REPORT SUMMARY SHEET

Transcription

1 REPORT SUMMARY SHEET Meeting: Trust Board 27 th November 2014 Date: Title: Environmental Cleanliness Annual Report 2013/14 Lead Director: Corporate Objectives: Purpose: Director of Acute Services Provide safe, high quality care Make the best use of resources For approval. This report sets out the Trust s position with regard to environmental cleanliness during the year 1 April 2013 to 31 March It also advises Trust Board of the controls and systems in place to support the delivery and maintenance of high quality environmental cleanliness standards within the Southern Health and Social Care Trust. Summary of key areas: The Trust s 2013/14 self-assessment against the Environmental Cleanliness Controls Assurance Standard was subject to internal audit and the overall score was substantive at Formal weekly quality control checks have been introduced into augmented care areas to ensure compliance with domestic practices. Approximately 96 of Domestic Services staff working in hospitals have been assessed proficient in the BICSc (British Institute of Cleaning Science) standard. The Trust s four BICSc Assessors were successfully re-audited on the 28 January 2014 by BICSc. The washing of in-patient acute beds at Daisy Hill Hospital has transferred from Nursing to Domestic Services to increase efficiency and standardise service delivery across the Trust. A Regional Environmental Cleanliness Audit Sub Group has been established to review the environmental cleanliness audit process and agree an audit tool and a monitoring system to

2 replace Maximiser. During 2013/14 the DHSSPSNI reviewed the Regional Healthcare Hygiene and Cleanliness Standards and Audit Tool and the Guidance on Cleaning Sinks and Taps in Clinical Settings but the outcomes are not yet known. Environmental Cleanliness Annual Report 2013/14 Page 2 of 25

3 ENVIRONMENTAL CLEANLINESS Annual Report 2013/14 Environmental Cleanliness Annual Report 2013/14 Page 3 of 25

4 CONTENTS PAGE Contents Page Number 1.0 Strategic Context Operational Context Governance Arrangements Monitoring and Audit Arrangements Training Discharge, Terminal & Isolation Cleaning... Service Improvements... Maximiser Reviews by DHSSPSNI Key Priorities for 2014/ Appendices 17 Environmental Cleanliness Annual Report 2013/14 Page 4 of 25

5 1.0 STRATEGIC CONTEXT The Trust s strategic context is set out within the following key documents:- DHSSPS Cleanliness Matters A regional strategy for improving the standard of Environmental Cleanliness in HSS Trusts (Sept 2005) DHSSPS Cleanliness Matters Toolkit Practical guidance for the assessment of standards of Environmental Cleanliness in HSS Trusts (Sept 2005) DHSSPS Controls Assurance Standard on Environmental Cleanliness (April 2010) The National Specifications for Cleanliness in the NHS (NPSA 2007) DHSSPS Ward Sister s Charter An action plan for the prevention and control of Healthcare Associated infections in Northern Ireland 2010 Towards Cleaner Hospitals and Lower Rates of Infection (DOH 2004) Medicines and Healthcare Products Regulated Agency (MHRA) sterilization, disinfectant and the cleaning of medical equipment. Guidance on decontamination from the Microbiology Advisory Committee to Department of Health (MHRA) (MAC Manual) Revised Healthcare Cleaning Manual (2009) NPSA recommended cleaning frequencies BSEN 13548: 2001 Cleaning Services DHSSPSNI Regional Healthcare Hygiene and Cleanliness Standards & Audit Tool (2011) DHSSPS Guidance on cleaning of sinks / basins and taps in clinical settings including augmented care settings / neonatal units (August 2012) Quality 2020 A 10-Year Strategy to protect and improve quality in health and social care in Northern Ireland DHSSPSNI Policy for the Provision and Management of Cleaning Services in the HSC Sector July 2014 (Draft) NICE Public Health Guidance - Prevention and control of healthcareassociated infections - Quality Improvement Guide 2012 DHSSPS Standards for Better Health (April 2006) DHSSPSNI Regional Infection Prevention & Control Audit Tools for Augmented Care Settings in NI (Dec 2012) 2.0 OPERATIONAL CONTEXT There are over 300 whole time equivalent staff employed within Domestic Services who carry out cleaning duties. Services are provided across a range of hospital and community settings. Domestic Services are an integral part of the ward team and support the delivery of clinical care by ensuring the ward is a clean, safe and attractive place, conducive to patient care. On acute sites there are ward-based domestic staff who not only provide a cleaning service ranging from bed-washing to specialist Environmental Cleanliness Annual Report 2013/14 Page 5 of 25

6 cleaning but also duties associated with catering/ patient feeding. Domestic Services provide a responsive service to meet the needs of the service thus maintaining bed availability. Domestic Services staff have a significant role to play in infection prevention and control. The Trust has robust operational cleaning schedules and procedures in place to support service delivery. The Trust has adopted a colour coding system for cleaning materials and equipment which references the National Colour Coding Guidelines and this has been applied within Domestic Services across the Trust. 3.0 GOVERNANCE ARRANGEMENTS 3.1 Managerial Accountability The Trust s Chief Executive has overall accountability for environmental cleanliness within the Trust. The Director of Acute Services is the designated Executive Director with lead responsibility for Environmental Cleanliness. On a day to day operational basis, three Locality Support Services Managers have overall responsibility for the delivery of domestic services and the achievement and maintenance of environmental cleanliness standards in conjunction with ward managers, and heads of departments, facilities and homes. The Locality Support Services Managers are also available to provide advice to ensure high standards of environmental cleanliness in Trust facilities. These Locality Support Services Managers are accountable to the Assistant Director of Acute Services, Functional Support Services. 3.2 Trust Environmental Cleanliness Committee The Trust Environmental Cleanliness Committee ensures that a high level of environmental cleanliness is achieved and maintained throughout the Trust. The Committee meets on a quarterly basis and it is chaired by the Assistant Director of Acute Services, Functional Support Services. The Committee includes representatives from Support Services, Infection Prevention and Control, Nursing, Estates and a service user. The Environmental Cleanliness Committee is a sub-committee of Senior Management Team (SMT) and any environmental cleanliness issues will be reported to SMT by the Director of Acute Services and escalated on to Trust Board if appropriate. Environmental Cleanliness Annual Report 2013/14 Page 6 of 25

7 3.3 Trust Environmental Cleanliness Policy and Strategy The Trust Environmental Cleanliness Policy was approved by Trust Board on 26 February The policy was reviewed in May 2014 and the next review date is May The Trust has developed its own Environmental Cleanliness Strategy which sets out key objectives and identifies how the Trust will provide a high quality cleaning service. The aim of the strategy is to ensure provision of a high quality cleaning service which meets and maintains standards across all Trust premises, ensuring a clean, comfortable and safe environment for patients, clients, visitors, staff and members of the public. 3.4 Environmental Cleanliness Controls Assurance Standard A controls assurance standard on Environmental Cleanliness was issued in 2005 (updated April 2010), with a requirement for Trusts to achieve substantive compliance. The Trust has achieved this level of compliance. 4.0 MONITORING AND AUDIT ARRANGEMENTS The Cleanliness Matters Regional Strategy requires the Trust to perform audits to monitor cleanliness standards and as part of the Regional Strategy, the DHSSPS issued a toolkit, which provided all HSC facilities with a standardised methodology for assessing the standard of cleanliness. This toolkit which contains 49 elements is used by the Trust to undertake internal Departmental Audits. The DHSSPS issued a new Regional Healthcare Hygiene and Cleanliness Standards and Audit Tool in July The Department advised Trusts to use this audit tool to complement audit processes already in place for environmental cleanliness based on the Cleanliness Matters Strategy. Since September 2011 the Trust has used the Regional Healthcare Hygiene and Cleanliness Standards and Audit Tool for Managerial Audits. A Regional Environmental Cleanliness Audit Sub Group has been established to review the environmental cleanliness audit process and agree an audit tool, and the Trust is represented on this group. Environmental Cleanliness Annual Report 2013/14 Page 7 of 25

8 4.1 Internal Audit Arrangements Departmental Audits During 2013/14 Departmental Audits were undertaken in all hospitals across the Trust and Support Services continued to roll out Departmental Audits in community facilities. Departmental Audits are normally undertaken by a domestic supervisor and a ward/ department/ facility manager and results are shared at the time of audit. The frequency of audit is dependent on the risk categorisation of the area in question and since September 2011 the Trust has applied the following frequencies:- Departmental Audits Functional Rating Frequency Examples of areas Very High Risk Weekly/Fortnightly Neonatal, Special Care Baby Unit, Theatres, Day Surgery, Intensive Care Unit High Risk Monthly Emergency, In-patient Wards, Moderate Risk 3 monthly for clinical areas and 6 monthly for nonclinical areas Sterile Services Departments Out-patients, Physiotherapy - 3 monthly Laboratories, General Pharmacy, Residential Accommodation, common public areas - 6 monthly Low Risk 12 monthly Non-sterile supply areas, plant rooms, record storage, offices The average overall monthly Departmental Audit scores for each of the hospitals during 2013/14 are shown in the table below:- Hospital Apr-13 May-13 Jun-13 Jul-13 Aug-13 St Luke's South Tyrone Longstone Mullinure CAH Lurgan DHH Bluestone Average Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Environmental Cleanliness Annual Report 2013/14 Page 8 of 25

9 The scores reflect the overall weighted score for each hospital taking into account all risk categories ie very high, high, moderate and low risk category areas. 85 or above indicates an acceptable level of cleanliness in accordance with the DHSSPS Cleanliness Matters Strategy. An Audit Exception Report is sent each week to Senior Management Team if scores from the Departmental Audits in any very high or high risk areas fall below 85. Graphs depicting the very high, high, moderate and low risk scores for each of the hospitals during 2013/14 are shown at Appendix 1. A summary of the average Departmental Audit scores for community facilities is shown at Appendix Managerial Audits Managerial Audits are unannounced and they are undertaken throughout the Trust on a rolling basis. It is aimed to carry out a Managerial Audit annually in all very high and high risk areas and they are initially targeted at wards/departments where Departmental Audit scores fall below 85. Managerial Audits are conducted in very high, high and moderate risk areas on a sample basis including key rooms, eg bathroom, toilet, sluice, side room and bay area. The Managerial Audits are undertaken by a Managerial Audit Team which provides a level of independence. There is a Managerial Audit Team for each locality which comprises of the following personnel:- Infection Prevention & Control Nurse Support Services representative Estates representative Service User Managerial Audits were undertaken in 24 areas within hospitals between April 2013 and March 2014 and a table containing the audit scores is provided at Appendix 3. Managerial Audits were also undertaken in 11 Community facilities during 2013/14 and scores for the environment are shown in the table below. Environmental Cleanliness Annual Report 2013/14 Page 9 of 25

10 Facility Environment Portadown HC 94 Armagh Com. Hospital 82 Banbridge Polyclinic 97 Brownlow Health Centre 92 Crozier House 99 Crozier Lodge 99 Meadows 99 Eden SEC 99 Bannvale SEC 92 Gilford HC 94 Manor Day Centre 99 Compliant 85 or above Partial Compliance 76 to 84 Minimal Compliance 75 or below Environmental Cleanliness Controls Assurance Self- Assessment In 2013/14, a self-assessment of the Trust s position against the Environmental Cleanliness Controls Assurance Standard was undertaken. The self-assessment was subject to review by Internal Audit and the overall score was substantive at The Domestic Services Working Group has been meeting during 2013/14 to take forward and implement the actions required to maintain and improve compliance with the Controls Assurance Standard. The Trust also organised a regional meeting which was chaired by the Assistant Director of Acute Services, Functional Support Services to cross compare scores and evidence used by other Trusts Domestic Practice Audits Domestic Practice Audits are undertaken in hospital wards and departments by the Training and Quality Officer, Support Services. These audits are carried out to ensure that staff are adhering to procedures and they are performing tasks in accordance with BICSc training and good practice. During 2013/14 17 audits were undertaken and any issues identified during the audits were addressed with staff at the time. Environmental Cleanliness Annual Report 2013/14 Page 10 of 25

11 4.1.5 Hand Hygiene Audits Hands are a major vehicle for transmission of infection and therefore effective hand hygiene is important in preventing the spread of infection. Domestic Services staff are trained on the 7 step technique to decontaminate hands appropriately and hand hygiene audits are conducted to ensure compliance by all staff of all disciplines including Domestics. The audit results are shared with Support Services and any issues highlighted during the audits are forwarded to the Domestic Services Manager to raise with the staff member concerned Quality Control Monitoring During 2013/14 formal weekly quality control checks by Assistant Managers/Supervisors were introduced into augmented care areas to ensure compliance with domestic practices and any issues arising from these checks are addressed with staff at the time. Quality control checks of domestic stores are also undertaken Complaints During 2013/14, there were 3 complaints reported to the Trust in respect of environmental cleanliness and details are shown in the table below. Location Nature of Complaint Response Emergency Person dissatisfied Department, CAH with the cleanliness of the department. Emergency Department & 4 North, CAH Antenatal, CAH Person unhappy with standard of cleanliness. Person unhappy with standard of cleanliness in particular regarding waste. Domestic and Nursing cleaning schedules reviewed. Domestic cleaning schedules and processes reviewed. Nursing staff in Emergency Department reminded that if additional cleaning is required between patients to contact Domestic Services staff. Reviewed cleaning schedule and regular checks were initiated by the Department. Environmental Cleanliness Annual Report 2013/14 Page 11 of 25

12 4.1.8 Compliments During 2013/14, Domestic Services received 25 compliments, as follows:- Craigavon Area Hospital - 12 Daisy Hill Hospital - 2 Lurgan Hospital - 3 Bluestone Unit - 3 St Luke s Hospital - 3 Community Facilities Service User Survey / User Involvement Functional Support Services has a rolling programme of annual service user surveys to support continuous improvement and Personal and Public involvement. A survey was carried out in hospitals across the Trust in December 2013 to seek patient views on the services provided by Domestic, Catering, Laundry and Portering. Patients were chosen at random and 185 questionnaires were completed (80 Craigavon, 52 Daisy Hill, 23 South Tyrone, 15 Lurgan and 15 the Bluestone Unit). The results of the survey were very positive with the majority of patients being satisfied with the standard of cleanliness and there were no actions to be taken forward by Domestic Services Patient Environment Leadership Walkabouts To ensure the Trust has a Board to Ward approach in reducing the spread of infection, senior managers including the Assistant Directors of Acute Services carried out a series of Patient Environment Leadership Walkabouts at Craigavon Area Hospital during December 2013 and January Any issues arising were recorded and action plans for improvement were developed for the appropriate personnel to take forward. 4.2 External Audits RQIA undertook 9 unannounced Hygiene Inspections during 2013/14 and action plans were developed to address issues raised by RQIA during their visits. A table showing a breakdown of the scores is provided at Appendix TRAINING 5.1 BICSc The Trust is an accredited centre for BICSc (British Institute of Cleaning Science) training and assessment. BICSc is the largest independent Environmental Cleanliness Annual Report 2013/14 Page 12 of 25

13 professional and educational body within the cleaning industry and is ISO 9001 registered. BISCs has replaced the COPC (Cleaning Operators Proficiency Certificate) with the CPSS (Cleaning Professional Skills Suite) and from June 2013 the Trust has delivered the new certificate to staff. The new CPSS focuses on skills development and the certificate includes three mandatory units, designed to ensure the safety of the cleaning operatives and the users of the building. Approximately 96 of Domestic Services staff working in hospitals have been assessed proficient in the BICSc standard. The outstanding 4 comprises mainly bank staff. There were celebration of achievement events held in Craigavon on 15 May and 7 August 2013 when Domestic Services staff received their certificates from the Locality Support Services Manager. BICSc Assessors are re-audited annually to ensure they are assessing to the required standard and the Trust s four Assessors were successfully reaudited by BICSc on the 28 January Sink Cleaning All Domestic Services staff working in hospitals are trained on the 2 and 4 cloth methods for cleaning sinks, basins and taps in clinical areas in compliance with the DHSSPSNI guidance on cleaning sinks and taps in clinical settings. 5.3 Infection Prevention & Control Infection Prevention and Control awareness training is delivered to Domestic Services staff within the hospitals as part of an agreed training plan. During 2013/14 there were 13 sessions arranged for staff as follows:- Craigavon Area Hospital & Bluestone Unit 5 Daisy Hill Hospital 2 St Luke s Hospital 3 South Tyrone Hospital 2 Lurgan Hospital DISCHARGE, TERMINAL & ISOLATION CLEANING Domestic Services conduct a range of specialised cleaning services including Discharge cleaning undertaken following the discharge/transfer/movement of a patient. Environmental Cleanliness Annual Report 2013/14 Page 13 of 25

14 Terminal cleaning following the discharge/transfer/movement of a patient with a known or suspected infection. Isolation cleaning if patients have a suspected or proven transmissible infection. These specialised cleaning services ensure bed spaces/ rooms are cleaned effectively which helps to reduce the transmission of healthcare acquired infections such as MRSA and C-Difficile. They also assist with patient flow throughout the hospitals. The number of requests for terminal cleans over the last two years is shown in the table below:- Hospital 2012/ /14 Craigavon Daisy Hill South Tyrone Lurgan St Luke's Mullinure 59 0 Longstone 11 0 Bluestone Unit 4 4 Total SERVICE IMPROVEMENTS 7.1 Bed Washing Historically, bed washing was conducted by Nursing staff at Daisy Hill Hospital but from April 2014 the washing of in-patient acute beds transferred to Domestic Services to standardise service delivery across the Trust. This change has released some of the Nurses time for direct patient care and is therefore a better use of resources. In addition, it offers a more consistent, efficient and flexible service, which optimises patient flow and thereby reduces delays for patients. 7.2 Capital Spend to improve the Environment The following table includes a brief overview of the capital works completed during 2013/14 that have improved environmental cleanliness. Environmental Cleanliness Annual Report 2013/14 Page 14 of 25

15 Location Works Craigavon Area Hospital Urology, Fractures & Ramone Outpatients Theatres & Recovery Complete refurbishment. Complete refurbishment. 3 South Short Stay Sanitary areas refurbished. 1 East Corridor flooring replaced and 2 showers refurbished. 2 West 2 bays, shower and toilet refurbished. 1 West Refurbishment of an existing area to provide a dedicated colposcopy suite. Neonatal / 3 North Provision of a shared facility for the cleaning of incubators and other specialist neonatal equipment. Winter Ward, Ramone Refurbishment of ward and sanitary areas to make fit for patients over the Winter period. Daisy Hill Hospital Theatres Emergency Department Special Care Baby Unit New purpose built modular theatres and existing theatres refurbished. Complete refurbishment. Provision of a dedicated room for the cleaning of nursing and near patient equipment. 8.0 MAXIMISER In January 2014 the Trust cancelled the renewal of the licence for Maximiser (the electronic system used for monitoring Departmental Audits) due to ongoing technical difficulties and the fact that Maximiser was due to be discontinued in January The Trust had reviewed the elements used on the Maximiser system and designed its own audit tool, however before the revision of elements had been approved by Senior Management a Regional Environmental Cleanliness Audit Environmental Cleanliness Annual Report 2013/14 Page 15 of 25

16 Sub Group was established to review the environmental cleanliness audit process and agree an audit tool and a monitoring system to replace Maximiser. 9.0 REVIEWS BY DHSSPSNI During 2013/14 the DHSSPSNI reviewed the Regional Healthcare Hygiene and Cleanliness Standards and Audit Tool and the Guidance on Cleaning Sinks and Taps in Clinical Settings. The Trust fed comments into both these reviews however the outcomes have not yet been issued KEY PRIORITIES FOR 2014/ Develop and implement an action plan for the standardisation of cleaning processes by September Develop competency training material including video clips for Domestic Services and commence the roll out of training to staff by July Regionally agree an environmental cleanliness audit tool and source a monitoring system To implement the DHSSPSNI Policy for the Provision and Management of Cleaning Services in the HSC Sector when approved by the Minster of Health. Environmental Cleanliness Annual Report 2013/14 Page 16 of 25

17 Appendices Appendix 1 Graphs showing scores (very high, high, moderate and low risk) from Departmental Audits undertaken in hospitals throughout the Trust 2013/14 Appendix 2 Summary of Average Departmental Audit Scores for Community Facilities 2013/14 Appendix 3 Managerial Audit Scores for Hospitals 2013/14 Appendix 4 RQIA Hygiene Inspection Scores 2013/14 Environmental Cleanliness Annual Report 2013/14 Page 17 of 25

18 Appendix 1 The following graphs show scores (very high, high, moderate and low risk) from Departmental Audits undertaken in hospitals throughout the Trust from April 2013 March Environmental Cleanliness Annual Report 2013/14 Page 18 of 25

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22 Summary of the Average Departmental Audit Scores Community Facilities 2013/14 Appendix 2 Q/E June 2013 High Risk Areas No. of Audits Completed Overall Domestic Manager Estates Armagh Community Hospital Moderate Risk Areas No. of Audits Completed Overall Domestic Manager Estates MHD Day Centres/ SECs MHD Resource Centres MHD Respite Units MHD Supported Living Health Centres/Clinics OPPC Residential OPPC Day Centres CYP Residential CYP Respite Units CYP Children's Centres Others Low Risk Areas No. of Audits Completed Overall Domestic Manager Estates Offices Community Ambulance Stations Q/E September 2013 High Risk Areas No. of Audits Completed Overall Domestic Manager Estates Armagh Community Hospital Moderate Risk Areas No. of Audits Completed Overall Domestic Manager Estates MHD Day Centres/ SECs MHD Resource Centres MHD Supported Living MHD Respite Units Health Centres/Clinics OPPC Residential OPPC Day Centres CYP Residential CYP Respite Units CYP Children's Centres Others Low Risk Areas No. of Audits Completed Overall Domestic Manager Estates Offices Community Ambulance Stations

23 Q/E December 2013 High Risk Areas No. of Audits Completed Overall Domestic Manager Estates Armagh Community Hospital Moderate Risk Areas No. of Audits Completed Overall Domestic Manager Estates MHD Day Centres/ SECs MHD Resource Centres MHD Supported Living MHD Respite Units Health Centres/Clinics OPPC Residential OPPC Day Centres CYP Residential CYP Respite Units CYP Children's Centres Others Low Risk Areas No. of Audits Completed Overall Domestic Manager Estates Offices Community Ambulance Stations Q/E March 2014 High Risk Areas No. of Audits Completed Overall Domestic Manager Estates Armagh Community Hospital Moderate Risk Areas No. of Audits Completed Overall Domestic Manager Estates MHD Day Centres/ SECs MHD Resource Centres MHD Supported Living MHD Respite Units Health Centres/Clinics OPPC Residential OPPC Day Centres CYP Residential CYP Respite Units CYP Children's Centres Others Low Risk Areas No. of Audits Completed Overall Domestic Manager Estates Offices Community Ambulance Stations 23

24 Managerial Audit Scores for Hospitals 2013/14 Appendix 3 Date Location Ward/Dept Environment Patient Linen Waste Sharps Patient Equipment Hygiene Factors Hygiene Practices Average Oct-13 CAH Intensive Care Unit Aug-13 CAH ENT Outpatients Dept Nov-13 CAH X-Ray Oct-13 CAH Medical Admissions Unit Nov-13 CAH 1 South Jan-14 CAH 4 South Jan-14 CAH 2 Medical Ramone Apr-13 Daisy Hill Special Care Baby Unit May-13 Daisy Hill Renal May-13 Daisy Hill Delivery Suite Nov-13 Daisy Hill Day Procedure Unit Nov-13 Daisy Hill High Dependency Unit Apr-13 Daisy Hill Sterile Services Dept Jun-13 Daisy Hill Maternity Aug-13 Daisy Hill Male Medical / Coronary Care Sep-13 Daisy Hill Paeds Oct-13 Daisy Hill Female Medical Nov-13 Daisy Hill Female Surgical Dec-13 Daisy Hill Emergency Department Jan-14 Daisy Hill Male Surgical Mar-14 Lurgan Outpatients Dept May-13 Lurgan Ward Jan-14 Mullinure Gillis Ward May-13 South Tyrone Ward Compliant 85 or above Partial Compliance 76 to 84 Minimal Compliance 75 or below Not audited

25 Appendix 4 RQIA Hygiene Inspections 2013/14 Areas Inspected Male Surgical DHH 24/4/2013 Male Medical DHH 24/4/2013 Ward 1 South Tyrone 27/6/2013 Neonatal CAH 30/7/2013 & 6/8/2013 Special Care Baby Unit Daisy Hill 10/9/2013 & 12/9/2013 Emergency Dept CAH 3/12/ North CAH 3/12/ South Medical CAH 3/12/2013 Emergency Dept CAH 18/2/2014 Environment Linen Waste Sharps Patient Equipment Hygiene Factors Hygiene Practices Average Score Level of Compliance Compliant 85 or above Partial Compliance 76 to 84 Minimal Compliance 75 or below 25