1. Purpose. 2. Current Performance. Agenda Item: 64/09. Public Board Meeting, 21 May Infection Control Performance Report May 2009

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1 Agenda Item: 64/09 Public Board Meeting, 21 May 2009 Infection Control Performance Report May 2009 Presented by: Graham Ramsay 1. Purpose This report updates the Board on the current performance with respect to both MRSA and C. diff infection rates. It invites the Board to comment on the current levels of infection and to seek assurance that everything that is required in relation to actions to reduce and prevent the opportunities for infection becoming a serious threat to patient safety are being taken. This report also includes the Matron s report, which updates the Board on the Matrons contribution to the cleanliness and infection control agenda. 2. Current Performance 2.1 Surveillance a) MRSA Bacteraemia One MRSA bacteraemia was reported in the month of March with none reported in April. The Trust ended the year with a total of 13 MRSA bacteraemias against the annual trajectory of 21. The trajectory set for the year is 18. b)clostridium difficile The total number of C.difficile toxin positive isolates reported in March being classified as WHHT acquired was 3. This resulted in a total of 63 cases that are considered to be WHHT acquired during the year against the trajectory of 183, well within the trajectory. In April however, 12 WHHT acquired C. diff toxin results were reported. Root Cause Analyses are being conducted on all of these cases and any underlying causes will be reported to the Board in July. The new trajectory set for the year is 160 with an aspirational target of 110. Due to the transfer of acute services from Hemel Hempstead to Watford, York ward has closed, however Letchmore Ward continues to operate as the isolation unit for both MRSA and Clostridium difficile. 2.2 Practice Performance a) IV Report The IV therapy nurse finished her secondment in March. There have currently been no applicants for this post. IV training however continues by the Practice Development team.

2 b) Hand Hygiene Compliance Lewisham Audits Weekly Hand Hygiene observations continue in all clinical areas, with results distributed and displayed on all Wards/Departments Infection Control Notice Boards for all members of staff, patients and visitors to view. The categories captured within the audit are: Nurses - including Student Nurses and Health Care Support Workers Doctors - including Medical Students Figure 1 shows the percentage compliance score for each category each week for the month of April. It appears that compliance for nurses ranges between 99%-100% with an overall monthly average of 99% (compared with 96% 98% in March), and Doctors ranging between 80-97% with an overall monthly average of 88% (compared with 87%- 95% in March). The Trust s overall monthly average hand hygiene compliance score for April is 94%. Where there is non-compliance, this is addressed at the time with the relevant staff. Figure 1 Lewisham audits of staff compliance with hand decontamination April 09 Overall WHHT Weekly Hand Hygiene Compliance Scores 100 % Compliance Nurse Doctor Overall 60 30/03/ /04/ /04/ /04/ /04/2009 Week Commencing c) The Health Act 2006/Hygiene Code During 2008/09 the Trust remained compliant with all 11 duties in the Hygiene Code with the exception of sub duty four 4f relating to decontamination of equipment and instruments. The Trust is taking forward action specifically to address current compliance issues relating to these services. On 1 st April, the Care Quality Commission reviewed the Hygiene Code which now has nine duties. d) Saving Lives Action plan/balanced scorecard Divisional Saving Lives Action Plans continue to be updated on a quarterly basis. These action plans/balanced scorecard reports help serve as an indicator/method of monitoring compliance & progress within the divisions in relation to Saving Lives and also with the Hygiene code.

3 In relation to the seven Saving Lives Clinical High Impact Interventions (HII), the divisions continue to provide the Trust s Infection Control Committee with monthly divisional HII audit reports. These are discussed and action taken as appropriate. 2.3 Education and Training During the month of April a total of 136 healthcare workers have received infection control training delivered by the Infection Control Nurses. The sessions provided include corporate induction sessions for new staff and mandatory training updates for all staff. Table 1. Total number of staff trained by ICN s April 09 Band Month Unknow n April Total Nurses/Midwives HCA s Doctors /Medical Students Other Total April Total Table 2. Bands of Staff Trained by ICN s April 09 Total Table 3. Numbers of Staff Trained by ICN s by Division, April 09 Medicine Surgery Women/ Clinical Other Total Childrens Support April Total Hygiene Code In October 2006 the Department of Health published the Code of Practice for the Prevention and Control of Healthcare Associated Infections. This Code of Practice forms one part of the Health Act The purpose of the Code of Practice is to help NHS bodies plan and implement how they can prevent and control HCAI. It sets out criteria by which managers of NHS organisations are to ensure that patients are cared for in a clean environment, where the risk of HCAI is kept as low as possible. Failure to observe the Code of Practice may either result in an Improvement Notice being issued to the NHS body by the Health Care Commission or being reported for significant failings and placed on special measures. NHS bodies must also comply with all relevant legislation such as the Health and Safety at Work Act 1974 and Control of Substances Hazards to Health Regulations. The Code of Practice requires the Board to have in place an agreement outlining its collective responsibility for minimising the risks of infection and the general means by which it prevents and controls such risks. A statement, similar to the one below, was approved by the Board in April 2008 and needs to be confirmed for the year : The Board of West Hertfordshire Hospitals NHS Trust fully acknowledges its collective responsibilities in respect of minimising the risk of infection to all patients staff and others

4 using its sites or services. It regularly reviews the current assurance processes through regular reporting to the Board and is confident that the appropriate mechanisms are in place to mitigate risk as far as possible. The Board will continue to keep under review all necessary systems and processes and refer any failures in the systems and processes to the Audit Committee for detailed investigation. The Audit Committee will provide the Board with the necessary overarching assurance that the necessary mechanisms are in place and are adequate The Board has registered with the Care Quality Commission in respect of the Hygiene Code. Registration was granted without qualification. 4. Matrons Report 4.1. Background Matrons continue to have an important and essential role in the organisation in providing effective management support and leadership development to clinical nursing and midwifery staff. The Matrons continue to report quarterly to the Trust Board on cleanliness and infection control, thereby providing reassurance that they are supporting the delivery of a safe and clean environment for patient care Achievements Infection Control Matrons continue to challenge poor practice and compliance with the Bare Below the Elbow initiative, hand hygiene and monitoring completion of infection control audits. Audits continue on HII insertion and continuation of the care of all indwelling devices. Matrons continue to perform monthly Cross Division Lewisham Hand Hygiene and commode audits and weekly Hygiene Code audits in their own areas. Matrons, supported by the Trust s Infection Control Team, contribute to the RCA process for MRSA bacteraemias and Hospital Acquired C Diff toxin positive cases MRSA C Diff Matrons continue to embed the use of specific skin preparation for insertion of central lines and blood cultures as recommended by the Infection Control Team and preparation of equipment. Nominated Matrons attend weekly and monthly Infection Control meetings. The Matrons continue to ensure successful early isolation of suspected cases within a timely frame. 4.3 Privacy & Dignity Matrons have been instrumental in delivering a number of Privacy and Dignity initiatives. Examples of these include: -

5 The completion of the NHS Institute for Innovation & Improvement Baseline Assessment of Mixed Sex Accommodation; 24 clinical areas within the Acute Medical Care and Surgical Divisions audits during June The assessment demonstrated all 24 areas were Green and identified as areas of good practice that should be shared across the Trust. Audits will continue on a 6-monthly basis. Matrons continue to ensure that Do not Disturb signs are used in all clinical areas; to reinforce the message that permission must be sought before entering a closed room or bed space with curtains drawn. A number of Matrons have been designated as Divisional Leads responsible for progressing the Safeguarding Vulnerable Adults agenda. Supporting the Protected Mealtime Initiative to ensure that patients are not disturbed during meal times and dignity is maintained. Instrumental in the implementation of Mixed Sex Accommodation Policy and resultant Audits. Instrumental in Challenging poor practice through measurement against Quality indices. Identifying themes of complaints and developing Action Plans. 4.4 Improving Cleanliness Matrons are responsible for ensuring that every area is providing a clean environment, to meet local and statutory obligations, in the following ways: - Hygiene Code Duties - Matrons continue to conduct weekly Hygiene Code Monitoring spot check audits and monitor that the clinical areas within their area of responsibility are undertaking daily Hygiene Code monitoring and maintaining Infection control boards. Monthly monitoring of domestic duties and daily stewardship and involvement in Peat inspections. Supporting the continued implementation of the Deep Cleaning Programme 4.5 Matrons Charter Action Plan The focus of the Matron continues to be on: Providing a clean environment of care Ensuring best practice in infection control Improving clinical care standards Treating patients with dignity & respect The Matron s Charter action plan is reviewed and updated on a regular basis (refer to Appendix 1). 5. Recommendation 5.1 The Board are therefore asked to: Note the current levels of reported MRSA and Cdiff cases and the continued contribution of the Matron to the cleanliness and infection control agenda as reported by them in section 3.

6 Graham Ramsay Director of Prevention and Infection Control May 2009

7 MATRON S CHARTER ACTION PLAN - REVIEWED & REVISED - DECEMBER 2008 PROGRESS REPORT APRIL Introduction The role of the Matron was reintroduced into the NHS in 2001 as a result of public consultation. The publication of: Modern Matrons - Improving the Patient Experience (2003) sets out the 10 key responsibilities of the Matron, which are: To lead by example To make sure that patients get quality care Ensuring staffing is appropriate to patient needs Empowering Nurses to take on a wider range of clinical tasks Improve hospital cleanliness Ensure patients nutritional needs are met Improving wards for patients Making sure patients are treated with respect Preventing hospital acquired infection Resolving problems for patients and their relatives by building closer relationships The following year (October 2004), the Matron s Charter was launched. The philosophy underpinning the Charter is that cleanliness is everyone s responsibility and set out ten broad principles for Delivering Cleaner Hospitals (refer to box 1). On 1 st November 2007, Chris Beasley, Chief Nursing Officer & David Flory, Director General of NHS Finance & Operations, Department of Health outlined that Trust s should focus the role of the Matron on: Providing a clean environment of care Ensuring best practice in infection control Improving clinical care standards

8 Treating patients with dignity and respect Box 1. Matrons Charter Standards (2004) 1. Keeping the NHS clean is everybody s responsibility 2. The patient environment will be well maintained, clean and safe 3. Matrons will establish a cleanliness culture across their units 4. Cleaning staff will be recognised for the important work they do. Matrons will make sure they feel part of the team 5. Specific roles and responsibilities for cleaning will be clear 6. Cleaning routines will be clear, agreed and well publicized 7. Patients will have a part to play in monitoring and reporting on standards of cleanliness 8. All staff working in health care will receive education in infection control 9. Nurses and Infection Control Teams will be involved in drawing up cleaning contracts, and Matrons will have the authority and power to withhold payment 10. Sufficient resources will be dedicated to keeping hospitals clean 2. BACKGROUND Over the past four years within the Trust, the Matrons have embraced and actively driven forward the Matron s Charter. An action plan was originally developed which described specific targets for delivering the 10 key principles within the Matrons Charter. With continuous monitoring and engagement with the Director of Nursing & Patient Services, Director of Estates & Facilities, Heads of Nursing/Midwifery, Infection Control colleagues, and Medirest contractors, the original targets have either been achieved or have been embedded into everyday practice. As a result of this achievement, Trust Matrons can now focus on the 10 key responsibilities set out in the 2003 document to improve the patient experience. This paper sets out the strategy for delivering the 10 key responsibilities of the Matrons role and provides a more accurate reflection of the complexity of the role. 3. LOCAL APPROACH TO IMPROVING THE PATIENT EXPERIENCE The delivery of the Matron s ten responsibilities for improving the patient s experience will include the key elements of the Matron s Charter, aligned with Standards for Better Health and will be monitored via the Monthly Matrons meeting chaired by the Director of Nursing. A progress report will be produced and presented to the Trust Board quarterly. The benefits of this approach are/include:

9 The impact of the Matrons role can be measured against the original intended purpose as set out in the 2003 document Matrons will continue to drive the agenda for keeping hospitals clean, reducing hospital acquired infection & promoting dignified care Set the strategic direction for the role of the Matron over the next two years Below is a detailed delivery plan, which identifies the measures that will be put in place to enable the Matrons to deliver the 10 key responsibilities of the Matron role. MATRON S 10 KEY RESPONSIBILITIES - DELIVERY PLAN Leading by Example KEY RESPONSIBILITIES PRIORITY FOCUS TIMESCALE Provide effective clinical leadership in order to improve systems & processes so that the clinical team is better able to meet the patients needs effectively & efficiently & ensure a smooth patient pathway In conjunction with the Senior Sister take responsibility for the delivery of high quality patient care & experience in the Wards/Departments for which s/he is responsible Undertake any leadership development necessary to meet the requirements of the role Support the transfer of acute services & delivery of new models of care/team building Support the implementation of Releasing Time to Care Initiative in conjunction with Director of Nursing & Head of Practice & Innovation Oversee the implementation of the Confidence in Caring Initiative in conjunction with Senior Sisters & Practice & Innovation Team Role model regularly in clinical areas To actively engage in the development of Nursing Metrics to inform & shape practice & quality care provision, in conjunction with Divisional Heads of Nursing, Director of Nursing, Head of Practice & Innovation & Senior Sisters All Matrons to have an annual appraisal All Matrons to have coaching/mentorship Achieved & Ongoing April/May year programme Ongoing Ongoing Yearly

10 Ongoing SFBH - C5b, C8a, C8b PROGRESS: A number of the Matrons are attending Trusts Clinical Leadership Programme (Leadership Academy) or are undertaking a Degree programme Matrons continue to receive an annual appraisal & regularly role model in Clinical areas Confidence in Caring pilot areas identified within Medicine and Surgery. Active engagement with Senior Sisters, Matrons & Head of Practice & Innovation Releasing Time to Care pilot areas identified within Surgery & Maternity Services Nursing Metrics data collection commenced. Metrics data discussed regularly with the Director of Nursing

11 To Make Sure that Patients Receive High Quality Care Co-ordinate & monitor care delivery through benchmarking fundamental & essential aspects of care to ensure high quality nursing care is provided Respond quickly to remedy deficiencies in all aspects of care Meet regularly with Senior Sisters to ensure that standards of care are maintained & discuss themes raised within complaints & incidents SFBH - C1a, C8a, C14a, C14b Use the Evaluation of Practice day to identify good practice to share & areas for development Undertake a Root Cause Analysis in incidences of hospital acquired pressure ulcers, C.Diff & MRSA Bacteraemias, in conjunction with Senior Sister, Tissue Viability lead, Director of Nursing & Assistant DIPC Identify trends - Clinical Indicator Datasets Ensure documented monthly 1:1s with Senior Sisters take place with actions & agreed measurable outcomes Ensure complaint themes, trends & patterns are explored with Senior Sisters & all relevant Divisional Meetings March 2009 & thereafter 6 monthly 2008/09 Review monthly Monthly At least monthly PROGRESS: Continued evaluation of Essence Care Benchmarks through audit and observation of care Matrons are actively involved in all RCAs when a MRSA Bacteraemia is identified. Sharing of good practice takes place at Divisional Senior Sisters meetings Complaint themes are discussed at 1-1 meetings with Matrons & Senior Sisters. Action plans implemented from lessons learned

12 Ensuring that Staffing is Appropriate to Patient Needs Work collaboratively with the recruitment teams to maintain staffing levels within the agreed establishments In conjunction with monitor staffing levels & skill-mix to maintain safe staffing levels Co-ordinate & strengthen the role of the Ward Housekeeper by meeting monthly to review effectiveness of their contribution to improving the patient experience Ensure that service improvement changes in clinical areas is noted at yearly budget setting & an increase/decrease in staffing establishments recognised or documented within the Trust s Risk Register SFBH - C10a, C11a Implement the Trust s Recruitment & Retention Plan locally Participate in Monthly Bank Interviews Continually review skill mix in conjunction with Heads of Nursing & Senior Sisters Utilise Electronic Rostering (ER) system to manage workforce more proactively, ensuring efficiency, equity & safety in conjunction with Senior Sisters Undertake additional training on the use of ER Performance Indicators Actively engage in the implementation of a Trust Acuity tool Ensure all areas have a Housekeeper Work with key Divisional Team members to set new financial year budget Ongoing April 2009 May/Jun 09 Achieved & Ongoing Early 2009

13 PROGRESS: Continued implementation of monthly recruitment interviews for band 5 and band 2. Continued participation in monthly Bank interviews and recruitment of Housekeepers Continued review of skill mixes in all areas through audit and risk assessment Active engagement with Senior Sisters, Divisional Managers and Director of Finance to set and maintain budget programmes Electronic Rostering implemented in all clinical areas Empowering Nurses to take on a Wider Range of Clinical Skills Undertake an annual appraisal of Senior Sisters & Specialist Nurses within the Wards/Departments for which s/he is responsible Review service delivery & support nursing staff to acquire new skills to meet the needs of changing service All Senior Sisters to have yearly appraisals All newly appointed Band 5 Registered Nurses to participate in the Trust s development programme & newly qualified staff to be assigned a Preceptor All Band 6 Nurses to participate in the Trusts Development programme 2008/09 Support the Senior Sister in the professional development of staff at Bands 1-4 In conjunction with the Training Department, develop competencies for Bands 1-4 linked to KSF SFBH C11c PROGRESS: Trust Preceptorship Programme to be audited by Corporate Nursing in Spring Carolyn Morrice Development of competencies for Bands 1-4 linked to KSF currently in train. KSF outline developed for Matrons Annual appraisals are undertaken Improving Hospital Cleanliness Spring 2009 Continue to include cleanliness & infection control as a regular agenda item on ward & departmental site meetings ensuring discussion & implementation of changes in practice from themes of audits, & incidents Encourage a robust reporting system which ensures appropriate escalation Embed the 10 Hygiene Code Duties locally Deliver on identified actions from Health Care Commission Visit October 2008 Ongoing. Regular review Review monthly

14 when cleaning is below an acceptable level Matrons Charter 10 Standards, SFBH C4a, C20a, C21 & Hygiene Code Duties Ensure Service level agreements meet service needs Ensure PEAT results reflect daily walkabout findings Continue to undertake weekly & daily Hygiene Code Audits Continue to undertake daily walkabouts and weekly walkabouts with Director of Nursing Review monthly Review monthly Review daily/weekly Daily/weekly PROGRESS: Matrons continue to undertake: monthly cross-divisional Lewisham audits & weekly Hygiene Code audits, thereby embedding good infection control practice locally Weekly walkabouts with the Director of Nursing continue Matrons are involved in monthly PEAT inspections Participate in joint working with Medirest in weekly & monthly Infection Control Meetings Matrons are actively involved in embedding the 11 Hygiene Code Duties locally. Infection control remains a regular agenda item on all relevant Divisional meetings Maximiser monitoring jointly conducted and formally reviewed with appropriate escalation Ensure patients nutritional needs are met Support clinical staff to promote & enforce the Protected Mealtime initiative Act as a champion for the Nutrition Now campaign to improve the nutritional status of older people in Hospital. Support Senior Sisters to ensure that nutritional assessment, food intake charts & care plans are completed to meet the needs of patients that are nutritionally at risk All areas to adhere to protected mealtimes across the organisation Reinforce principals/best practice summarised Top 10 tips Nutrition (Nutrition Now Campaign) Measure compliance through Evaluation of Practice day in conjunction with Senior Sisters February 2009 & thereafter 6 monthly

15 Meet regularly with housekeepers & catering staff to reduce meal wastage All ward areas to reduce number of meals wasted in Ongoing a month to single figures SFBH - C15b PROGRESS: Wards continue to reduce food wastage & support the Protected Meal Times initiative Nutrition Now placemats distributed to all inpatient areas, promoting the message Stop, Serve & Observe - Make Food a Priority - used in conjunction with Red Trays for patients with compromised nutritional status

16 Improving wards for patients Support Senior Sisters to utilise Ward environment budgets to make improvements to Ward/Department areas as necessary Use feedback from privacy & dignity audits to improve facilities & promote single sex accommodation Undertake weekly Hygiene Code inspections of the ward environment & participate in site based PEAT visits Improve & standardise the quality of written information available for patients & relatives Respond to feedback from Mystery Shopper visits undertaken by Heads of Nursing/Midwifery Matrons Charter 10 Standards, SFBH - C13a, C20a & C20b All Divisions to have an environmental budget to improve the patient environment Repeat mixed sex accommodation self assessment (NHS Institute Tool) Sustain best practice guided by the Trust Mixed Sex Accommodation Policy Report issues/share ideas at fortnightly Hygiene Code meetings chaired by the Director of Nursing All ward areas to have local information for patients including accommodation arrangements Complete action plans with Senior Sisters in response to findings April 2009 April 2009 & thereafter 6 monthly Ongoing PROGRESS: Matrons are actively involved in the 6 monthly baseline privacy & dignity audits Heads of Nursing/Midwifery continue to undertake Mystery Shopper audits. Action plans developed & implemented Monitoring of mixed sex accommodation is undertaken. Elimination of mixed sex accommodation review undertaken Refer to the detailed Trust HCAI Action Plan

17 Making sure patients are treated with respect Ensure patients experience is positive, reinforcing the Trust Pledge Ensure best standards/initiatives relating to Practice Privacy & Dignity are embedded locally Monitor patient feedback from the PET tracker system and complaints & compliments received All clinical areas to have at least one Dignity Champion All patients to be met & greeted on arrival & orientated to the ward. Ensure Pledge is embedded in everyday practice Evaluate locally in conjunction with Senior Sisters & Head of Practice & Innovation Discuss findings at Senior Sisters monthly 1:1s. Encourage the use of this feedback to inform changes in practice Implement locally Ongoing By April 2009 SFBH - C13a PROGRESS: The Trust s Pledge is actively reinforced in all clinical areas The Trust currently has 60 plus Dignity Care Champions 15 PET trackers have been implemented within the organisation Best Standards for Privacy & Dignity currently being reviewed in line with DH Guidance

18 Preventing Hospital Acquired infection All areas will have a designated Infection Control Link Nurse Continue to undertake Monthly High Impact Intervention audits Embed Hygiene Code Duties locally Continue to audit hand hygiene compliance Continue to participate in Infection Control Awareness Week Promote correct decontamination procedures for mattresses & equipment Matrons Charter 10 Standards; Hygiene Code Duties, SFBH - C4a, C20a All Link persons to feedback to own clinical areasdocumentary evidence required Matron designated infection control lead to attend infection control meetings. Review results locally & at the ICC meeting Review at all relevant meetings Sustain compliance at 95%-100% To actively participate in Think Clean day audits Monitor each other s areas & feedback. Review effectiveness Bi-monthly Monthly Monthly Monthly 6 monthly Monthly Monthly

19 PROGRESS: Refer to the detailed Trust HCAI Action Plan Resolving problems for patients & their relatives by building closer relationships Actively engage with PAL s Department to improve communication & information for patients & carers Act on feedback from patients, carers & patient forum groups to improve quality Monitor the implementation of action plans agreed as a result of complaints In collaboration with the Complaints Department, identify themes from complaints within the Wards/Departments & make improvements based on the lessons learned SFBH - C14c Deal with concerns raised & communicated by PALS on the same day in conjunction with the Senior Sister/Deputy Establish Senior Sister Surgeries Review all feedback at all relevant Divisional meetings & at 1-1 meetings Ensure a comprehensive record of complaints includes action plans & evidence of change as a result of recommendations Use Nursing Metrics (Quality Indicators) to monitor & inform focus & change Review feedback at all relevant Divisional meetings & at 1-1 meetings By April 2009 Ongoing PROGRESS: Nursing & Midwifery Metrics implemented Trust wide Weekly Complaints Performance Reports are circulated by the Director of Nursing Complaints themes/trends are explored at all Divisional & CLIP meetings

20 NB: In conjunction with delivering the measurable outcomes outlined in the above plan, the Trust Matrons are responsible for delivering and embedding the Trust s Nursing & Midwifery Strategy ( ), and the Patient & Involvement & Experience Strategy ( ). 4. Conclusion The actions outlined in the above plan provides an opportunity to evaluate the range of responsibilities that form the key components of the Matron s role, whilst continuing to maintain the standards set out in the Matrons Charter (2004). Gary Etheridge Trust Matrons Director of Nursing & Patient Services West Hertfordshire Hospitals NHS Trust Revised plan produced in December 2008 Plan updated in February & April 2009 G:\Corporate Nursing\Nursing Directorate\MODERN MATRONS\MATRON'S CHARTER\2009\6090 Matrons' Charter Action Plan ~ Revised April 09.doc

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