RHG Congress 2018 - Rachel Cutting

Sheffield Teaching Hospitals Trust
Improving standards in IVF:
Introducing the
marginal gains concept
Rachel Cutting MBE
PR / Principal Embryologist
/ Quality Manager

Overview
• What do we want to achieve: how do we define
high standards / what do we want to improve?
• What can we implement to drive high standards
• Introduce concept of marginal gains

What do we want to achieve in
our IVF programme?
– Superiority
– Excellence
– Safety / minimise risk
– Consistency
– Reproducibility
– Happy staff
– Lots of babies!

• Quality is a process of meeting the needs
and expectations of patients and health
service staff
(WHO 2000)
• Quality is the degree to which care
services influence the probability of
optimal patient outcomes
(American Medical Association, 1991)
High standards liked to Quality

Improving standards in IVF
Success rates
Safety
Complications Multiple birth rates
Incidents
Patient satisfaction / complaints
Staff competence

How far we can reach depends on.....

What can we implement to
drive high standards?

Quality Management System
• QMS
– Involves the whole organisation
– Quality manual
– Quality objectives
– Quality policy
– Quality assurance
– Quality control

Policy
Manual
(Signposting Document)
Templates/forms- master document index
Forms, Documents & Records)
Operational Procedures
Operational Procedures

Practical examples of
implementing
high standards of working

Training / Competency Assessment
• Ensure defined training
programme
• Properly supervised
• Competency assessed
and signed off
• CPD
• Regular assessment of
competence

Comprehensive SOPs
• Standard format
• Title
• Scope
• Task description
– What are you doing?
• Describe each task in detail
– How do you to it?
– How do you record it?
– What do you do with the information?
• Involve everyone
• Review frequently

Quality Control
• Measuring specific equipment
• Continuous vs ‘spot checks’
– Incubators
• continuous
– Fridges
• continuous
– Heated stages
• checked weekly

How do we reach that bit
higher?

Marginal gains
• The concept of marginal gains has revolutionised
British Cycling
• Nike have adopted the theory in an attempt to
break the 2 hour marathon record

Nike’s approach
• At the start the athletes were immediately joined by six pacers, who
adopted an arrowhead formation behind a Tesla electric car with a
giant clock timer on it
– Wind tunnel studies show that this formation would help them as it saves energy
• carbohydrate-rich sports drink
– delivered by helpers on mopeds so he did not have to slow down
• Zoom Vaporfly Elite shoes
– allows runners to roll through instead of bending toes and losing energy.

What are marginal gains
If you break down everything you could think
of that goes into our service,
and then improve it by 1%,
you will get a significant increase when you
put them all together

Could the same
approach also
improve areas of
our unit?

Patients
Stimulation
regimen
Laboratory
design
Egg retrieval
Culture
Conditions
Staff
Laboratory
environment
Equipment Technology

Appointments
Egg Collections
Labs
Embryo transfers
Waiting room
Daily MDT meeting
Forms
Recovery space
Staff
Admin
Embryology
Clinical
Nursing

SOP Review
• Each member of the team checks another
one
• Juniors to check seniors against SOPs
• Identifies non conformances / deviations
• Discussed at lab meetings

Embryologist assessed: ……………………………… DATE...............
Poor Borderline Competent Expert
Is all the paper work in place for the
embryo transfer?
Is the Embryo Transfer Sheet in the
patient’s notes completed?
Is the verbal witness procedure carried
out with the doctor and nurse present in
theatre?
Are the details of the embryos clearly
explained to the patient?
Is the Embryo Freezing Advice Sheet
completed if embryos are being
cryopreserved?
Is the type and batch number of catheter
recorded?
Has the embryo(s) been transferred to a glue
dish at least 30 mins before the procedure?
Is the catheter prepared correctly and
warmed?

At the end of the procedure is the media flushed
through the catheter to check for retained embryos?
Is sterile technique used at all times during
processing?
Is the laboratory record completed and signed?
Is the heated stage used throughout and are the
dishes kept outside the incubator for a minimum time
to maintain viability
Overall performance
Suggestions for development:
Any deviations observed from SOP
Agreed action
Assessor’s signature:…………………………………………………Date:………………………
Assessed against 10
Is the dish ID check performed through the hatch
with the scan nurse and the IVF witness check
completed?
Are the embryos loaded correctly into the catheter?

Temperature Monitoring -
Accuracy
• Heated stages
– Use dishes as use for
treatment (RI tags)
– Test full range of dishes
used (slight differences)
– Probe holder to keep
stable in the drop

Egg Collection
• Temperature control
• Flush syringes
• Needles
• Theatre temperature
• Level of flush tubes
• Speed
• Oocyte viability
– Time in MOPs plus

Lab heated stage

Improvements
• Pre warm needles
(incubator in theatre)
• Flush syringe 10mls – max
2 mins
• Stabilise theatre
temperature at 24o
C
• No overfilling of flush tubes
• Doctor and embryologist
work at similar speed
• Oocytes placed in GIVF in
incubator when change
sides

Osmolarity
o
C
pH

Dish preparation
• Simple task – but not one to be
complacent with!
• Prevent changes in osmolarity
– 1 dish at a time (embryoscope)
– Cold stage / prep at room temperature /
bottles not on heated stages
– Care with oil overlay in dishes in non
humidified incubators (embryoscope)
(increased volume of oil)
– Use opened bottle within 1 week

Cryopreservation Programme
Improve survival rates?

Warming solutions
• Ice formation on warming is of comparable
or greater importance to ice formation on
cooling in determining survival of
cryopreserved samples.
• Focus on warming rate
• Temperature mapping exercise
• Aim to maximise survival rates

mins
O
C

Thaw order

Little steps are good!
 Consistency in quality
 Staff are competent and safe
 Reduces risk
 Ensures continuous improvement
 Shares / promotes best practice
 Pushes success rates a little
higher?

Conclusions
• Positive attitude towards improvement
– Engage your whole team

RHG Congress 2018 - Rachel Cutting

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