineers will be experienced with. They will have developed key relationships with clinical teams to enable timely access, as they are already performing routine maintenance such as filter changes and plant cleaning. With this in-depth knowledge, surely these are the best people to carry out the verifications? In addition, such work instils a feeling of ownership and pride in them as the individuals responsible for ensuring that the systems are running optimally and delivering the standard of air required for the clinical area.  

Drawing on the AP’s knowledge

In the early stages, while the CP(V) gains confidence, they can draw on the knowledge of an Authorised Person (AP) in the NHS Trust. The AP(V) is “…is responsible for the practical implementation and operation of Management’s safety policy and procedures relating to the engineering aspects of ventilation systems” (2021b, p. 9).² Further advice and support can be sought from the retained independent Authorising Engineer (AE) to provide assurances on the verifications performed by in-house staff. Another safety net is the multidisciplinary Ventilation Safety Group (VSG), who have oversight of all CHV systems.

The other benefit of in-house verification is that local staff will be able to fit the work in around clinical demands much more flexibly than an external contractor taking advantage of opportunistic availability. An external contractor will make prior arrangements with the clinical team weeks in advance of the intended visit, and their appointment may have to be cancelled numerous times due to urgent patient needs, which must take priority. In this instance there is likely to be a financial cancellation penalty for every failed attempt, further increasing the cost. In-house teams can be much more adaptable and responsive, and can take advantage of access to ventilation systems at short notice.

External vs internal costs

There are several factors to consider when making cost comparisons. Clearly there are labour costs, but also the cost of test equipment and its annual calibration. Table 1 shows approximate test equipment costs, although many NHS Trusts will already have some or all of this equipment.  

Costs vary, but a ‘ballpark figure’ for an external contractor carrying out a verification on a general operating theatre is in the order of £1,000-£1,500, and the work would take about one working day, depending upon the complexity of the system. The majority of CP(V)s working in the NHS will be on the Band 5 or 6 pay scale, depending on their organisation and other duties. Pay scales – including the usual 16% on-costs – are given in Table 2, which indicates the daily rate of an Estates technician appointed as a CP(V) at the mid-point in the scale. Table 2 shows that the daily rate for a Band 5 Estates technician is £153.86, and for a Band 6, £187.35, including on-costs at mid-point on the pay scale.

Work undertaken outside normal working hours

Even if the work is carried outside of normal working hours, which is often a requirement to gain access to the plant, at an enhanced rate (normally 1.5 times the standard rate), we get a daily rate of £238.79 for Band 5 or £281.03 for Band 6. This compares with the outsourcing cost of £1,000 to £1,500. Aggregate this to the 50 systems or more in an acute hospital Trust, and the savings really can stack up. In year one alone, taking into account the purchase of the test equipment, the savings to the Trust are still in excess of £50,000. In subsequent years there are additional savings, as the initial outlay for test equipment has already been made, so the requirement would be for annual calibration only.

So far, we have identified that the CP(V) trained staff will already possess the skills to carry out the work, and that financially the figures offer real opportunities for savings. Bringing this work ‘in house’ also gives the staff better ownership. It is understandable that there may be some reluctance to take this responsibility on, which could ultimately impact on patient safety.  

A ‘stepwise’ approach advocated

The first step in the process is to confirm that the organisation has an accurate asset register of all the critical systems. This register should be a live document, as hospitals are in a continuous state of flux, with areas being refurbished, new equipment being delivered, and new departments opening or changing use. The register will thus need frequent updating.  

Do all the systems have the appropriate documentation, including ‘as fitted’ drawings and the original design figures? It is surprising that a significant proportion of critical systems in clinical use have no design figures, and minimal records available. This poses the question of how the system was commissioned and validated. Where this information is not available, attempts should be made to obtain it. If this proves unsuccessful, then the previous verification report is the best data we will have to work from.

Critical systems where access may be easier would be areas such as Pathology and the mortuary, and even isolation rooms may be a good starting point, then moving on to Endoscopy and imaging departments, perhaps before attempting operating theatres (see Figure 1). Endoscopy and many imaging departments will shut down out of normal daytime hours, making access to them much easier. Isolation rooms may well be empty between patients, making access simpler, and potentially available during the normal day. Operating theatres are likely to be more difficult to access, and there is likely to be at least one emergency theatre running 24 x 7, so forward planning is essential.

Interestingly, there is no requirement in HTM 03-01 for CP(V) refresher training, unlike other HTM guidance, such as that related to medical gases. However this might be considered good practice. Refresher training hones the skills and ensures that the CP(V) is kept up to date with current practices and advances in HVAC.

Conclusions

In the current financial climate, where there are increasing competing pressures on overburdened NHS budgets, the opportunity to bring in house work activities and services currently being delivered by contractors is now being considered in a variety of areas. This paper has outlined one such opportunity – to bring in-house the requirement under HTM 03-01(2021) for the annual verification of CHV systems. The existing workforce will already have the necessary skillset to carry out this work, and there are significant realisable cost savings, as I have outlined.  

A phased approach has been proposed to ensure that staff are comfortable with taking on these new tasks, which are within the remit of a CP(V), supported by their AP and AE. VSGs should provide support to facilitate this approach within their organisations.

References

1 HTM 03-01. Specialised Ventilation for Healthcare premises – Part A: The concept, design, specification, installation and acceptance testing of healthcare ventilation systems. NHSE / NHSI, London, 22 June 2021.

2 HTM 03-01. Specialised Ventilation for Healthcare Premises – Part B: The management, operation, maintenance and routine testing of healthcare ventilation systems. NHSE / NHSI London, 22 June 2021.

3 Workplace (Health, Safety and Welfare) Regulations 1992. SI 1992 No 3004. https://tinyurl.com/68uwvvmz

4 Building Regulations 2010. SI 2010 No 2214. https://tinyurl.com/2rts2trb

5 Health Act 2009. Her Majesty’s Stationery Office, 2009.  https://tinyurl.com/38yf5nxa