St. James s Hospital (SJH) Prevention and Control of Healthcare Associated Infections (PCHCAI) Inspection (HIQA) QIP Page 1 of 5

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1 St. James s Hospital (SJH) Prevention and Control of Healthcare Associated Infections (PCHCAI) Inspection (HIQA) QIP Page 1 of 5 Prevention and Control of Healthcare Associated Infections (PCHCAI) QIP Environment & Equipment Hygiene 1.0 Review and improve the Hospital s Ward Assessment process. i.e. Monthly Self Assessment and Weekly Ward Assessment Revise the Ward Assessment Process to assure it includes the following elements: Reliable effective assessment tools Improved engagement with all ward staff at the time of assessment Immediate response to identified noncompliances (where possible) Improved (Reliability and effectiveness) Ward Assessment Process Revised Assessment Tools developed and introduced. Designated Assessment Team in place Assessment SOP in place 8 Week Pilot completed September Q QSID Facilities & Nursing Reliable Assessors (Training) Procedure for prompt reconciliation of related findings e.g. Environment Hygiene and TSD Implementation Phase 1 completed January 2016 Revised Assessment Process implemented January 2016 Procedure for providing immediate riskrated feedback and support to Ward and Department / Directorate Management Team Procedure for providing timely documented risk rated feedback to Ward and Department / Directorate Management Team Process for undertaking return follow up assessments Mechanism for reporting findings to Directorates, EMG and Hospital Board Further development work underway as follows: Training additional assessors Developing and implementing a rating scale that is aligned with patient safety and risk. Review and revise process used by Nursing to self assess / assure continuous compliance Further develop arrangements for follow up visits. Transfer assessment tools and reports to electronic format.

2 St. James s Hospital (SJH) Prevention and Control of Healthcare Associated Infections (PCHCAI) Inspection (HIQA) QIP Page 2 of 5 Environment & Equipment Hygiene (Continued) Recommendations / Goals Actions Outcomes Progress Time Lead 2.0 Revise and improve processes for reporting and effecting identified repair / refurbishments works in a complete and timely manner Develop and implement a Rapid Response Team (RRT ) that will promptly undertake minor repairs identified in clinical area assessments Evaluate effectiveness of Rapid Response Team (RRT ) Rapid Response Team (RRT) in place Rapid Response Team (RRT) in place to undertake all repair and minor refurbishment work identified at time of weekly assessment. Facilities TSD Develop and implement an on line request and scheduling system for all repair / refurbishment new works that is accessible to staff On line Repair/ New Work Request system On line system in place for new work requests Review Tem in place Establish a team to undertake a regular review of new work requests in order to undertake the following: Identify the specifications & cost for the new works requested Escalate for financial approval when above Committee approval Level Identify priority works (risk assessed) Align works with existing projects e.g. decant, Aspergillus Protection, etc. Inform staff (requester) regarding work approval and date for commencement Provide staff with access (on line) to agreed work schedule Access for staff to prioritised work schedule Status of new works included in Facilities EMG & PCHCAI reports On line system for repair / refurbishment works in development Q2 2016

3 St. James s Hospital (SJH) Prevention and Control of Healthcare Associated Infections (PCHCAI) Inspection (HIQA) QIP Page 3 of 5 Environment Waste Management Recommendations / Goals Actions Outcomes Progress Time Lead 3.0 Review and amend current arrangements for the collection, segregation and disposal of clinical waste (i.e. yellow bags) in isolation facilities i.e. yellow bags in clinical waste receptacles only. Update and disseminate Waste policy to reflect amended practice Provide appropriate clinical waste receptacles (clinical waste bins) for use in isolation facilities where an assessment of potential waste generation identifies requirement Update waste assessment tool to audit compliance Revised Waste Management Policy Revised Waste Assessment Tool Improved waste segregation practices Policy revised and registered Waste Assessment Tool revised to include monitoring compliance with updated standard Monitoring commenced August 2015 Good compliance noted. Will remain a component of waste assessment Environment Services Manager

4 St. James s Hospital (SJH) Prevention and Control of Healthcare Associated Infections (PCHCAI) Inspection (HIQA) QIP Page 4 of 5 Communicable/Transmissible Diseases Management 4.0 Develop a programme Revise and update the Hospital s Aspergillosis SJH Aspergillus Policy to improve awareness of Aspergillus safety and controls for SJH staff, patients and site visitors Policy (Include education / promotion activities) Revised Aspergillus Policy registered and distributed to staff Q IPC Staff Awareness Disseminate revised policy to promote awareness. Develop and implement educational programmes to address the following: General information on Aspergillus Identifying patients at risk Awareness of environmental controls and prevention works being undertaken Awareness of individual patient risk assessment and controls Use existing communication methods to promote awareness and provide updates Intranet messaging Newsletter (nursing) Leaflets Updated IPC information / education programmes (on line & electronic) in use Improved compliance with control measures Multidiscipline Staff Information / Education programme developed Delivery aligned with the aspergillus upgrade works programme. Attendance records maintained by IPC Patient / Site Visitor Awareness. Revise patient information leaflet for distribution as follows: To inpatients in the clinical areas To patients scheduled to attend for OPD and / or Admission Upload information regarding building work and aspergillus risks and controls to SJH Intranet New Patient Information leaflet developed Further work required to define appropriate distribution mechanism Intranet information in development.

5 St. James s Hospital (SJH) Prevention and Control of Healthcare Associated Infections (PCHCAI) Inspection (HIQA) QIP Page 5 of 5 Hand Hygiene 5.0 Continue to promote and support best practice in hand hygiene Enhance local awareness and ownership of Hand Hygiene performance by developing and implementing the following processes Regular Ward/ Department review of Hand Hygiene data i.e. compliance with training and practice audits Publication of Ward / Department HH Performance on SJH Intranet HH compliance data i.e. training and practice audit findings published in all wards and SJH Intranet Data Presentation IPC working with IMS to include HH data (training and audits ) in Hospital s Dashboard Nursing Notice Boards (to include HH data) in development Q IPC Display of training and audit compliance data in all Wards / Departments Continued development of the HH Champions Programmes (Established July 2013) to provide the following Active champions in each clinical area Developed champion profile to include local promotion, training and audit. Continue to promote awareness and compliance amongst staff and site visitors using Hospital s communication tools including the following: Signage Hospital corporate publications and communications e.g. letters, reports etc. Hospital s patient communications e.g. appointment letters, booklets Advanced HH Champions Programme Sustained improvement in HH practice Additional Reminders in the Workplace Increased Awareness HH Champions Review of champion programme undertaken Q i.e. review of activity 2014 & focus group to elicit Champions experiences. Findings and recommendations for champions pending SJH Hand Hygiene logo developed and introduced across campus Hologram with HH reminder introduced to Concourse. Hand Hygiene logo included in Patients appointment letters. Continu ous All