Healthcare Associated Infection (HAI)

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Healthcare Associated Infection (HAI) Draft Standards August 2014 Healthcare Improvement Scotland 2014 First published August 2014 The publication is copyright to Healthcare Improvement Scotland. All or
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Healthcare Associated Infection (HAI) Draft Standards August 2014 Healthcare Improvement Scotland 2014 First published August 2014 The publication is copyright to Healthcare Improvement Scotland. All or part of this publication may be reproduced, free of charge in any format or medium provided it is not for commercial gain. The text may not be changed and must be acknowledged as Healthcare Improvement Scotland copyright with the document s date and title specified. Contents Introduction 5 Development of the draft Healthcare Associated Infection standards 7 How to participate in the consultation process 8 Draft standards for Healthcare Associated Infection 9 Standard 1 Leadership in the prevention and control of infection 9 Standard 2 Education to support the prevention and control of infection 12 Standard 3 Communication between agencies, and with the patient or their representative 15 Standard 4 HAI surveillance 18 Standard 5 Antimicrobial stewardship 20 Standard 6 Infection prevention and control policies, procedures and guidance 24 Standard 7 Insertion and maintenance of invasive devices 27 Standard 8 Decontamination 30 Standard 9 Acquisition of equipment 34 Appendix 1: Membership of the draft standards for healthcare associated infection short-life working group 39 3 4 Introduction About Healthcare Improvement Scotland We are the national healthcare improvement organisation for Scotland, established to advance improvement in healthcare. We have a vital role in supporting healthcare providers to deliver safer, more effective and more person-centred care. We do this through a unique combination of evidence-based standards and guidelines, a scrutiny and assurance approach that is fair but challenging, and quality improvement implementation support. For more information about our role, direction and priorities, please visit: Background to the revision of HAI standards In March 2008, NHS Quality Improvement Scotland published the National Standards for Healthcare Associated Infection (HAI) 1 which emphasised the need for all NHS board staff to be involved in infection control initiatives. The prevention and control of infection is everybody s responsibility, with standards being one part of the drive towards a safer NHSScotland. An example being the application of the HAI standards for the Healthcare Environment Inspectorate to carry out inspections of hospitals across NHSScotland since April However, the standards were not developed explicitly for this purpose. The Scottish Government HAI Task Force National Policy Group 2 highlighted that healthcare organisations and practitioners require clarity about actions to prevent and control HAI at the point of patient care, in all healthcare settings and Healthcare Improvement Scotland was tasked with revising the current standards. These draft standards are also aligned to the National Infection Prevention and Control Manual (2013) 3, with both these documents being the two key publications for healthcare organisations to adhere to, to ensure robust HAI practice and policy. These revised standards supersede all previous HAI standards produced by Healthcare Improvement Scotland s predecessor organisations. Scope The revised standards apply to all patients and members of the public, and all healthcare organisations and practitioners, including independent healthcare providers. Although the standards apply specifically to healthcare settings, they have been developed in recognition of the integration agenda and the principles that apply to standards in both health and social care. National standards for social care are produced by the Scottish Government and regulated against by the Care Inspectorate. 5 Information for patients and members of the public It should be noted that this is a technical document, developed to support staff to ensure the highest standards of infection prevention and control wherever healthcare is delivered. Each standard details what patients and the public can expect of healthcare services in Scotland following implementation. Format The standards have been revised following the six themes indicated below: 1. leadership, governance and accountability 2. education 3. communication 4. HAI surveillance 5. prevention and control of infection, and 6. decontamination and acquisition of equipment. All our standards follow the same format. Each standard includes a statement of the level of performance to be achieved, a rationale providing reasons why the standard is considered important, and a list of criteria describing the structures, processes and outcomes. Within these standards, all criteria are considered to be essential or required in order to demonstrate that the standard has been met. 6 Development of the draft Healthcare Associated Infection standards The development of the draft HAI standards builds on the available evidence and two previous sets of national standards produced by Healthcare Improvement Scotland s predecessor organisations. Namely, the Clinical Standards Board for Scotland s standards for Healthcare Associated Infection (HAI) Infection Control 4, and NHS Quality Improvement Scotland s standards for Healthcare Associated Infection (HAI) 1, published in 2001 and 2008, respectively. A short-life working group, chaired by Dr Margaret McGuire (Director of Nursing, NHS Tayside) was convened in January 2014 to consider these and other documents, including the Prevention and control of healthcare-associated infections: Quality improvement guide 5, a National Institute for Health and Clinical Excellence (NICE) publication, to help identify key themes for standards development. Six sub-groups were established to take this work forward under the following themes: leadership, governance and accountability, including workforce capacity and capability, and continuous quality improvement education communication, including multiagency working, and admission, discharge and transfer HAI Surveillance, including diagnostics prevention and control of infection, including antimicrobial stewardship, infection control precautions, and invasive devices, and environment and equipment, including cleanliness, decontamination, acquisition, and estates management. For information, membership of both the short-life working group and sub-groups is set out in Appendix 1. To ensure each standard is underpinned with the views and expectations of both patients and the public in relation to HAI, information was gathered from a number of sources, including: patient complaints relating to infection control a series of focus groups, and public partner feedback following inspections carried out by the Healthcare Environment Inspectorate. This information was provided to each sub-group to inform the standards development process. 7 How to participate in the consultation process We would like to receive your views on the draft standards in respect of: factual errors grammatical errors any critical omissions, and/or unnecessary information or inclusions. How to participate in the consultation process We are using a range of methods to capture comments and feedback, including: wide circulation of the draft standards to relevant professional groups, health service staff, voluntary sector organisations and individuals completion of our comments form - which is available at or from Ali McAllister (details below), and tailored focus group with members of the public and NHS staff. Responses to the draft standards for HAI should be submitted by close of business on 24 September Consultation feedback At the end of the consultation period, all comments will be collated and the short-life working group will respond to each comment received on the draft standards. All comments (which will be anonymised) will be published, together with the short-life working group s response on the Healthcare Improvement Scotland website (www.healthcareimprovementscotland.org). The final standards for HAI will be published in October 2014, with publication of the consultation report in November If you would like to know more information about the consultation process, please contact: Ali McAllister Project Officer Healthcare Improvement Scotland Delta House 50 West Nile Street GLASGOW G1 2NP Phone: Draft Standards for Healthcare Associated Infection Standard 1 Leadership in the prevention and control of infection Standard statement The organisation demonstrates leadership and commitment to infection prevention and control, to ensure a culture of continuous quality improvement throughout the organisation. Rationale Robust leadership in infection prevention and control is essential for effective decision- making, efficient use of resources, and ensuring the provision of high quality, safe, person-centred care. Criteria 1.1 Executive leadership, members of leadership teams and all senior managers have a working knowledge of the infection prevention and control policies and procedures as well as the national and local priorities that impact on care within their organisation. 1.2 There is an Executive Board member assigned to lead on infection prevention and control for the organisation. 1.3 There is an Infection Prevention and Control Team (IPCT) with the necessary expertise to support the organisation. 1.4 The organisation agrees and monitors key performance indicators (KPIs) for infection prevention and control, and executive leadership receives, reports and acts on these. 1.5 There is an infection prevention and control accountability framework, approved by executive leadership, which specifies the responsibilities, reporting structure and ownership of infection prevention and control risks at all levels in the organisation. 1.6 The organisation can demonstrate to patients, their representatives and staff, effectiveness and improvement in maintaining a safe care environment. 1.7 The organisation has strategic and operational systems that demonstrate compliance with infection prevention and control policy. 1.8 The organisation demonstrates a culture of learning from adverse events, including outbreaks and incidents, by receiving reports, and seeking confirmation of system change to reduce risk, prevent recurrence and promote resilience. 1.9 The organisation uses data from a variety of sources, including patient feedback, to meet its objectives and support a culture of learning and continuous improvement in infection prevention and control. 9 What does the standard mean for people receiving treatment or visiting a healthcare setting? Patients and visitors have confidence that the organisation has effective leadership and governance and that it promotes an organisational culture committed to continuous improvement in infection prevention and control. What does the standard mean for the organisation? The organisation is able to demonstrate achievements in continuous improvement in infection prevention and control. What does the standard mean for the infection prevention and control team? The IPCT is able to provide a proactive infection prevention and control service, supported by executive leadership, with whom they communicate risks and recommend actions. The IPCT supports clinical, and other staff, with data management, training, environmental assessments, risk assessments, practice audits and recommendations for practice that facilitate safe patient care and service improvement. What does the standard mean for frontline clinical staff? Clinical teams are supported by executive leadership and the IPCT through the provision of resources, a suitable environment, a reporting structure, guidance, training and education, and data that facilitates them to deliver effective infection prevention and control. What does the standard mean for support services? Support staff are aware of their role in maintaining a safe care environment. Evidence of achievement Staff can: o describe infection prevention and control activities appropriate to their role in the organisation o describe the data they use to influence practice to reduce HAIs and improve care processes o make contact with the IPCT when necessary o explain their own role and responsibilities in the prevention and control of infection, and o articulate the process for reporting and escalating infection prevention and control risks or incidents. There is a designated HAI Executive Lead. There is an organisational chart that shows the management and accountability of infection prevention and control from executive level to frontline care. Leadership walk rounds timetable and inspections. Executive Board reports or minutes. Ward scorecards. Infection Control Committee reports. 10 Risk registers. Outbreak management plans. Infection prevention and control KPIs. Infection prevention and control annual programme. HAI Improvement data. Patient satisfaction survey reports. Patient involvement in learning from adverse events. 11 Standard 2 Education to support the prevention and control of infection Standard statement Education on infection prevention and control is provided to all healthcare staff to enable them to minimise infection risks that exist in care and home settings. Rationale To minimise the infection risks associated with healthcare, staff are provided with the necessary knowledge and skills to practice behaviours integral to safe, effective and person-centred care. Staff are knowledgeable and competent. Criteria 2.1 The organisation assesses the education and training needs of all staff relating to the prevention and control of infection. 2.2 All staff within the organisation are provided with clear guidance on: roles and responsibilities in relation to prevention and control of infection, and education and training needs. 2.3 The organisation demonstrates an education programme that meets the need of staff which includes: mandatory induction and updates on HAI guidance, policies and procedures individually tailored HAI education to meet roles and responsibilities, and learning and sharing of HAI best practice, internally and externally. 2.4 The organisation evaluates the provision, quality and uptake of infection prevention and control training and responds to any unmet infection prevention and control education needs. 2.5 The organisation has multiple and integrated concurrent approaches for access and delivery of prevention and control of infection education across all professions and disciplines. 2.6 HAI-related intelligence and other data are utilised in the identification of education and training needs and the planned programme of education and training offered. 12 What does the standard mean for people receiving treatment or visiting a healthcare setting? People using the services are assured that staff delivering care are educated and trained in prevention and control of infection and use their learning to ensure care is safe, effective and person-centred. What does the standard mean for the organisation? The organisation can demonstrate a continuous quality improvement approach and a learning culture that strives to meet and maintain knowledgeable and competent staff to prevent and control infection. What does the standard mean for the infection prevention and control team? The IPCT supports the organisation to identify, provide and evaluate organisationwide infection prevention and control education needs. What does the standard mean for frontline clinical staff? Frontline clinical staff are able to demonstrate knowledge and competence in the delivery of care and act as a role model in the promotion of prevention and control of infection. Staff are able to effectively challenge colleagues to promote best infection prevention and control practices. What does the standard mean for support services? Support staff have the skills to practice safely and promote the prevention and control of infection. Evidence of achievement Individual performance management and development plans with clear objectives in relation to HAI and regular feedback on performance and competence. Recording and reporting structures for monitoring the uptake of training. Training evaluations (individual and organisational). Active organisational programmes for HAI education. Policies and procedures for staff education and training in relation to prevention and control of infection. Inclusion of training issues and needs in significant event analysis. Evaluation process to ensure that HAI training is appropriate, fit for purpose, quality assured and consistent with national guidance and standards. Training and achievement records. 13 Completion data and observation of implementation of national and local training programmes (assessment data, peer review, reflection). Use of profession-specific competencies and frameworks. Performance indicators for staff performance management in infection prevention and control which are checked on a regular basis. Training needs analysis informed by national initiatives, organisational strategy and local HAI outcomes. Reports of the proportion of staff undertaking mandatory infection prevention and control induction and update training. Patient and staff feedback on their experiences on the prevention and control of infection which inform learning activities. A range of forums to give staff the opportunity to learn from each other s experiences in relation to prevention and control of infection. Audit(s) of infection prevention activities undertaken across the organisation as a result of learning from others. Audit of hand hygiene and other practices noted in SICPs (Standard Infection Control Precautions) and feedback given to relevant staff. Feedback given to individuals and teams on HAIs, wound infection rates and other surveillance data. Audit of appropriate isolation facility usage. 14 Standard 3 Communication between agencies, and with the patient or their representative Standard statement The organisation has effective communication systems and processes in place to enable continuity of care and infection prevention and control throughout the patient s journey. Rationale Patients are vulnerable to infections and some present an infection risk to other patients, visitors and staff. As a single patient journey can involve staff in multiple care settings (ambulance, acute hospital, community hospital, care home, general practitioner or private health care provider) effective care provider communications are vital in the prevention and control of infection and safe person-centred care. Wherever possible, patients or their representatives must be assured of, and involved in, communications regarding their care. Criteria 3.1 The organisation has systems that require an infection prevention and control risk assessment (to and from the patient) to be made and documented on patient admission. 3.2 Where infection risks to the patient are identified appropriate actions are taken to minimise these risks. Both risks and actions are communicated with, and involve, the patient or their representatives. 3.3 Where infection risks are identified from the patient appropriate actions are taken to minimise these risks. Both risks and actions are communicated with, and involve, the patient or their representatives. 3.4 Patients, or their representatives, are provided with written information, in a format appropriate to the needs of the target audience, on specific infection-related risks (including any longer term implications) if relevant, during their care stay, e.g. leaflets on HAI, Clostridium difficile, norovirus. 3.5 Patients, or their representatives, are involved in the decision-making and care of invasive devices, specifically regarding the reduction of risks. 3.6 Staff seek confirmation of patients or their representatives understanding of the specific instructions related to their antibiotic therapy. 3.7 Staff communicate with the IPCT for advice regarding specialist infection prevention and control risks for individual patients. 3.8 Staf
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