The safety of every patient we care for is our number one priority

Size: px
Start display at page:

Download "The safety of every patient we care for is our number one priority"

Transcription

1 HUMBER NHS FOUNDATION TRUST INFECTION PREVENTION AND CONTROL STRATEGY Introduction Healthcare associated infections (HCAI) continue to be a major cause of patient harm and although nationally there have been significant reductions achieved in the number of patients developing serious infections such as MRSA (Meticillin Resistant Staphylococcus aureus) bacteraemia and Clostridium difficile, the rates of other HCAI have risen due to the emergence of resistant organisms in healthcare settings. It is therefore important that the reduction of HCAI remains a high priority on any patient safety agenda. The provision of an Infection Prevention and Control Strategy is an essential requirement for any organisation. Its purpose is to; Clarify the outcomes that they wish to achieve; Determine the broad priorities that will be adopted to achieve those outcomes; Identify the ways that progress will be measured. This strategy aims to set out the direction of all infection prevention and control activity undertaken within or on behalf of Humber NHS Foundation Trust over the next two years. It also is designed to ensure compliance to Care Quality Commission (CQC) Outcome 8 (Regulation 12), Cleanliness and Infection Control standards and to achieving local and national targets. 2. The Trust Vision Caring, Compassionate, Committed As outlined in the Humber NHS Foundation Trust Organisational Plan the trust affirms its commitment to being a leading provider of integrated health services. It also aims to be recognised for the care, compassion and commitment of all staff. In order to support the delivery of this vision and to prevent any avoidable harm to any patient due to infection we aim to focus on 6 main areas of improvement as highlighted below. The proposed objectives are intended to focus on the continuing requirement to reduce HCAI and to firmly embed infection prevention in to everyday practice to keep patient, visitors and staff safe. 3. Strategic Priorities Priority 1: Patient Safety The safety of every patient we care for is our number one priority We are proud to report that we have an excellent track record on preventing HCAI and continue to perform well against both national and locally agreed targets. Achievements over the last year have included; 0 patients reported as developing a trust apportioned MRSA blood stream infection. Prevention and Control Strategy Page 1

2 0 trust apportioned Clostridium difficile infection. An improvement in staff hand hygiene compliance (98% compared to 95% in ). In line with the NHS Operating Framework , we want to ensure that the incidence of serious HCAI continues to remain within or better than agreed thresholds and that cleanliness in our healthcare premises meets the highest standards. We acknowledge that the public rightly expect healthcare environments to be clean and safe. Service users need to be confident that all our premises and equipment used in the delivery of healthcare will exceed minimum standards of cleanliness and be appropriate for purpose. Over the next 2 years we aspire to; Comply fully with all requirements of the Code of Practice on the prevention and control of infections and related guidance. Provide a patient environment that is clean and acceptable to patients, visitors and staff. Achieve all national and locally agreed infection prevention and control targets. Develop a multi-disciplinary approach to antimicrobial stewardship. Priority 2: Quality & Clinical Governance We are committed to developing a robust governance framework which monitors the quality of all our infection prevention and control activity Sustainable reductions in HCAI like MRSA and Clostridium difficile require the proactive involvement of every member of staff working across all healthcare settings. All staff have a role to play in reducing HCAI and making that contribution is crucial. To ensure that all staff are aware of their individual responsibilities it is extremely important to ensure that there are effective structures, processes and systems in place to monitor the quality of all infection prevention and control activity, providing assurance to the public about the quality of care that is being delivered and the improvements that are being made. A trust wide review of operational structures has recently been undertaken and have now entered the final stages of implementation. We are committed to ensuring that teams at all levels within the organisation are able to define their specific roles and responsibilities, outcome measures and infection performance indicators across their workforce. To support this over the next 2 years we will; Ensure there is corporate ownership of the infection prevention and control agenda. Prevention and Control Strategy Page 2

3 Develop a robust infection prevention and control governance reporting structure in line with local and national requirements. Improve clinical and managerial engagement in infection prevention and control improvement work by establishing and managing an operational framework which monitors and assures improvement on HCAI. Priority 3: Patient Experience We are committed to keeping patients and the public informed about all aspects of their care and ensuring they are involved whenever possible in key decisions Engaging with patients, users and carers is essential in the planning, designing and delivery of any care. Benefits include a more responsive service, improved patient outcomes, improved patient experience and shared decision making. We would like to increase the level of patient and public involvement in infection prevention and control matters in order to share ideas and become more patient focused, improving the overall patient experience. Over the next 2 years we will; Improve the quality and availability of patient information available. Create opportunities to hear patients and family members describe their perspective of infection prevention and control practice within the hospital care experience in order that improvements can be made. Promote patient involvement in all national infection related patient safety initiatives such as World Hand Hygiene Day. Priority 4: Clinical Effectiveness We are committed to improving the care we provide by continually striving for excellence As a trust we are committed to developing excellence in the quality of care we deliver to our patients. We want to deliver care that is evidence-based and consistently applied in all areas across the trust. To do this we need to measure how consistent and reliable our care is throughout all areas. We aim to identify any variations in infection prevention and control practice and address any areas or issues where improvement is needed. Over the next 2 years we will; Ensure that staff continue to have access to infection prevention and control policies and guidance that reflects current national policy, statutory requirements and best evidence based guidance. Ensure that a robust infection prevention and control audit programme is in place. Develop a quality improvement programme aimed at minimising the risk of urinary catheter related infections. Prevention and Control Strategy Page 3

4 Priority 5: Partnership working We are committed to working in partnership to improve the care we provide by being open, transparent and inclusive Working collaboratively across organisational boundaries is essential in the reduction of HCAI and achieving infection prevention targets. Benefits include; The ability to improve decision making due to a broader understanding of the bigger picture. The access to increased capacity and expertise providing the opportunity to achieve more for less. An increase of responsiveness through economies of scale and availability of more resources. Work has commenced in the strengthening of partnership working with all providers and Commissioners to drive forward a further reduction of HCAI across the whole health care economy. Over the next 2 years we will; Continue to share learning with regional partners and learn from others by the continued attendance at regular local and regional meetings. Continue to participate in the development of policies and procedures across the whole health economy to guarantee a unified approach to delivering high standards of infection prevention and control. Remain committed to supporting national initiatives and innovations in order to improve the patient journey. Complete a rigorous investigation of all episodes of any HCAI and evidence learning from them. Priority 6: Providing leadership in infection prevention and control We are committed to ensuring that exemplary infection prevention and control principles are firmly embedded within every staff members daily practice Infection control and the prevention of all infection remains a major goal within all healthcare settings and ultimately is the responsibility of everyone who works within the trust. Exemplary care should be delivered by staff who understand and effectively discharge their roles and individual responsibilities for the prevention and treatment of HCAI. To support staff the Infection Prevention and Control Team (IPCT) currently deliver an evidence-based educational programme for all members of trust staff. Prevention and Control Strategy Page 4

5 An organisational review of the Trust Statutory and Mandatory Training Programme has recently been completed and is expected to provide the IPCT with an opportunity to develop a wider range of options for staff to fulfil development and training needs. Over the next 2 years we will; Aim to develop a wider range of options for staff to fulfil development and training needs. Review and refresh the infection prevention and control training programme to ensure it remains responsive to both national requirements and staff needs. Sustain and enhance the infection prevention and control link practitioner programme. 4. Strategy Delivery How will we achieve all the priorities highlighted within this strategy? The strategy will be delivered though; The formulation and delivery of a Trust Infection Prevention and Control Quality Improvement Plan (Appendix 1). Visible and strong trust board leadership; the strategy is approved by the Board and will be supported and overseen by members of the Executive Team. Clear lines of responsibility and effective performance management of all Care Group s. The formulation of infection prevention and control policies which reflect national recommendations, statutory requirements, latest guidance and local need. The inclusion of infection prevention and control issues in all business planning processes as a matter of course. A varied trust infection prevention and control training programme. Local and trust performance management; performance against HCAI targets are reported through the Trust key performance indicators. A programme of infection prevention and control assurance reporting; including progress with audit action plans, environmental issues and observation of clinical practice utilising the Infection Prevention Society s (IPS) Quality Improvement Tool (QIT) framework. Rigorous investigation of all episodes of HCAI and evidence of learning from them. Regular monitoring and reporting of HCAI in accordance with Department of Health and Trust approved reporting requirements. Performance managing areas where problems are identified. Sustaining a motivated engaged workforce. Improved engagement with all patients and the public. 5. Strategy Implementation, Monitoring and Review The Trust Board is responsible for ensuring the trust has appropriate infection prevention and control systems and resources in place to enable delivery of all the Prevention and Control Strategy Page 5

6 infection prevention and control objectives. This strategy and the Trust Infection Prevention and Control Quality Improvement Plan will be approved and reviewed by the Trust Board. Progress made against the strategy will be monitored bi-monthly by the HCAI Group. A quarterly briefing report will be prepared and presented to the Quality and Patient Safety Committee. This will highlight any achievements made as well as escalating any areas of concern. An Annual Infection Prevention and Control report will be produced and presented to the Trust Board. Other reports will be produced by exception. 6. Dissemination of Strategy The strategy will be available on the trust intranet. Awareness of the strategy will be raised through education and training, staff briefing and the IPCT newsletter. Prevention and Control Strategy Page 6

7 Appendix 1 Infection Prevention and Control Quality Improvement Plan April 2015 April 2016 Priority 1. The safety of every patient we care for is our number one priority No. Development area Action Performance 1.1 Ensure compliance with Develop and implement an Work plan produced all requirements of the Annual Infection with measurable Code of Practice on the Prevention and Control outcomes included. prevention and control of Work Plan for infections and related guidance ensuring all statutory duties are effectively discharged. Bi monthly briefing report presented at the Quality and Patient Safety 1.2 Strengthen approach to the delivery of a trust-wide environmental audit programme ensuring all trust properties meet the fundamental standards of cleanliness and safety. Develop and implement a robust multidisciplinary environmental infection prevention and control audit programme. IPC/ Head of Estates and Environ mental Services Committee. A multidisciplinary infection prevention and control environmental audit programme agreed and completed in all trust owned premises Date 31 st July 30 th March Quarter 1 Annual Infection Prevention and Control Work Plan developed. Draft produced and presented to the IPCC First briefing repot presented at the inaugural meeting Quarter 1 Agreement in principle received from Stephen Dale/ Rob Atkinson. Multi- disciplinary audit programme commenced with extremely positive feedback received Prevention and Control Strategy Page 7

8 No. Development area Action Performance 1.2 cont A report and improvement IPCT. Evidence produced plans to be produced for that any gaps in all areas audited. compliance have been escalated to the appropriate Care Group Triumvirate to 1.3 Maintain the delivery of a zero tolerance approach to MRSA apportioned infection. Undertake continuous surveillance of all alert organisms eg MRSA. action. To have Zero trust apportioned cases of MRSA bacteraemia. Date 30 th March from both the matrons and estates personnel involved. Defects are logged and actioned in a more timely manner. Action plans produced for each area audited Quarter 1 No cases reported- Remains within agreed threshold. No cases reported- Remains within agreed threshold. 1.4 Maintain progress against the delivery of contractually agreed trajectories for MSSA (meticillin sensitive staphylococcus aureus), Clostridium difficile, and E.coli bacteraemia. Undertake continuous surveillance of all alert organisms eg MSSA, C. difficile, and E.coli bacteraemia. To remain within the annual contractually agreed trajectory 30th March Quarter 1 No cases reported- Remains within agreed threshold. 1 trust apportioned C. difficile reported. (Cumulative position for the year 1 Remains within annual trajectory (4 ) Prevention and Control Strategy Page 8

9 No. Development area Action Performance 1.5 Promote antimicrobial stewardship. Support the ongoing monitoring of antibiotic prescribing practice in the Trust in-patient units. Chief Pharmac ist Compliance data produced and improvement noted. Date 1st October Compliance data produced and shared with the HCAI group. Antibiotic choice noted to be appropriate in all cases where the indication was highlighted. 1.6 To review the Scottish Antimicrobial stewardship programme package for potential utilisation within the Trust. Nurse/ Medicine Manage ment Nurse. An appraisal completed and outcome shared with HCAI Group members. 1 st November Meeting date arranged for Debbie Davies and Julie Moore to discuss the potential roll out within the organisation 1.7 Maximise the approach to learning from infection acquisition and incidents to improve patient safety and experience. An RCA / PIR investigation to be completed for any trust apportioned infection or incident e.g. C.difficile infection / MRSA and MSSA bacteraemia. Nurse Investigation completed within specified PHE time frames and report produced to highlight learning. Quarter 1 1 st August 2015 No alert organisms currently identified. RCA analysis currently underway for Trust apportioned C. difficile. Prevention and Control Strategy Page 9

10 Priority 2. We are committed to developing a robust governance framework which monitors the quality of all our infection prevention and control activity No. Development area Action Performance Date 2.1 Ensure there is corporate ownership of the trust infection prevention and control agenda. Production of an Annual Infection Prevention and Control report. D Report received and approved by the Trust Board. May Action completed. Presented and approved by the Trust Board Ensure there is a robust infection prevention and control governance reporting structure in place which fulfils local and national requirements. Infection Prevention and Control Strategy Develop an internal infection prevention and control governance framework to ensure board to ward reporting in relation to infection prevention and control. D D Strategy received and approved by the Trust Board. Framework produced and approved by the Trust Board. October Infection Prevention and Control Strategy produced. to the Trust Board agenda for October 2015 HCAI Group Tor reviewed and amended. Presented at the Quality &Patient Safety Committee Robust processes are in place to ensure all infection prevention and control activities are monitored and performance managed. Annual Infection Prevention and Control Quality Improvement Plan to be developed for Annual Infection Prevention and Control Quality Improvement Plan completed. Plan approved by the Quality and Patient Safety Committee. October Annual Infection Prevention and Control Quality Improvement Plan developed and agreed. Prevention and Control Strategy Page 10

11 No. Development area Action Performance 2.4 Robust processes are in The infection prevention D Infection Prevention place to ensure all and control service and Control Team infection prevention and requirements to be service requirements control activities are reviewed. determined. monitored and performance managed. 2.5 Develop and adopt an Infection Prevention and Control Dashboard to ensure early warning indicators are robust. Infection Prevention and Control Dashboard developed and approved at the Quality and Patient Safety Committee. Date 1 st January 30 th October Current arrangements reviewed. IPC to extend contact until March A full review will commence in December Draft dashboard presented at the HCAI Group 22/10/15. Circulated for wider consultation prior to adoption Priority 3. We are committed to keeping patients and the public informed about all aspects of their care and ensuring they are involved whenever possible in key decisions 3.1 Strengthen patient and family engagement in all aspects of infection prevention and control practice. Key themes identified for learning and action plan produced. 1 st January Dates requested and received for the IPCT to attend the Quality Circle meetings. Create opportunities to hear patients and family members describe their experience of infection prevention and control practice within the healthcare setting. Patient Carer Experience Group ToR membership amended to include Infection Prevention and Control representation. Prevention and Control Strategy Page 11

12 No. Development area Action Performance 3.2 Strengthen patient and The IPCT to attend the unit IPCT Evidence of family engagement in all Quality Circle meetings attendance and a plan aspects of infection of action produced to prevention and control address any issues practice. raised. 3.3 Ensure all patients, service users and carers are provided with suitable information on all infection concerns. The Nurse to become an active member of the Patient carer Experience Group Review all patient and public information leaflets currently utilised within the Trust. Review all comments received by staff following completion of the East Riding Consortium infection control audits. Produce or sign post the patients and public to good quality patient information This to include materials from national or local antimicrobial awareness campaigns. IPC IPC Evidence of attendance at the Patient Carer Experience Group Good quality patient information is readily available to both staff and patients on the Trust website. Date Quarter 1 1st January 1st January 15 th November st January 1st January Inaugural meeting arranged for 9th November 2015 A review of all patient information available on the intranet has commenced. An analysis of all staff comments made and areas for improvement have been identified. Prevention and Control Strategy Page 12

13 Priority 4. We are committed to improving the care we provide by continually striving for excellence No. Development area Action Performance 4.1 Provide evidence about Refresh the infection An improvement plan the quality of care in a prevention and control produced in each service to establish audit programme to area. Progress confidence amongst staff, measure compliance with Modern monitored by the Care patients. trust infection prevention Matron. Group. Exception and control policies. reports required against any gaps in compliance. Date Quarter st Audit programme September refreshed and in place. 4.2 Provide evidence about the quality of care in a service to establish confidence amongst staff, patients. 4.3 Ensure all policies in place are reviewed to ensure they reflect national policy, statutory requirements, latest guidance and local need. An infection prevention and control dashboard to be developed for all in patient and community areas Review all the Infection Prevention and Control policies in place. Modern Matron. An improvement plan produced in each area. Progress monitored by the Care Group. Exception reports required against any gaps in compliance. All policies reviewed and re approved. 1 st October st October Draft Infection prevention and control dashboard developed. To be presented at the Health Care Group Infection meeting Hand Hygiene Policy/ Cleaning and Disinfection of Medical Devices and MRSA policy all reviewed and out for consultation. Prevention and Control Strategy Page 13

14 No. Development area Action Performance 4.4 Develop a quality Baseline Trust wide improvement programme urinary catheter to minimise the infection associated infection risks associated with rate identified. urinary catheter infections. 4.5 Sustain improvements made in hand hygiene compliance. Produce an improvement work plan which includes a timetable for the completion of; i) A Trust wide baseline prevalence audit of urinary catheter usage and management to determine associated infection rate. iii) An assessment of staff urinary catheter management knowledge. Review and refresh the Trust Hand Hygiene statement pertaining to bare below the elbow. D Briefing report produced and findings reviewed by Care Groups. Action plan produced to determine future training needs Statement completed and circulate to all Trust staff Date Quarter th September 1 st November 1st November 1 st September Urinary catheter prevalence completed. Data currently being analysed. Staff questionnaires underway. Quarter 1 Hand Hygiene Statement amended and cascaded in the Global Newsletter August The Hand Hygiene Policy has been amended to reflect the changes. Endorsement has been received from the HCAI Group Prevention and Control Strategy Page 14

15 No. Development area Action Performance 4.5 cont Sustain improvements made in hand hygiene compliance. The Trust will participate and promote the World Health Organisation (WHO) Hand Hygiene Day. Evidence of participation and update of activities cascaded. Date Quarter Committee meeting agenda for 13th November th May Priority 5. We are committed to working in partnership to improve the care we provide by being open, transparent and inclusive 5.1 Participate in the development of unified policies and procedures across the whole health economy to guarantee a single approach to delivering high standards of infection prevention and control. Work in partnership with the Yorkshire branch of the Infection Prevention Society to develop a selection of regionally approved policies. Participation and development of policies and the cascade of work completed. 1 st April Quarter 1 Meeting arranged for Meeting held as arranged. Planned work programme has been agreed. 5.2 Support national patient safety initiatives and innovations in order to minimise the risk of infection and raise awareness. The Trust will participate and promote International Infection Prevention Week. Evidence of participation and outcomes achieved. 25 th October All link practitioners informed of the IP week. A global cascaded to all areas with a variety of resources to support the planned activities. Hand hygiene Prevention and Control Strategy Page 15

16 No. Development area Action Performance 5.3 Improve communication channels with regional health care providers and Commisioners. To be an active participant and member of the Humber HCAI Group. DIPC Evidence of attendance at the meeting. The production of joint work projects. Date Quarter 1+2 competency assessment dates to be arranged for all Directors The last 2 regional group meetings have unfortunately been cancelled by the CCG Awaiting confirmation of a further date. Meetings have taken place with colleagues across the patch to discuss HCAI issues and the development of future project work development. A Yorkshire and Humber Network event is planned for Novemeber to share learning, discuss initiatives, showcase best practice and offer peer review and support opportunities. This will take place in November The Nurse Prevention and Control Strategy Page 16

17 No. Development area Action Performance Date Quarter continues to attend the regional infection prevention society network meetings quarterly to share practice with IPCT colleagues across the Yorkshire region. Priority 6. We are committed to ensuring that exemplary infection prevention and control principles are firmly embedded within every staff members daily practice 6.1 Deliver exemplary care by professionals who are aware of their responsibility and accountability for the prevention and treatment of HCAI. 6.2 Sustain a motivated engaged workforce. 6.3 Maintain and strengthen the Link Practitioner programme. Review and refresh the infection prevention and control training programme in line with the Trust Board approved Training Programme Develop a newsletter detailing HCAI news and initiatives. Sustain a motivated engaged Link Practitioner workforce. Nurse. IPC Training programme reviewed and refreshed. Training figures to be monitored. Positive staff evaluation. Launch first edition of newsletter and continue to produce quarterly. Measure meeting attendance rate. Produce meeting evaluations and evidence of changes 1 st October 1 st September Training programme reviewed and refreshed. Mandatory requirements amended. Additional bespoke sessions have commenced at various bases and locations 1 st staff newsletter produced and circulated August March Quarter 1 Link practitioner training sessions completed. Link practitioner Prevention and Control Strategy Page 17

18 No. Development area Action Performance 6.3 cont. made at unit / department level. Date Quarter training sessions completed Evaluations reviewed positive feedback received. Attendance rate data to be included in the proposed infection prevention and control dashboard. All link practitioners currently commencing a 1.1 supervision programme to develop /enhance performance Prevention and Control Strategy Page 18

Prevention and control of healthcare-associated infections

Prevention and control of healthcare-associated infections Prevention and control of healthcare-associated infections Quality improvement guide Issued: November 2011 NICE public health guidance 36 guidance.nice.org.uk/ph36 NHS Evidence has accredited the process

More information

TRUST BOARD. Date of Meeting: 05/10/2010

TRUST BOARD. Date of Meeting: 05/10/2010 TRUST BOARD Date of Meeting: 05//20 Enclosure: 7 Agenda Item No: 8.3 Title of Report: Interim Report for Infection Prevention and Control 20-2011 Aims: To inform the Board of the work of the Trust in controlling

More information

Infection Prevention. & Control. Report

Infection Prevention. & Control. Report Infection Prevention & Control Report April 2012 March 2013 Author Joanne Raper, Infection Prevention & Control Nurse Manager Page 1 of 10 1.0 Purpose of the Paper The purpose of this report is to provide

More information

Public health guideline Published: 11 November 2011 nice.org.uk/guidance/ph36

Public health guideline Published: 11 November 2011 nice.org.uk/guidance/ph36 Healthcare-associated infections: prevention ention and control Public health guideline Published: 11 November 2011 nice.org.uk/guidance/ph36 NICE 2017. All rights reserved. Subject to Notice of rights

More information

abc INFECTION CONTROL STRATEGY

abc INFECTION CONTROL STRATEGY abc INFECTION CONTROL STRATEGY 1. INTRODUCTION East and North Hertfordshire NHS Trust (ENHT) considers the reduction of Healthcare Associated infections (HCAI) a key component of patient safety systems

More information

Infection Prevention and Control Strategy (NHSCT/11/379)

Infection Prevention and Control Strategy (NHSCT/11/379) Infection Prevention and Control Strategy (NHSCT/11/379) September 2010 September 2010 Contents Page No. 1. Foreword 1 2. Introduction 2-3 3. Key Principles 4-5 4. Objectives 6-13 5. Organisational Arrangements

More information

PATIENT AND SERVICE USER EXPERIENCE STRATEGY

PATIENT AND SERVICE USER EXPERIENCE STRATEGY PATIENT AND SERVICE USER EXPERIENCE STRATEGY APRIL 2017 TO MARCH 2020 Date 24 March 2017 Version Final Version Previously considered by The Patient Experience Group version 0.1 draft The Executive Management

More information

INFECTION CONTROL SURVEILLANCE POLICY

INFECTION CONTROL SURVEILLANCE POLICY INFECTION CONTROL SURVEILLANCE POLICY Version: 3 Ratified by: Date ratified: July 2016 Title of originator/author: Title of responsible committee/group: Senior Managers Operational Group Head of Infection

More information

Arrangements. Version 10

Arrangements. Version 10 UNIQUE IDENTIFIER NO: C-64-2014 Nurse Section A - Arrangements Version 10 Important: This document can only be considered valid when viewed on the Trust s Intranet. If this document has been printed or

More information

Annual Report Infection Prevention and Control. RDaSH. Helen Dabbs Deputy Chief Executive/Director of Nursing & Partnerships

Annual Report Infection Prevention and Control. RDaSH. Helen Dabbs Deputy Chief Executive/Director of Nursing & Partnerships RDaSH Infection Prevention and Control Annual Report Helen Dabbs Deputy Chief Executive/Director of Nursing & Partnerships Dr Deborah Wildgoose Deputy Director of Nursing and Standards Rachel Millard Head

More information

Director of Infection Prevention and Control Annual Report 01 April March 2013

Director of Infection Prevention and Control Annual Report 01 April March 2013 Director of Infection Prevention and Control Annual Report 01 April 2012 31 March 2013 Agenda Item: Reference: Meeting Name: Board Meeting Meeting Date: 3 rd June 2013 Lead Director: Lisa Cooper Job Title:

More information

HEALTHCARE ASSOCIATED INFECTION PREVENTION AND CONTROL REPORT JUNE 2016

HEALTHCARE ASSOCIATED INFECTION PREVENTION AND CONTROL REPORT JUNE 2016 Appendix--75 Borders NHS Board HEALTHCARE ASSOCIATED INFECTION PREVENTION AND CONTROL REPORT JUNE Aim The purpose of this paper is to update Board members of the current status of Healthcare Associated

More information

NHS Highland Infection Prevention & Control Annual Work Plan End of Year

NHS Highland Infection Prevention & Control Annual Work Plan End of Year NHS Highland Board 5 April Item 5.7 NHS Highland & Control Annual Work Plan End of Year Update for COIC Prepared by Catherine Stokoe and Jonty Mills (as of 01/03/) Objective Activity Time Scale Lead Officer

More information

Staffordshire and Stoke on Trent Partnership Trust Infection Prevention and Control team. Director of Infection Prevention and Control Annual Report

Staffordshire and Stoke on Trent Partnership Trust Infection Prevention and Control team. Director of Infection Prevention and Control Annual Report Staffordshire and Stoke on Trent Partnership Trust Infection Prevention and Control team Director of Infection Prevention and Control Annual Report April 215 to March 216 1 Executive Summary The Health

More information

Infection Prevention and Control Strategy

Infection Prevention and Control Strategy Infection Prevention and Control Strategy 2015 2018 Foreword This three year plan has been produced to support the work which has been taken forward in previous years across the organisation to reduce

More information

Infection Prevention and Control Annual Report

Infection Prevention and Control Annual Report Infection Prevention and Control Annual Report 2016/2017 Dr Deborah Wildgoose Director of Nursing and Quality Lisa Connor Associate Nurse Director Doncaster Care Group Infection Prevention and Control

More information

REPORT SUMMARY SHEET

REPORT SUMMARY SHEET Quality care for you, with you REPORT SUMMARY SHEET Meeting: Date: Title: Lead Director: Corporate Objective: Purpose: High level context: Trust Board 27 th October 2016 Infection Prevention and Control

More information

REPORT SUMMARY SHEET

REPORT SUMMARY SHEET Quality care for you, with you REPORT SUMMARY SHEET Meeting: Date: Title: Lead Director: Corporate Objective: Purpose: High level context: Trust Board 29 th September 2016 Infection Prevention and Control

More information

Foundation Trust Board of Directors 25 May Infection Prevention and Control and Pressure Ulcer Prevention Activity 2016/17

Foundation Trust Board of Directors 25 May Infection Prevention and Control and Pressure Ulcer Prevention Activity 2016/17 Foundation Trust Board of Directors 25 May 2017 Infection Prevention and Control and Pressure Ulcer Prevention Activity 2016/17 M Situation This report provides an overview of the NHFT Infection Prevention

More information

Establishing an infection control accreditation programme to control infection

Establishing an infection control accreditation programme to control infection International Journal of Infection Control www.ijic.info ISSN 1996-9783 Establishing an infection control accreditation programme to control infection Julie Parker Sheffield Teaching Hospitals NHS Foundation

More information

For further information please contact: Health Information and Quality Authority

For further information please contact: Health Information and Quality Authority For further information please contact: Infection Prevention and Control 13-15 The Mall Beacon Court Bracken Road Sandyford Dublin 18 Phone: +353 (0)1 293 1140 Email: ipc@hiqa.ie URL www.hiqa.ie Guide

More information

The Newcastle upon Tyne Hospitals NHS Foundation Trust. Clinical Assurance Toolkit (CAT) Strategy

The Newcastle upon Tyne Hospitals NHS Foundation Trust. Clinical Assurance Toolkit (CAT) Strategy The Newcastle upon Tyne Hospitals NHS Foundation Trust Clinical Assurance Toolkit (CAT) Strategy Effective: January 2014 Review: January 2015 1. Introduction The Trust s Nursing and Midwifery Strategy,

More information

FOREWORD Introduction from the Chief Executive 2 BACKGROUND 3 OUR TRUST VALUES 4 OUR AIMS FOR QUALITY 5 HOW WE MEASURE QUALITY 16

FOREWORD Introduction from the Chief Executive 2 BACKGROUND 3 OUR TRUST VALUES 4 OUR AIMS FOR QUALITY 5 HOW WE MEASURE QUALITY 16 Contents FOREWORD Introduction from the Chief Executive 2 BACKGROUND 3 OUR TRUST VALUES 4 OUR AIMS FOR QUALITY 5 - Our achievements so far - Our aims for quality 2017 2020 AIM 1: AIM 2: AIM 3: AIM 4: Reducing

More information

OPERATIONAL POLICY INFECTION PREVENTION AND CONTROL POLICY NO.1

OPERATIONAL POLICY INFECTION PREVENTION AND CONTROL POLICY NO.1 OPERATIONAL POLICY INFECTION PREVENTION AND CONTROL POLICY NO.1 Applies to: All employees of Wirral Community NHS Trust Group for Approval Infection Prevention and Control Group Date of Approval 25 January

More information

Infection Prevention and Control Annual Report Produced by: The Director of Infection Prevention and Control

Infection Prevention and Control Annual Report Produced by: The Director of Infection Prevention and Control Infection Prevention and Control Annual Report 2009 Produced by: The Director of Infection Prevention and Control Reviewing the period: January 2009 - December 2009 Approved by Infection Control Committee:

More information

Infection Prevention and Control Annual Report 1 st April st March 2013

Infection Prevention and Control Annual Report 1 st April st March 2013 Infection Prevention and Control Annual Report 1 st April 2012-31 st March 2013 Patient friendly version Edited by: Fighting Infection Together (FIT) group Table of Contents Section: Page: 1 Introduction

More information

Job Description and Person Specification

Job Description and Person Specification Job Description and Person Specification Chief Nursing Officer / Director of Infection Prevention and Control RESPONSIBLE TO: ACCOUNTABLE TO: LIAISES WITH: Chief Executive Chief Executive Executive and

More information

Infection Prevention and Control. Quarterly Report

Infection Prevention and Control. Quarterly Report Infection Prevention and Control Quarterly Report 1 st July 2009 30 th September 2009 Dr Nick Harper Director of Infection Prevention and Control Mrs Johanne Lickiss Nurse Consultant Infection Prevention

More information

Infection prevention and control

Infection prevention and control Infection prevention and control Annual Report 2016/17 National Infection Prevention and Control Strategic Management Team Dee Sissons Executive Director of Nursing, Marie Curie Director, Infection Prevention

More information

Trust Policy for the Prevention and Control of Infection

Trust Policy for the Prevention and Control of Infection Trust Policy for the Prevention and Control of Infection Approved by Version Issue Date Review Date Contact Person IPCC October 2015 3 October 2015 October 2018 Paul Bolton Page 1 of 25 1. Title of document/service

More information

Reducing HCAI- What the Commissioner needs to know.

Reducing HCAI- What the Commissioner needs to know. Reducing HCAI- What the Commissioner needs to know. Sarah Mantle HCAI/AMR project lead NHS England #NHSEngAMR Do Tweet Introduction Healthcare Associated Infections (HCAI) can develop as a result of direct

More information

Quality Improvement Strategy

Quality Improvement Strategy Quality Improvement Strategy The Board s Strategic Implementation Plan 2014 2017 Approved at Betsi Cadwaladr University Health Board on Following approval at the Board, there are some minor amendments

More information

Date ratified November Review Date November This Policy supersedes the following document which must now be destroyed:

Date ratified November Review Date November This Policy supersedes the following document which must now be destroyed: Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified by Cleaning Policy NTW(O)71 James Duncan Deputy Chief Executive / Executive Director of Finance Steve Blackburn Deputy

More information

Public Services Reform (Scotland) Bill. Scottish Independent Hospitals Association

Public Services Reform (Scotland) Bill. Scottish Independent Hospitals Association Public Services Reform (Scotland) Bill Scottish Independent Hospitals Association The following submission is presented to the Health and Sport Committee of the Scottish Government as an outline of the

More information

HEI self-assessment. Completing the self-assessment - Guidance to NHS boards

HEI self-assessment. Completing the self-assessment - Guidance to NHS boards HEI self-assessment Completing the self-assessment - Guidance to NHS boards INTRODUCTION This document should be read in conjunction Healthcare Improvement Scotland healthcare associated infection (HAI)

More information

Status: Information Discussion Assurance Approval. Claire Gorzanski, Head of Clinical Effectiveness

Status: Information Discussion Assurance Approval. Claire Gorzanski, Head of Clinical Effectiveness Report to: Trust Board Agenda item: Date of Meeting: 2 October 2017 SFT3934 Report Title: Annual quality governance report 2016-2017 Status: Information Discussion Assurance Approval X Prepared by: Executive

More information

West Hertfordshire Hospitals NHS Trust Reducing Clostridium difficile infection Action Plan [Updated 19/3/13] Item 37/13

West Hertfordshire Hospitals NHS Trust Reducing Clostridium difficile infection Action Plan [Updated 19/3/13] Item 37/13 Introduction purpose: West Hertfordshire Hospitals NHS Trust Reducing Clostridium difficile infection Action Plan 2012-2013 [Updated 19/3/13] Item 37/13 This action plan has been developed by West Hertfordshire

More information

Appendix 1: C.diff elements with the Trust s HCAI recovery Plan and Risk to Delivery

Appendix 1: C.diff elements with the Trust s HCAI recovery Plan and Risk to Delivery Appendix 1: C.diff elements with the Trust s HCAI recovery Plan and Risk to Delivery Issue Action Risk to Year-end trajectory for C difficile infections is 29 cases. Week commencing 09.12.13 - Performance

More information

The challenge for today - best practice, better outcomes and safer healthcare

The challenge for today - best practice, better outcomes and safer healthcare The challenge for today - best practice, better outcomes and safer healthcare A practical guide to improving practice & monitoring compliance against the National Quality Standard for Healthcare associated

More information

CDI case checklist and standard assessment tool. Liz Stokle, AMRS and HCAI Programme Lead, Nurse Epidemiologist, PHE

CDI case checklist and standard assessment tool. Liz Stokle, AMRS and HCAI Programme Lead, Nurse Epidemiologist, PHE CDI case checklist and standard assessment tool Liz Stokle, AMRS and HCAI Programme Lead, Nurse Epidemiologist, PHE Background to work December 2013, Working Group set up to address concerns about: whether

More information

Quality Strategy and Improvement Plan

Quality Strategy and Improvement Plan Quality Strategy and Improvement Plan 2015-2018 STRATEGY DOCUMENT DETAILS Status: FINAL Originating Date: October 2015 Date Ratified: Next Review Date: April 2018 Accountable Director: Strategy Authors:

More information

Debbie Edwards Interim Deputy Director of Nursing Gail Naylor- Executive Director of Nursing & Midwifery. Safety & Quality Committee

Debbie Edwards Interim Deputy Director of Nursing Gail Naylor- Executive Director of Nursing & Midwifery. Safety & Quality Committee Report to Trust Board of Directors Date of Meeting: 29 July 2014 Enclosure Number: 7 Title of Report: Author: Executive Lead: Responsible Sub- Committee (if appropriate): Executive Summary: Ward Accreditation

More information

Healthcare Associated Infection Policy for Staff Working in NHS Grampian

Healthcare Associated Infection Policy for Staff Working in NHS Grampian Healthcare Associated Infection Policy for Staff Working in NHS Grampian Lead Author/Coordinator: Pamela Harrison, Infection Prevention and Control Manager Reviewer: Amanda Croft, HAI Executive Lead Approver:

More information

WRIGHTINGTON, WIGAN AND LEIGH HEALTH SERVICES NHS TRUST DIRECTOR OF INFECTION PREVENTION AND CONTROL ANNUAL REPORT

WRIGHTINGTON, WIGAN AND LEIGH HEALTH SERVICES NHS TRUST DIRECTOR OF INFECTION PREVENTION AND CONTROL ANNUAL REPORT WRIGHTINGTON, WIGAN AND LEIGH HEALTH SERVICES NHS TRUST DIRECTOR OF INFECTION PREVENTION AND CONTROL ANNUAL REPORT 2006-2007 Author(s) Gill Harris, Director of Infection Prevention and Control EXECUTIVE

More information

Item E1 - Bart s Health Quality Indicators

Item E1 - Bart s Health Quality Indicators Item E1 - Bart s Health Quality Indicators 1.0 Purpose 1.1 The purpose of this report is to provide the CCG Board with an update on quality matters across pertaining to our main local Provider organisations.

More information

Inspecting Informing Improving. Hygiene code inspection report: West Hertfordshire Hospitals NHS Trust

Inspecting Informing Improving. Hygiene code inspection report: West Hertfordshire Hospitals NHS Trust Inspecting Informing Improving Hygiene code inspection report: West Hertfordshire Hospitals NHS Trust December 2008 Outcome of inspection for: Hospital(s) visited: West Hertfordshire Hospitals NHS Trust

More information

Revised East Kent Hospitals University NHS Foundation Trust C. difficile Recovery / Action Plan April 2014

Revised East Kent Hospitals University NHS Foundation Trust C. difficile Recovery / Action Plan April 2014 Background Revised East Kent Hospitals University NHS Foundation Trust C. difficile Recovery / Action Plan April 2014 The C.difficile objective for EKHUFT in 2013 2014 was 29 cases and in April 2013, the

More information

Quality Assurance Framework

Quality Assurance Framework Quality Assurance Framework NHS Bromley Clinical Commissioning Group Quality Assurance Framework was developed to support the commissioning, contract monitoring and procurement processes. NAME OF ORGANISATION/SERVICE

More information

Quality Accounts April 2015 to March 2016

Quality Accounts April 2015 to March 2016 Quality Accounts April 2015 to March 2016 Group Chief Executive s Statement I am pleased to welcome you to our Quality Accounts 2016. Our 2016 Quality Accounts provide a transparent picture of BMI Healthcare

More information

QUALITY STRATEGY

QUALITY STRATEGY NHS Nene and NHS Corby Clinical Commissioning Groups QUALITY STRATEGY 2017-2021 Approved: By the Joint Quality Committee on 11 April 2017 Ratified: By the NHS Corby Clinical Commissioning Group on 25 April

More information

Report by Liz McClurg, Infection Control Manager on behalf of Heidi May, Board Nurse Director & Executive Lead, Infection Prevention & Control

Report by Liz McClurg, Infection Control Manager on behalf of Heidi May, Board Nurse Director & Executive Lead, Infection Prevention & Control INFECTION PREVENTION & CONTROL ANNUAL WORK PLAN (2013 2014) Highland NHS Board 4 June 2013 Item 5.5(c) Report by Liz McClurg, Infection Control Manager on behalf of Heidi May, Board Nurse Director & Executive

More information

Quality Accounts: Corroborative Statements from Commissioning Groups. Nottingham NHS Treatment Centre - Corroborative Statement

Quality Accounts: Corroborative Statements from Commissioning Groups. Nottingham NHS Treatment Centre - Corroborative Statement Quality Accounts: Corroborative Statements from Commissioning Groups Quality Accounts are annual reports to the public from providers of NHS healthcare about the quality of services they deliver. The primary

More information

THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST HEALTHCARE ASSOCIATED INFECTIONS (HCAI)

THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST HEALTHCARE ASSOCIATED INFECTIONS (HCAI) THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST HEALTHCARE ASSOCIATED INFECTIONS (HCAI) Agenda item A4(i) EXECUTIVE SUMMARY The paper highlights the increasingly challenging HCAI targets for the

More information

Infection Prevention and Control Policy

Infection Prevention and Control Policy Infection Prevention and Control Policy March 2012 Ref: PCD053 (v5) Status: Infection Prevention and Control Policy Policy Reference Number IC017 Status Version 5 Implementation Date September 2007 Current/Last

More information

Staffordshire and Stoke on Trent Partnership NHS Trust. Operational Plan

Staffordshire and Stoke on Trent Partnership NHS Trust. Operational Plan Staffordshire and Stoke on Trent Partnership NHS Trust Operational Plan 2016-17 Contents Introducing Staffordshire and Stoke on Trent Partnership NHS Trust... 3 The vision of the health and care system...

More information

Document Details Clinical Audit Policy

Document Details Clinical Audit Policy Title Document Details Clinical Audit Policy Trust Ref No 1538-31104 Main points this document covers This policy details the responsibilities and processes associated with the Clinical Audit process within

More information

Reducing the risk of healthcare associated infection

Reducing the risk of healthcare associated infection i Reducing the risk of healthcare associated infection Healthcare associated infection Introduction The Royal Marsden takes the safety of our patients very seriously. That means doing everything we can

More information

Briefing 73. Preparing for change: implementing the new pre-registration nursing standards

Briefing 73. Preparing for change: implementing the new pre-registration nursing standards September 2010 Briefing 73 The new standards for education from the Nursing and Midwifery Council provide the framework for pre-registration nurse education programmes and will determine how we train our

More information

Infection Prevention and Control: Audit Policy

Infection Prevention and Control: Audit Policy Infection Prevention and Control: Audit Policy Document Status Version: 2.0 Approved DOCUMENT CHANGE HISTORY Initiated by Date Author Code of Practice September 2010 Dee May (Infection Control Specialist)

More information

Date of publication:june Date of inspection visit:18 March 2014

Date of publication:june Date of inspection visit:18 March 2014 Jubilee House Quality Report Medina Road, Portsmouth PO63NH Tel: 02392324034 Date of publication:june 2014 www.solent.nhs.uk Date of inspection visit:18 March 2014 This report describes our judgement of

More information

Quality and Safety Committee. Prevention and Control of Healthcare Acquired Infections performance to February 2012

Quality and Safety Committee. Prevention and Control of Healthcare Acquired Infections performance to February 2012 Betsi Cadwaladr University Health Board Committee Paper 05.04.12 Item QS12/37.5 Name of Committee: Subject: Summary or Issues of Significance National / Local Objectives Addressed: Legislation or Healthcare

More information

Infection Prevention & Control Annual Report 2011/2012

Infection Prevention & Control Annual Report 2011/2012 Infection Prevention & Control Annual Report 2011/2012 Board of Directors Approval date: 1 November 2012 Infection Prevention & Control Committee Submission date: 1 August 2012 Position at 31 March 2012

More information

Laying the Foundations the first DIPC annual report for Dudley and Walsall Mental Health NHS Partnership Trust. Alison Geeson Head of Nursing

Laying the Foundations the first DIPC annual report for Dudley and Walsall Mental Health NHS Partnership Trust. Alison Geeson Head of Nursing Director of Infection Prevention and Control (DIPC) Annual Report April 2009 to March 2010 Laying the Foundations the first DIPC annual report for Dudley and Walsall Mental Health NHS Partnership Trust

More information

The prevention, management and control of Healthcare Associated Infections (HCAI) in hospitals (ROCR-LITE/08/014/FT6)

The prevention, management and control of Healthcare Associated Infections (HCAI) in hospitals (ROCR-LITE/08/014/FT6) NATIONAL AUDIT OFFICE STUDY The prevention, management and control of Healthcare Associated Infections (HCAI) in hospitals (ROCR-LITE/08/014/FT6) National Audit Office study The prevention, management

More information

Direct Commissioning Assurance Framework. England

Direct Commissioning Assurance Framework. England Direct Commissioning Assurance Framework England NHS England INFORMATION READER BOX Directorate Medical Operations Patients and Information Nursing Policy Commissioning Development Finance Human Resources

More information

Infection Prevention and Control Annual Report 2012/13

Infection Prevention and Control Annual Report 2012/13 Infection Prevention and Control Annual Report 2012/13 Infection Prevention and Control Annual Report 2012/13 1 Contents 1. Executive Overview 2. Key Achievements 3. Infection Prevention and Control Team

More information

Job Title 22 February 2013

Job Title 22 February 2013 Surveillance of Infection Policy HH(1)/IC/613/13 Previous document(s) being replaced Location Policy Policy Name RHCH CP021 Surveillance Policy BNHH IC/289/09 Surveillance of Infection Protocol Document

More information

Quality Framework Healthier, Happier, Longer

Quality Framework Healthier, Happier, Longer Quality Framework 2015-2016 Healthier, Happier, Longer Telford & Wrekin Clinical Commissioning Group (CCG) makes quality everyone s business. Our working processes are designed to ensure we all have the

More information

Patient Experience Trust Action Plan

Patient Experience Trust Action Plan Patient Experience Trust Action Plan Key Deliverable Actions Required Lead(s) Time Scale / Review Date 1. Patient feedback: To use the various types of patient feedback available to direct the focus of

More information

Inspection Report. Royal Infirmary of Edinburgh. NHS Lothian 18 and 19 January February 2010

Inspection Report. Royal Infirmary of Edinburgh. NHS Lothian 18 and 19 January February 2010 Inspection Report Royal Infirmary of Edinburgh NHS Lothian 18 and 19 January 2010 2 February 2010 qüé=eé~äíüå~êé=båîáêçåãéåí=fåëééåíçê~íé=áë=~=é~êí=çñ=kep=nì~äáíó=fãéêçîéãéåí=påçíä~åç= The Healthcare Environment

More information

BOARD CLINICAL GOVERNANCE & QUALITY UPDATE MARCH 2013

BOARD CLINICAL GOVERNANCE & QUALITY UPDATE MARCH 2013 Borders NHS Board BOARD CLINICAL GOVERNANCE & QUALITY UPDATE MARCH 2013 Aim The aim of this report is to provide the Board with an overview of progress in the areas of: Patient Safety Person Centred Health

More information

Solent. NHS Trust. Patient Experience Strategy Ensuring patients are at the forefront of all we do

Solent. NHS Trust. Patient Experience Strategy Ensuring patients are at the forefront of all we do Solent NHS Trust Patient Experience Strategy 2015-2018 Ensuring patients are at the forefront of all we do Executive Summary Your experience of our services matters to us. This strategy provides national

More information

The Dementia Challenge:- Every Nurse s business providing care and support to everybody affected by dementia and their carers.

The Dementia Challenge:- Every Nurse s business providing care and support to everybody affected by dementia and their carers. The Dementia Challenge:- Every Nurse s business providing care and support to everybody affected by dementia and their carers. Dementia Self-Assessment Framework for all in patient settings Dementia Self-Assessment

More information

National Waiting Times Centre Board. Clinical Governance Committee

National Waiting Times Centre Board. Clinical Governance Committee Board Strategy National Waiting Times Centre Board Name Q-Pulse No Summary Associated documents Target audience Board-Strategy-3 Outlines the Board s approach to delivery of safe and effective care through

More information

JOB DESCRIPTION. Deputy Director of Nursing - Tissue Viability. Director of Nursing. Tissue Viability Support Tissue Viability Nurse

JOB DESCRIPTION. Deputy Director of Nursing - Tissue Viability. Director of Nursing. Tissue Viability Support Tissue Viability Nurse JOB DESCRIPTION Job Title: Reporting to (title): Tissue Viability Nurse Specialist Deputy Director of Nursing - Tissue Viability Professionally Accountable to (title): Responsible for Supervising (if appropriate):

More information

Annual Report Infection Prevention and Control. RDaSH. Helen Dabbs Deputy Chief Executive/Director of Nursing & Partnerships

Annual Report Infection Prevention and Control. RDaSH. Helen Dabbs Deputy Chief Executive/Director of Nursing & Partnerships RDaSH Infection Prevention and Control Annual Report L-R: Karen Foltyn - Senior Clinical Nurse Specialist IPC, Rachel Millard - Head of Clinical Effectiveness, Emma Stables - Senior Clinical Nurse Specialist

More information

Version: 3.0. Effective from: 29/08/2012

Version: 3.0. Effective from: 29/08/2012 Policy No: RM51 Version: 3.0 Name of policy: Learning from Experience Policy A systematic approach to incident, complaint and clai management, analysis and sharing safety lessons Effective from: 29/08/2012

More information

Safe Care and Support

Safe Care and Support SPECIALIST PALLIATIVE CARE May 2014 Safe Care and Support Supporting services to deliver quality healthcare 1 Introduction Welcome to the Quality Assessment and Improvement Workbook. This workbook will

More information

Infection prevention and control within health and social care: commissioning, performance management and regulation arrangements (England)

Infection prevention and control within health and social care: commissioning, performance management and regulation arrangements (England) Infection prevention and control within health and social care: commissioning, performance management and regulation arrangements (England) Purpose and aim of the briefing Introduction During transition

More information

Board Meeting 01/12/16 Open Session Item 10. Performance and Quality Report to the Board December 2016

Board Meeting 01/12/16 Open Session Item 10. Performance and Quality Report to the Board December 2016 Board Meeting 01/12/16 Open Session Item 10 Performance and Quality Report to the Board ember Introduction This report summarises key areas of performance which includes, but is not limited to, Local Delivery

More information

SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY: BOARD OF DIRECTORS 22 FEBRUARY 2012

SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY: BOARD OF DIRECTORS 22 FEBRUARY 2012 SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY: BOARD OF DIRECTORS C 22 FEBRUARY 2012 Subject: Supporting : Author: Status (see footnote): Update on the Clostridium difficile (C.diff)

More information

COMMISSIONING FOR QUALITY FRAMEWORK

COMMISSIONING FOR QUALITY FRAMEWORK This document is uncontrolled once printed. Please check on the CCG s Intranet site for the most up to date version COMMISSIONING FOR QUALITY FRAMEWORK Document Title: Commissioning for Quality Framework

More information

Job Title: Head of Patient &Public Engagement and Patient Services Directorate: Corporate Affairs Department: Patient and Public Engagement

Job Title: Head of Patient &Public Engagement and Patient Services Directorate: Corporate Affairs Department: Patient and Public Engagement Job Description Job Title: Head of Patient &Public Engagement and Patient Services Directorate: Corporate Affairs Department: Patient and Public Engagement Grade 8b Tenure: Permanent Location of Post:

More information

CLOSTRIDIUM DIFFICILE ACTION PLAN

CLOSTRIDIUM DIFFICILE ACTION PLAN CLOSTRIDIUM DIFFICILE ACTION PLAN Action plan to address the rise in cases of Clostridium difficile (C.diff) at Sheffield Teaching Hospitals NHS Foundation Trust ACTION KEY MILESTONES PERSON RESPONSIBLE

More information

Infection Prevention and Control Assurance

Infection Prevention and Control Assurance Infection Prevention and Control Assurance Who Should Read This Policy Target Audience All Clinical Staff Version 1.0 November 2015 Infection Prevention and Control Assurance Policy Ref. Contents Page

More information

Reducing the risk of healthcare associated infection

Reducing the risk of healthcare associated infection i Reducing the risk of healthcare associated infection Healthcare associated infection Introduction The Royal Marsden takes the safety of our patients very seriously. That means doing everything we can

More information

GOVERNING BODY REPORT

GOVERNING BODY REPORT GOVERNING BODY REPORT 1. Date of Governing Body Meeting 16 th November 2017 2. Title of Report: 3. Key Messages: BUPA ceased to be the registered provider of Crawfords Walk Nursing Home in October. The

More information

COMMUNITY AND OLDER PEOPLE S MENTAL HEALTH SERVICE FRAMEWORK FOR:

COMMUNITY AND OLDER PEOPLE S MENTAL HEALTH SERVICE FRAMEWORK FOR: MINDING THE GAP COMMUNITY AND OLDER PEOPLE S MENTAL HEALTH SERVICE FRAMEWORK FOR: GOVERNANCE ASSURANCE AND PERFORMANCE. 1. INTRODUCTION AND CONTEXT Providing, delivering and developing the highest standards

More information

Medical Director Director of Quality and Nursing Version 1

Medical Director Director of Quality and Nursing Version 1 Applies to: Committee for Approval Clinical Staff employed by Wirral Community NHS Trust Trust Board Date of Approval August 2014 Committee for Ratification Education and Workforce Committee Review Date:

More information

Infection Prevention and Sepsis Team Annual Report

Infection Prevention and Sepsis Team Annual Report 2016/17 Infection Prevention and Sepsis Team Annual Report We will be a leading centre in healthcare driven by excellence in patient experience, research, teaching and education. Helen Bucior Infection

More information

Quality Improvement Strategy

Quality Improvement Strategy / Colchester Hospital University NHS Foundation Trust Quality Improvement Strategy 2015-2018 Including our four Quality goals Strategy Author Angela Tillett, Medical Director Version 1 Date of Issue -

More information

Performance and Delivery/ Chief Nurse

Performance and Delivery/ Chief Nurse Governing Body 26th May 2017 Quality and Performance Report 22nd May 2017 Author: Other contributors: Executive Lead Audience Eileen Clark - Acting Director of Clinical Performance and Delivery/ Chief

More information

Biggart Dementia Project

Biggart Dementia Project Biggart Dementia Project Report 2009 / 2010 1.0 Situation 1.1 In NHS Ayrshire & Arran it has been identified that there is a need for improved education and training that supports staff in secondary care

More information

HEALTH AND SAFETY MANAGEMENT AT UWE

HEALTH AND SAFETY MANAGEMENT AT UWE HEALTH AND SAFETY MANAGEMENT AT UWE Introduction This document sets out the University s strategic approach to health and safety management. It contains the Statement of Intent that outlines the University

More information

Connolly Hospital Infection Prevention and Control Quality Improvement Plan 14 th March 2013

Connolly Hospital Infection Prevention and Control Quality Improvement Plan 14 th March 2013 Connolly Hospital Infection Prevention and Control Quality Improvement Plan 14 th March 2013 1. Summary The Infection Prevention and Control Quality Improvement Plan clearly defines the priorities for

More information

Open and Honest Care in your Local Hospital

Open and Honest Care in your Local Hospital Open and Honest Care in your Local Hospital The Open and Honest Care: Driving Improvement Programme aims to support organisations to become more transparent and consistent in publishing safety, experience

More information

Quality Improvement Strategy 2017/ /21

Quality Improvement Strategy 2017/ /21 Quality Improvement Strategy 2017/18-2020/21 Contents Section Title Page Number Foreword from Chair and Chief Executive 2 Section 1 Introduction What does Quality mean to us? What do we want to achieve

More information

CLINICAL AND CARE GOVERNANCE STRATEGY

CLINICAL AND CARE GOVERNANCE STRATEGY CLINICAL AND CARE GOVERNANCE STRATEGY Clinical and Care Governance is the corporate responsibility for the quality of care Date: April 2016 2020 Next Formal Review: April 2020 Draft version: April 2016

More information

Healthcare associated infections across the health and social care community

Healthcare associated infections across the health and social care community Healthcare associated infections across the health and social care community Professor Brian Duerden CBE Inspector of Microbiology and Infection Control, Department of Health, London Infection is different..it

More information

INFECTION PREVENTION & CONTROL ANNUAL REPORT 2016 / 2017

INFECTION PREVENTION & CONTROL ANNUAL REPORT 2016 / 2017 INFECTION PREVENTION & CONTROL ANNUAL REPORT 1 2016 / 2017 AUTHOR Mustafa Ahmed Governance Improvement Manager DIRECTOR OF INFECTION PREVENTION & CONTROL Garry Marsh Executive Director of Patient Services

More information