Section A
Governance & Scope

5. PROCEDURES

5.1 The Head of Anesthesia (or designee) shall maintain the Scope of Services document and ensure it is current, controlled, and accessible to staff.

5.2 The Scope of Services document shall include, at minimum:

• a) Service Locations: OR, PACU, specific NORA sites, and procedural sedation areas.
• b) Service Hours: elective service hours and emergency/on-call coverage model.
• c) Patient Populations: adult/pediatric/obstetric services if applicable, and defined exclusions.
• d) Service Types: general anesthesia, MAC, regional/neuraxial techniques, procedural sedation levels, and any continuous catheter services if offered.
• e) Minimum Resources by Location: staffing model, minimum monitoring requirements, airway and resuscitation equipment availability, emergency drugs availability, and access to defibrillation and rapid response support.
• f) Escalation and Transfer Pathways: criteria and process for escalation to anesthesia leadership, activation of emergency response, and transfer to PACU/ICU/ward as appropriate.
• g) Boundaries and Limitations: case types not supported, sedation depth limits for non-anesthesia providers (if applicable), and patient selection restrictions.

5.3 Each NORA location shall have a documented approval process verifying minimum safety readiness before anesthesia/sedation services are initiated and at defined intervals thereafter.

5.4 PACU shall maintain documented admission criteria, monitoring standards, escalation criteria, and discharge criteria, consistent with hospital policy and departmental scope.

5.5 Changes to scope (new services, new locations, change in patient population, change in staffing model) shall trigger a scope review and approval prior to implementation.

5. PROCEDURES

5.1 Credentialing Requirements (Minimum File Elements)

The credentialing file shall include, at minimum:

• a) Valid professional license/registration and identification verification
• b) Verification of qualifications (degree, specialty training, board certification where applicable)
• c) Verification of anesthesia or sedation-relevant training and experience
• d) Evidence of current mandatory life support certifications as required by role (e.g., BLS/ACLS/PALS where applicable)
• e) Evidence of recent clinical activity/case experience appropriate to requested privileges
• f) Professional references and employment verification as required by hospital rules
• g) Health clearance and immunization status per hospital policy
• h) Documentation of acceptance of hospital and department safety policies

5.2 Privilege Request and Review

• a) The practitioner submits a privilege request specifying the exact privileges requested.
• b) The Head of Anesthesia (or designee) reviews the request for alignment with the Scope of Services and location readiness.
• c) The relevant credentialing committee reviews the file and makes a recommendation.
• d) Final approval is granted per hospital medical staff governance process.
• e) Approved privileges are documented in the practitioner’s privilege delineation and communicated to relevant departments.

5.3 Privilege Categories (Standard Structure)

Privileges shall be organized and granted using defined categories such as:

• a) General anesthesia and airway management
• b) MAC and anesthetic support for procedures
• c) Regional and neuraxial anesthesia (including continuous techniques if offered)
• d) NORA anesthesia by location (as applicable)
• e) Procedural sedation privileges by depth (minimal/moderate/deep) and by approved location
• f) PACU clinical responsibilities as authorized by hospital rules

5.4 FPPE (Focused Professional Practice Evaluation)

• a) FPPE is required for newly granted privileges or new practitioners.
• b) FPPE methods may include direct observation, chart review, outcomes review, and supervised/proctored cases.
• c) FPPE duration and case numbers are defined by the department based on the privilege risk profile.
• d) Successful completion is documented before independent practice is confirmed.

5.5 OPPE (Ongoing Professional Practice Evaluation)

• a) OPPE data is reviewed at defined intervals for all privileged practitioners.
• b) OPPE data sources may include adverse event reports, audit results, case volume, peer review, compliance with documentation standards, and outcomes indicators.
• c) Performance concerns trigger corrective action plans, targeted education, or repeat FPPE as appropriate.

5.6 Restrictions, Limitations, and Suspension of Privileges

• a) Privileges may be restricted or suspended based on safety concerns, verified practice gaps, or failure to maintain required competencies.
• b) Any restriction/suspension shall follow hospital medical staff rules, with documentation, review, and appeal pathways as applicable.
• c) Reinstatement requires documented remediation and completion of any required FPPE.

5. PROCEDURES

5.1 Creation and Format

• a) Department policies shall follow the standard format: Purpose, Scope, Definitions, Policy, Procedures, Responsibilities, Documentation/Records, Compliance/Audit, References.
• b) Clinical tools (checklists, cognitive aids) shall include clear triggers/indications, steps, responsibilities, and required documentation.

5.2 Review and Approval

• a) Draft documents shall be reviewed by relevant clinical leads (OR, PACU, sedation, NORA, regional anesthesia) and quality/safety representatives as applicable.
• b) Final approval shall follow the hospital’s designated medical staff governance and document control requirements.
• c) The document becomes effective only upon controlled publication.

5.3 Distribution and Access

• a) Controlled documents shall be accessible at point of care through the official hospital system.
• b) If printed copies are required, they shall display the current version and effective date and be replaced immediately upon revision publication.
• c) Locally stored copies shall not be used when a controlled system version exists.

5.4 Implementation

• a) New or revised documents shall be communicated to affected staff.
• b) Training/competency validation shall be completed when changes affect workflow, responsibilities, or safety-critical steps.
• c) Implementation shall include readiness of required forms, supplies, and equipment.

5.5 Revision and Archiving

• a) Each revision shall include a documented summary of changes.
• b) Version numbering and effective dates shall be updated.
• c) Superseded versions shall be archived and removed from active use areas.

5.6 Exception Management

• a) Deviations from policy shall be clinically justified and documented.
• b) Recurrent deviations shall trigger review of feasibility, training, resources, or workflow design.

5. PROCEDURES

5.1 Head of Anesthesia Department

• a) Oversees governance, safety, quality improvement, and compliance with anesthesia policies.
• b) Ensures service coverage, on-call structure, and escalation support.
• c) Ensures only privileged practitioners provide anesthesia/sedation within approved scope and locations.
• d) Ensures incident review, improvement actions, and training/drills are implemented.

5.2 Duty/On-Call Anesthesia Consultant or Designated Senior Cover

• a) Provides escalation support for OR, PACU, NORA, and sedation areas.
• b) Responds to airway emergencies, severe adverse events, and urgent clinical consultation requests.
• c) Supports decisions on cancellation, escalation of monitoring, or unplanned ICU transfer for safety.

5.3 Anesthesia Professional (Anesthesia Provider)

• a) Confirms readiness for anesthesia care through appropriate assessment.
• b) Provides intra-procedural anesthesia care with appropriate monitoring and documentation.
• c) Ensures safe transfer of care and complete handover to PACU/ICU/ward or procedure recovery area.
• d) Practices within granted privileges and escalates when patient risk exceeds resources.

5.4 PACU Charge Nurse / PACU Leadership

• a) Ensures PACU readiness, staffing assignments, and emergency response readiness.
• b) Ensures admission handover is received and documented.
• c) Ensures continuous monitoring and timely escalation based on deterioration criteria.
• d) Coordinates safe discharge readiness and transfer communication.

5.5 PACU Registered Nurse

• a) Provides continuous recovery monitoring, symptom management, and documentation.
• b) Recognizes deterioration early and escalates without delay.
• c) Ensures discharge criteria are met and documented prior to transfer or discharge.

5.6 Sedation Provider (When Privileged)

• a) Performs pre-sedation assessment and confirms patient suitability.
• b) Administers sedation within approved depth, location, and medication limits.
• c) Ensures rescue readiness and escalates when deeper-than-intended sedation or deterioration occurs.
• d) Ensures sedation documentation and discharge criteria documentation are completed.

5.7 Sedation Monitor

• a) Performs continuous patient monitoring during sedation and early recovery as required.
• b) Documents monitoring and records adverse events and interventions.
• c) Escalates immediately when deterioration is detected and supports rescue actions.
• d) Does not leave the patient unattended during active sedation and early recovery.

5.8 Anesthesia Technologist

• a) Supports equipment readiness, safety checks, and availability of supplies.
• b) Ensures emergency carts and airway equipment are stocked and checked.
• c) Reports equipment faults and removes unsafe equipment from service per hospital process.

5.9 Handover and Escalation

• a) OR-to-PACU handover shall occur in person and include the department-defined minimum content.
• b) Clinical deterioration triggers immediate escalation and emergency response activation when indicated.
• c) Transfers to ICU/ward require clear documentation of status, treatment provided, and ongoing plan.

5. PROCEDURES

5.1 Orientation

• a) Orientation includes workflows, documentation standards, medication safety, monitoring expectations, handover requirements, and escalation procedures.
• b) Orientation includes verification of required certifications and completion of role-specific checklists.
• c) Completion of orientation is documented prior to independent practice.

5.2 Competency Framework

• a) The department maintains a competency framework defining required competencies by role for OR anesthesia, PACU recovery care, procedural sedation, NORA anesthesia/sedation, and regional/neuraxial services.
• b) Assessment methods may include direct observation, skills checklists, written assessments, simulation performance, and chart audit review.
• c) Competency validation is documented and retained as an official record.

5.3 Mandatory Training

• a) Required life support training is maintained according to role and hospital rules.
• b) Training includes recognition and management of anesthesia/sedation complications and escalation criteria.
• c) Training includes safe medication practices, labeling, high-alert medication handling, and documentation requirements.

5.4 High-Risk Event Readiness (Simulation and Drills)

• a) Scheduled simulation/drills are conducted for critical events relevant to anesthesia/sedation practice.
• b) Participation is documented, and performance gaps generate improvement actions.
• c) Post-drill debriefing identifies system issues and tracks corrective actions.

5.5 Remediation and Restrictions

• a) Staff who fail competency validation receive a documented remediation plan.
• b) Clinical duties may be restricted until remediation is completed and competence is revalidated.
• c) Revalidation is documented and communicated to relevant leadership.

5.6 Annual Program Review

• a) Training completion rates, audit findings, and incident trends are reviewed to update training priorities.
• b) Training is updated when new services, equipment, medications, or policy changes are introduced.