content: board assurance framework ipc corporate delivery ... · ipc corporate delivery plan ......

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Ref: TB28/58/12 Appendix D

Northern Health and Social Care Trust

Subject: Governance

Content: Board Assurance Framework

Trust Board is responsible for ensuring it has effective systems in place for governance, essential for the

achievement of its’ organisational objectives. The purpose and design of the Board’s Assurance Framework is to

ensure that the Board can be effective in driving the delivery of its’ objectives. This document assists the Board in

identifying, managing and minimising the principal risks to achieving the corporate objectives and shows the

position at March 2012.

IPC Corporate Delivery Plan

to consider progress at March 2012 on the Infection Prevention Control Corporate Delivery Plan 2010/2013.

Author: Dr P Flanagan

FOR CONSIDERATION

Date: 16 March 2012

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All sub-objectives to be delivered by December 2011 and sustained thereafter with regular monitoring/testing for assurance.

Definitions RAG Rating

Green on target to deliver actions to

PCOPS = Primary Care & Older Peoples Services achieve objective

N.D.L. – Nominated Directorate Lead for IPC Amber achievement of actions

AHS = Acute Hospital Setting not certain/doubtful.

MHD = Mental Health and Disability Directorate Red not likely to deliver objective in

Childrens = Children’s services Directorate timeframe. CCD = Corporate Communications Department

IPC = Infection prevention and control

PPMSS = Planning, Performance Management, Support Services CORPORATE INFECTION PREVENTION AND CONTROL DELIVERY PLAN

IPC CORPORATE DELIVERY PLAN

2010 – 2013 PROGRESS AT MARCH 2012

Incorporating recommendations from Dr Patel’s visit July 11

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Sub-Objectives Current position at March 2012

Further action required: Accountable officers

Timeframe RAG Evidence of achievement

Objective 1: To deliver high quality, evidence based treatment and care

1.1 All staff will have access to the Regional IPC manual in relation to prevention of Healthcare Associated Infections. 2010/2011

AHS, PCOPS & Children’s staff in Trust facilities all have access to the regional ward manual through Staffnet. Easy link from front page of staffnet Random surveys of staff provided assurance of knowledge of how to access policy. Homecare staff and T/R staff have hard copy access. Access to intranet included in facility induction.

Re-survey 20 staff to ensure that they can use intranet and find the manual, take local action as appropriate. Report survey findings to Directorate IPC group or IPCEH committee. Introduce annual review of IPC policy (as appropriate) with each policy reviewed, provide 1 page summary of content.

NDLS IPC Team

30th

Sept 2011 Completed From Sept 11

A G G

Survey results. Departmental induction content. Homepage of Staffnet has IPC feature that takes staff straight to regional manual link. View IPC policy

1.2 Rolling Audit Programme in place to measure compliance with best practice to prevent HCAI to include:

- Hand Hygiene - Environmental

Cleanliness - Commodes - Mattresses - IPC Nurse Audits - High Impact

Interventions (HIIs)

(This list is not exhaustive). 2010/2011

Hospitals Facilities comply with requisite audit programme. Performance is reported above 95% in almost areas. Peer audit now embedded in practice Relevant HII and SPI Care Bundles in use in all acute facilities. Essential steps programme being rolled out in community audit findings reported on dashboard to IPCEH and Governance Meetings. Rolled out in NNU and acute paeds

All audit findings to be collated and presented at Directorate IPC group. Given the consistent compliance findings of HII audits and the time involved in producing data, senior leaders will determine if these audits add value and if the time involved is justified.

NDLS DIPC /DON/ Head of Gov

August 2011 Complete roll out April 12

G G G G

Reduced variance between ward audit findings and IPCN audit findings. Minutes of Directorate IPC Meeting. Audit Reports

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1.2 contd.

Regional audit tool now in use across the Trust IPCN audit plan includes 6/12 monthly Hand Hygiene and MRSA & C Diff validation audits.

Audit Reports

1.3 Develop framework and implement competency assessment for peripheral line insertion, ongoing care and removal. 2010/2011

Line champion appointed, Feb 12. Project plan under development. Nurse training in ANTT completed. Medical training delivered 150 + doctors.

Complete project plan Implementation project plan.

.Line champion DON/ DIPC

March 31

st

2012 To be confirmed

G G

Training plan reports. Better RCA data for bacteraemia. Reduction in the number of Bacteraemias

1.4 Infection Prevention Control Link Workers will encourage and promote a culture of best practice within the clinical area. 2010/2011 and sustained.

All clinical facilities have IPC Link Nurses, some community areas also have link support workers. Link Nurses have all completed a module in IPC. Poor attendance of IPC Link Nurses at meetings with IPCN team due to ward pressures. Link nurse study day delivered in December .DON relaunched role.

IPCT continue to work with and support link nurses.

Lead IPC nurse with NDLs

May 2011 and ongoing

G

Reports on attendance minutes.

1.5 IPC Nurses will work with

Acute Hospitals –

Practice to continue.

IPC lead nurse

G

Minutes of directorate

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clinical staff providing advice and guidance to ensure best practice in relation to HIIs and prevention of HCAIs: 1. at directorate meetings 2. during facility visits 3. when providing targeted support. 2010/2011 and sustained.

Each acute facility has an aligned IPCN. IPCNs attend directorate meetings. If a facility has a poor audit the IPCN provides support until the unit’s standards are raised. IPCN attends daily bed management meetings on both acute hospital sites. .

Practice to continue

Ward managers Lead IPC nurse I

G G

meetings. Audit reports Minutes of IPCECH meetings.

1.6 Compliance with mandatory training requirements in relation to HCAI through delivery of a rolling IPC training programme. - All staff have IPC awareness training at induction. 2010/2011 and sustained.

Some difficulty with data capture but high level of compliance. IPC training to be included in consultant appraisal from June 2011. New IPC training model introduced Dec 11

. Head of Medical Education to advise on evidencing compliance levels with doctors in training. Medical staff seek DHSSPS position on standardised training content.

Head of Medical Education Dr Dornan Training Sub Group Chair

May 2012 June 2012

R G

. Manual training records. Revised training plan.

1.7 Training Delivery Plan for nurses and all other staff groups delivered by IPC nurses, in collaboration with Nurse Education and Development Consortium, to comply with regional guidance. 2010/2011 and sustained.

Regional guidance never issued. Progress on target. Re-establish training sub-group to refresh training plan

IPC training sub-group chair

Dec 2011

G

Revised training plan for 2011-2014 Completed

1.8 Promote and encourage

A number of research projects established in collaboration

Development of IPC R&D Strategy. Further research is

Director of

Sept 2011

G

Research papers

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Research and Development related to IPC 2010/2011 and sustained

with Trust Pharmacy and QUB and a number of publications have been produced since 2010 This includes three full papers relating to blood cultures, c.diff outbreak and prescribing linked to ESAC as well as three letters regarding MRSA management ,hand hygiene and hospital antimicrobial policies.

ongoing with submissions for publication being made In addition a Research and Development Office Fellowship has been attained with work commencing in September 2011 for three years.

Infection Prevention and Control IPC Doctor

Publications

Objective 2: To provide a clean and safe environment for treatment and care

2.1 Thoroughly clean buildings across the NHSCT environment. 2010/2011

Intensive cleaning programme in operation across the Trust. Domestic Services provide a cleaning service to all NHSCT Facilities. Cleaning standards are monitored by the Domestic Services Management Team in conjunction with ward/department Managers and the Infection Control Team.

Introduce Annual Environmental Hygiene Report for Trust Board. First one to be submitted to Trust Board by end June 2012.

DON and Assistant Director Support Services Assistant Director Support Services

Ongoing rolling programme September 2011

G G

Audit reports and HCAI Dashboard/Trust Board Performance Report Trust Board Minutes. Patient/Manager satisfaction survey March/April 2011 very positive (Antrim).

2.2 Cleaning in all areas in agreement with agreed cleaning schedules. 2010/2011 2.2. contd

Acute & Community Hospitals – all areas have cleaning schedules. Cleaning schedule completed and in place for Community Equipment store. Home Care workers are compliant with cleaning

Monitor cleaning schedules. Cleaning schedules for residential and respite units are being completed by Heads of Residential and Respite units with Guidance

Ward Managers Facility managers Domestic Services Managers

Immediate and ongoing September 2011

G G

Domestic Supervisors/Ward Managers at daily and monthly Environmental Cleanliness Audits observe if current Work Schedules are in place in domestic

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schedules for Trust property within clients homes

from Domestic Services Management. To review cleaning schedules for AHP and Treatment Rooms. Develop SLA’s with facilities.

Assistant Director Corporate Services

June 2011

A

stores. Domestic Services Managers and Domestic Services Supervisors update Work Schedules if any changes are made to organisation of domestic service. All Work Schedules to be dated. Assistant Domestic Services Managers in the Community are currently liaising with Head of Residential and Respite Units to complete Work Schedules. This is an ongoing process.

2.3 Monitoring and review of cleanliness of environment on a daily basis 2010/2011 2.3 contd

Acute Hospitals – daily review by ward sister and domestic supervisor. Clutter is a recurrent problem. Bed storage a problem (Antrim). Cardiac car garage now being used for bed storage. Observational visits in place

Continue monitoring and reviews of environmental cleanliness. Plan de-clutter initiatives quarterly. Next “Dump the Junk” Event planned for June 2011. Rota options being worked up for the appointment of a bed/mattress co-ordinator for Antrim. JD has been gradedat band 2. Clear Corridor Policy being

Ward managers Domestic services supervisor Assistant Director Support Services DON AHS Director

Immediate and ongoing June 2011 June 2011

A G

Corridors and wards free of clutter. Minutes of IPCEH. Observe for clutter on leadership walkrounds. Refurbishment of

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for Community Hospitals / Residential and Day Care facilities. Capital funding approved to refurbish bed store in Antrim. Completion due Oct

developed. Antrim Bed Store complete.

2.4 Implementation of a rolling audit programme to demonstrate a consistently high standard of environmental cleanliness is delivered.

Acute Hospitals – in place Cleaning schedules in place for AHP Clinics Peer audit now embedded practice. Audit programme in place for environmental cleanliness within community.

Assistant Director Support Services

Roll out commenceJune 2011

G

2.5 Facilities are maintained in accordance with Regulatory Estate requirements.

A new process has been agreed for prioritisation of minor works, with a patient safety dimension. Response times have been agreed.

Evaluate new process with directorate managers. Funding secured to appt. 2 officers to manage process and meet agreed standards

Director of PPMSS.

October 2011 June 2012

R

New system documented for inspection.

2.6 Design of new facilities and refurbishment of existing estate to reflect IPC guidance. 2010/2011

IPC team involved in scrutiny of plans at design stage and commissioning of new facilities and all refurbishment projects.

To continue.

Director of PPMSS

Immediate and ongoing.

G

Plans for new facilities. Established

2.7 Early identification of

Through the use of the

Monitor incident reports and

Bed management

Ongoing

G

CE and Directors

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patients with potential infective status and isolation in a timely manner. 2010/2011 Daily completion and review of Isolation Risk Assessment Tool (IRAT) to ensure safe and appropriate patient flow. 2010/2011

Infection Control Admission Risk Assessment Form (ICARAF)compliance is high. ICARAF is completed on a daily basis and reviewed at bed management meetings. Ward staff identify patients who pose a potential IPC risk and initiate precautions. IPC team immediately notify wards of suspicious lab results or confirmed infectious organisms so that appropriate action can be taken promptly. High level of lab testing for C Diff. Guidance on testing issued December 2010. Audit findings suggest poor compliance. Smart stool resources issued July 2011

RCA summaries to identify any failure in this process. Apply learning from Expert review of MSRA bacteraemia cases in respect of isolation and suppression therapy Quarterly audit of use of IRAT to be carried out. Process for collation of audit data not reliable in C’way.Under review. Evaluate use of Smart Stool resource pack taking account of new regional guidance on testing whch will be issued soon.

and Ward Managers. Line champion /ward managers DON/Deputy DON IPC Lead nurse and IPC Doctor

June 12 Established in 2010. To continue July/Oct June12 Sept 12

G G G G G

seek evidence of best practice through RCA meetings High level of compliance reported to IPCEH. IRAT Forms Reduction in number of C Diff specimens sent for C Diff testing.

2.8 Development of guidance

The Trust has guidance on the

No further action

Director of

2011

G

IRAT Forms, refer to

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for prioritising of single rooms for isolation of patients for infection control purposes.

prioritisation of single rooms for patient isolation. Any further business cases for inpatient facilities will specify single room accommodation and en suite facilities. Staff aware of patient experience issues raised at C Diff Inquiry re isolation rooms.

A research project regarding Patient and Staff Experience of being care for in an isolation facility to be undertaken.

PPMSS DON/Deputy DON

onwards June 2012

G

2.7 Research Report. Established/ completed

2.9 Re-designation of Ward A1, Antrim Area Hospital as isolation and cohort ward when necessary.

Local guidance in place (draft).

Policy guidance approved. Need to Audit the frequency of the implementation of the guidance and identify learning from same to further inform practice.

Patient Flow Manager/ Assistant Directors

Ongoing

A

Guidance available for reference. Established/ completed

2.10 Appropriate Outbreak Management with roles and responsibilities clearly defined.

Practical Steps for Outbreak Management in the clinical environment developed and disseminated. Outbreak policy has been revised. Account has been taken of C Diff Inquiry recommendations.

Implement in full .

Lead IPC Doctor Lead IPCN

June 2011

G

Post outbreak reports. Revised Outbreak policy. Completed

2.11 Strong and clear

Corporate co-ordination of PS

Leadership walk rounds now

Trust

May 2012

G

PS Leadership

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leadership at the highest level demonstrated through Patient Safety (PS) Leadership Walkrounds with a focus on infection prevention and control

Leadership Walkrounds for Assistant Directors, Senior Management Team and Non-Executive Directors focussing both on IPC and the patient safety issues. Decision taken to talk to patients re their experience when doing walkrounds. Guidance developed Support Services walkabouts in conjunction with the IPC Team ongoing. Nursing staff now attend. Public Representatives from IPC Committee attend when possible.

include speaking to patients. Reporting mechanism to be developed .

Governance Manager (patient safety). Assistant Director Support Services

November 11

G

walkrounds reports. Support Services walkabout reports.

2.12 Development of action plans to implement recommendations from IPC Nursing Audits and external reviews eg. RQIA inspections

Action plans developed after every audit, internal and external audit findings on IPCEH agenda and directorate IPC agenda. Summary and progress against action plans are monitored and reviewed at IPCEH Committee and Governance Management Board (GMB).

Directorates look for recurrent issues in audits across facilities and take managerial action if necessary.

Assistant Directors/ Governance Leads Corporate – Trust Governance Manager

Immediate and ongoing. Ongoing.

G G

Audit results and action plans available for inspection. Minutes of IPCEHC and GMB

Objective 3: To establish timely and effective HCAI surveillance programmes and systems to identify trends, investigate clusters and adverse incidents and to share learning

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3.1 ICT enabled surveillance of organisms to support detection of emerging trends and problems

Dr Scott leading the development of HCAI dashboard Phase 1 live from March 31

st, phase 2, May 12

Generate reports with greater analysis of data and post on staffnet for clinical staff to access. Develop dashboard to meet IPC surveillance requirements

Professor Scott Oct 2011

R

Surveillance reports data on staffnet.

3.2 Provision of timely information re Trust incidence of Clostridium difficile, MRSA and MSSA bacteraemias and other alert organisms. 2010/2011

All new C.Diff and MRSA cases are reported daily to DIPC.

HCAI system at 3.1 will address all surveillance needs

Lead IPC doctor Ref 3.1

Oct 2011

R

Reports on analysis of alert organism. Information on staffnet

3.3 Identified accountability for analysis and response to management of emerging patterns / trends. 2010/2011

IPC team accountable for analysis of emerging patterns and trends in alert organisms. Clinical teams accountable for taking the appropriate action as directed by IPC team and management. DIPC responsible to CE and Trust Board. IPC Doctor carried out MRSA bacteraemia case analysis for 211 cases

Continue to promote ownership of HCAI with clinical teams in all relevant communications. Consider ward based review of HCAI performance after visit to SHSCT.

DIPC/DON/ Operational Directors Dr Kearney

June 2011 Dec 2011

G G

Evidence of communication between IPC Team and Clinical Teams e.g notes of meetings. Clinical forum meeting with CE.

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3.4 Root Cause Analysis (RCA) to be completed by clinical team on all newly reported cases of Clostridium difficile and MRSA bacteraemia. 2010/2011 Nominated Directorate Leads to implement and monitor action plans to address emerging trends / issues arising from audits and RCAs. 2010/2011

RCA process for C Diff has been reviewed. 2011 RCA findings are reported at directorate IPC meetings and IPCEH com. Clinicians lead RCA and present to CE,MD and DON. RCA process for MRSA bacteraemia is completed. Community Hospitals and Residential Homes - RCA process initiated and completed in all new cases of C Diff, MRSA & MSSA Bacteraemia. Currently action plans are monitored through the management line. Action plans are developed if deficits are found.

Audit of RCA process to be carried out. Outcomes from completed? Action and learning to be discussed at the Directorate IPC group chaired by NDL.

DIPC/Operational Directors NDL/Lead Nurse Assistant Directors & Governance Leads

Ongoing on quarterly basis. Immediate and ongoing. Sept 2011 Immediate

G G G

Audit findings. Minutes of meeting. Directorate IPC Group IPCEH . Directorate IPC minutes. Completed/ established

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3.5 A Senior Management HCAI review panel to hold individual staff members to account for new cases of HCAI. 2010/2011

CE, selected Directors and an IPCN meet clinical teams where a bacteraemia or C Diff has occurred in one of their patients. They review RCA findings and share learning. Learning reports issued from RCA meetings

CE to introduce HCAI performance into Directors monthly accountability reviews.

DIPC Chief Executive DON/Operational Directors DIPC

July 2011 Dec 11

G G

Minutes of review panel. Minutes of accountability meetings.

3.6 A dashboard of key performance indictors developed, implemented and monitored: Environmental Cleanliness Hand Hygiene Commode Audits Mattress Audits IPC Nurse Audits Staff training by professional grouping

- Antibiotic Prescribing

- User Feedback (list illustrative / not exhaustive). 2010/2011

A corporate dashboard of identified KPI’s presented to SMT and Trust Board monthly. Discussed at Directorate Team and at monthly AD Governance forums.

Directorate monitoring of KPI dashboard to continue. Ensure corrective action is taken when performance dips. Action and learning to be discussed at the Directorate IPC group chaired by NDL monitoring. Review arrangements for ensuring problems are identified and acted on. Review escalation arrangements for low compliance with any HCAI KPI’s, review action taken.

Director. Assistant Directors Lead Nurse Assistant Directors Assistant Directors Operational Directors/ Assistant Directors

Immediate and ongoing. Immediate and ongoing. Immediate and ongoing. Sept 2011

G G G G G

Dashboard and minutes of meetings. Performance against KPIs displayed in wards.

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Objective 4: To ensure all staff are aware of their responsibility and accountability for the prevention and treatment of HCAIs

4.1 Accountability and responsibility for prevention of HCAIs embraced at all levels of the organisation -‘Infection prevention and control is everybody’s business’ is reflected as a core organisational value. 2010/2011.

Responsibility for IPC and prevention of HCAI’s is a standing agenda item on directorate meetings and Directorate IPC groups;

• General Managers meetings

• Ward managers meetings.

• Governance Management Board and Governance

Committee. HCAI work relaunched at October 11 event. A new accountability structure has been drafted introducing a strategic forum chaired by the CE. A clinical forum has met with CE and DIPC further meetings as required.

Involve NEDS on leadership walkarounds and report findings. Increase clinical engagement in HCAI. Fully develop new accountability structure – Local medical governance groups established, to become M-D Promote use of reporting system. Ward based teams to review HCAI. Performance supported by local Governance Leads.

Head of Governance & Patient Safety Strategic IPC Forum Associate Medical DIR /Dir AHS All staff. Associate Medical Director/Directors AHS

Sept 12 Immediate and ongoing. Sept 2011

G G G G

Minutes of Directorate Meetings. Mi Minutes of Strategic Forum.

4.2 Directors are responsible for HCAI prevention within directorates and report through to Trust Board on HCAI key performance indicators. 2010/2011

Corporate HCAI dashboard displays individual facilities and results from the IPC audits completed. There needs to be validation of self – audits, ref to action at 1.2

Remedial action needed to reduce MRSA bacteraemia. Continued analysis and review of individual directorate dashboards at directorate IPC group, IPCEHC and GMB. Introduce peer audit.

NDL DIPC/DON and Directors

G

HCAI targets met.

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4.3 Any breaches of IPC policies are acted on by management. 2010/2011

Any breaches of IPC policy to be addressed within line management structures. System developed for colleagues to whistle-blow on persistent breachers. Any recent breaches of policy reports to non Trust staff.

All breaches to be discussed at Directorate IPC Group. To be reviewed Action and learning to be discussed at the Directorate IPC group chaired by NDL. Incident reports to be reviewed quarterly by Directorate IPC and IPCEH.

NDL NDL/DIPC


A

Minutes of Directorate meeting. Record of breaches in place and monitored.

4.4 Directors review and put in place arrangements to ensure effective multidisciplinary approaches to prevention of HCAI. 2010/2011

All operational directors have implemented the following: -IPC Standing agenda item on all directorate and team meetings -NDL role -Training plans for all staff groups -Development and monitoring of action plans resulting from IPC nurse audits and unannounced inspections by external agencies.

When local governance groups become multidisciplinary they will strengthen local approaches

Operational Directors

Sept 2012 G

Minutes of meetings.

4.5 Nominated Directorate Leads report on dashboard of KPI’s at Directorate Governance meetings and Infection Prevention and Control and Environmental Hygiene Committee.

IPC Standing agenda item on all directorate and team meetings. NDL reports on RCA findings at IPCEH.

Continue with current practice and refine reports.

NDL/Surveillance Officer.

Immediate and ongoing

G

Minutes and papers from meetings. Established

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4.6 Ongoing development of ‘Board to Ward’ culture to reduce HCAI to the irreducible minimum through:

- Implementation and monitoring of HCAI action plans

- Ongoing training and development to enable staff to deliver on the trust’s HCAI agenda.

Training plans for all staff groups. Action plans are developed to address findings of all IPC audits and inspections. Audits are usually performed annually and it is now agreed that manager will re-audit areas of poor compliance in the interim to ensure improvement is sustained.

IPC nurse audits and RQIA reports to be addressed at the directorate IPC group Implement agreed plans for following up on audit action plans and sustained progress.

System to re-audit and monitor improvement being developed bt directorate management

NDL Directors AHS management/NDL

Immediate May 2011 and ongoing

R

Local teams and managers demonstrate ownership through practice, policy compliance and concern for performance. Trust Board provides visible leadership and TB agenda includes HCAI. Established

4.7 All staff have a clear understanding of their responsibility for prevention of HCAI as referenced in their job descriptions, objectives, competency assessment and job plans.

All staff have prevention of HCAI referenced in their job descriptions. Guidance issued to medical staff regarding IPC training as part of their PDP.

HCAI prevention message to be reinforced annually through review of practice and setting of individual objectives. Consultant staff should discuss HCAI as part of appraisal.

Directors and Management teams Medical Director

Ongoing. June 2011

G G

Record of staff objectives. Record of medical appraisals.

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4.8 IPC nurses maintain visibility at clinical level to support staff to prevent HCAI.

Each IPC nurse has responsibility for specific facilities, to support and guide staff in the delivery of safe, effective and evidence informed practice. IPCNs have almost daily presence on wards (acute).

No further action.

Lead IPCN.


G

Ask Ward Managers on Leadership Walkarounds.

4.9 HCAI Performance data: Staff have access to timely reports on Trust incidence of HCAI’s and local audit results and feedback on their performance.

HCAI performance data disseminated through the line management structures to all staff and standing agenda item at staff meetings. HCAI performance data displayed on White Boards at the entrance to all facilities. Develop use of staffnet. Lead Nurses now have access to IPC ‘L’ drive.

Refer to: Dashboard development at 3.1

Dr Scott DIPC/PPMSS Director

Sept 2011

R

Dashboard data.

Objective 5: To ensure the public have confidence in the care setting and the quality of care and treatment provided

5.1 Implementation of the HCAI Communication Strategy to provide information to identified target audiences.

HCAI Communication Strategy developed and regular targeted messages provided. C Diff Inquiry highlighted communication issues. Quarterly news sheet is distributed to Home care workers detailing infection control issues. regular validation audits for C diff and MRSA (by IPCN) introduced

HCAI communication strategy continues to be implemented within directorates through the directorate IPC groups. Action plan arising from Public Inquiry Recommendations.

Assistant Directors Associate Medical Director & Clinical Leads Lead IPC Nurse

March 2011 All short term actions by Sept 2011 July 11

G G G

Communications Strategy available. C Diff Plan progress reports. Audit Reports Established

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5.2 Review user feedback processes to ensure the views of service users are informing infection control processes and are integrated into the planning, implementation and monitoring of same.

• 2 public representatives on IPECH Committee.

• Talking to patients re experience being

introduced to leadership walkaround.

• Roll out of improving patient and client experience standards . Ongoing

To be fully developed and reporting mechanisms created. Scrutinise patient experience feedback for IPC issues and feedback to wards.

Head of Governance & Patient Safety DON

Sept 2011 Dec 2011 and ongoing.

G G

Report from walkarounds. Patient survey results to Trust Board/User Feedback Committee.

5.3 Develop a range of information leaflets on all alert organisms for patients, their families and carers, to include: Isolation precautions Hand hygiene Implications for visiting Treatment Laundry instructions.

Information leaflets on most common organisms available from PHA under review. Available on all wards. Staff tick and sign and date when information given to patients/relatives on IPCN advice sheet. Audit in February 2011 found good compliance.

PHA provides all IPC information leaflets. Supplies have been delivered

Lead IPCN Deputy DON and Head of Communications

June onwards. June 2011 for priority leaflets.

G G

Leaflets available on request.

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5.4 Clear communication with patients, their families and carers to update re: increased incidence / trend within a particular unit / facility.

Patients and families are not routinely told about the level of HCAI in a ward or hospital. WRiT introduced Dec 11. Document requires doctors to record significant conversations with pt or family outbreak policy will have a linked communications plan for all stakeholders

Audit of use of WRiT planned

Dr Dornan/ Medical director

June12

G

Audit Findings

5.5 HCAI Audit data on display publicly and prominently at the entrance to each clinical area / facility.

Displayed in all acute facilities on white boards.

Continue current practice Consider introducing MRSA, C Diff, commodes, mattress audit to whiteboards.

Ward Managers

June 2011

G

Can be seen on each ward. Established

Objective 6: To ensure safe and appropriate prescription of antibiotics

6.1 Compliance with Regional Guidelines for Empirical Antibiotic Therapy in Hospitalised Adults.

Medicine, Surgery and Gynae are audited weekly on Adherence to Regional Empirical Antibiotic Policy. Compliance is consistent at 90% and above. This is displayed on ward whiteboards. A programme of pharmacy visits and antibiotic audits in community hospitals, started April. Anti-microbial ward round established in ICU, piloted in SSW, plan is for weekly rounds in admission wards, Antrim. Results are fed to consultants monthly.

Continue audit programme. Challenge inappropriate non-compliance. . Report findings from anti-microbial ward rounds to consultant and Medical Director. .

Prof Scott Lead IPC Doctor Pharmacy

Immediate and ongoing May 2011 Oct 2011

G G G

Audit results are disseminated monthly and a quarterly report is produced by the Antimicrobial Management Team. Reports from anti-microbial ward rounds. Observe whiteboards

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6.1a Comparative assessment of antimicrobial usage regionally

Adherence to the Belfast Trust guidelines for antimicrobial use in children has been audited. The Trust participates via the antimicrobial pharmacist network in monitoring of antimicrobial use. Trust has led regional audit of antimicrobial use in respiratory infection and is also leading and participating in the regional audit of antimicrobial therapy in UTI

Results are being processed.

Prof Scott

July 2011

G

Quarterly usage data is reported for each Trust allowing appropriate comparisons to be made.

6.2 Audit programme of antimicrobial compliance in line with policy standards to provide assurance that risks of patients being exposed to high risk antibiotics are being minimised.

The use of ‘High Risk’ antibiotics are restricted throughout the Trust. An exemption form is required by pharmacy prior to dispensing these antibiotics. Ongoing audit of the exemption forms demonstrate average compliance of 95%. Antibiotic policy amended August 2010 to restrict co-amoxiclav for CAP. 4

th

quarter figures show positive impact. Consultants get monthly feedback on the appropriateness of antibiotics prescribed.

Continue current practice High risk antibiotics usage to be reviewed at Directorate IPC group and IPCEH. Regular surgical prophylaxis audits currently carried out in Antrim.

Prof Scott DIPC, lead IPC doctor and Dr Dornan and AHS Director Professor Scott


G G

Audit Results are disseminated monthly and a quarterly report is produced by the antimicrobial management team.

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6.3 Surgical prophylaxis in line with Trust guidance.

An audit of Surgical Prophylaxis in Antrim and Causeway Hospitals was carried out. Regarding antibiotic choice compliance was found to be 80%

Assess findings for learning action points and disseminate. Discuss at Directorate IPC group and with surgical staff.

Prof Scott Ms Getty

May 2011 June 2011

G G

Audit report minutes of meetings.

6.4 Appropriateness of antibiotic usage reviewed at Infection Prevention Control and Environmental Committee.

Review of antibiotic appropriateness and usage standing agenda item at IPCEHC. Antibiotic appropriateness audits are reviewed.

Also review at IPC directorate Group

DIPC Dr Dornan AHS Director


A

Audit results and minutes of IPCEH.

6.5 AMT provides strong leadership for prescribing practice.

AMT meets quarterly and identifies areas of poor prescribing and considers methods of improvement. 12-24 month plan to be finalised at October meeting.

12 -24 month plan completed. Under continuous review.

Dr Kearney Professor Scott

A Prescribing data and guidance adherence.

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