Hand Hygiene Policy. Standards for Hand Hygiene Procedures

Transcription

1 Hand Hygiene Policy Subject: Policy Number Ratified By: Standards for Hand Hygiene Procedures PSQ/09/066 Date Ratified: April 2009 Version: 2 Policy Executive Owner: Hospital Management Board Nursing Director Designation of Author: Infection Prevention and control team - Lead infection prevention and control nurse Name of Assurance Committee: Date Issued: January 2009 Review Date: January 2011 Target Audience: Other Linked Policies: Key Words: Patient Safety & Quality Committee All staff members Outbreak Policy C.diff Policy MRSA Policy Hand Hygiene, Decontamination Page 1

2 Contents Paragraph Page Key Points 4 1 Introduction 5 2 Purpose 5 3 Microbiology of the hands 5 4 Hand Hygiene Facilities 6 5 The levels of Hand Hygiene 6 6 Cleansing agents for Hand Hygiene Duration of Hand Hygiene 8 7 Hand Hygiene Procedure 9 8 Skin Care 10 9 Performing Hand Hygiene using Alcohol Hand Rub Hand Hygiene Training Reference 12 Appendices Appendix 1 Six Steps of Effective Hand Hygiene Appendix 2 Areas missed during hand washing and applying alcohol hand gel Appendix 3 Hand Hygiene Audit template- Lewisham Tool Appendix 4 5 moments of Hand Hygiene Appendix 5 Bare Below the Elbows Policy Appendix 6 Equality Assessment Tool Appendix 7 Checklist for the Review and Approval of Procedural Document Page 2

3 Version Control Sheet Version Date Author Status Comment 1 Dec 08 Lead Infection Prevention and Control Nurse Draft 1 Dec 08 Lead Infection Prevention and Control Nurse Draft 1 Dec 08 Lead Infection Prevention and Control Nurse Draft 1 Dec 08 Lead Infection Prevention and Control Nurse Working Draft Working Draft Working Draft Working Draft Added section 9 Hand Hygiene Training and also update of References. Added Appendix 3 Hand Hygiene Lewisham Tool Added appendix 4 Your 5 moments of Hand Hygiene 2 April 09 Final Ratified by HMB 2 September 09 Final Minor amendment approved by Nursing Director Page 3

4 KEY POINTS Wash your hands with soap and water: When starting a shift When there is any diarrhoea on the ward When visibly soiled Before drug rounds When serving food On entering & leaving wards Observe Bare Below The Elbow Policy Use alcohol gel on hands immediately before you touch a patient and before putting on non-sterile gloves Page 4

5 1. INTRODUCTION Hand Hygiene is one of the most important infection prevention and control practices for preventing the spread of disease as hands are the principle routes by which cross-infection occurs. The spread of infection and the transmission of microorganisms from one patient to another via the hands of health workers or from hands that have become contaminated from the environment can lead to serious outcomes and infections. Studies have shown that hand hygiene is the simplest, most effective measure for preventing healthcare acquired infections (Pittet, 2001) Also improving the adherence of hand hygiene has shown to terminate outbreaks in health care facilities, reduce transmission of anti-microbial resistant organisms (e.g. MRSA) and reduce overall infection rates. Clinical staff members in the trust will receive hand hygiene training once a year by the Infection Prevention and Control Team. Training for non-clinical staff members will be supported by The Learning Programmes Team. This will form part of the compulsory training programme. 2. Purpose 2.1 Aim: To promote hand hygiene and to define responsibilities and actions required for compliance with good hand hygiene practice throughout the organisation. 2.2 Objectives: To identify the importance of hand hygiene in the prevention of healthcare associated infection To describe the key elements of good hand hygiene practice To identify strategies to implement the policy and improve compliance with good hand hygiene practice, 3. MICROBIOLOGY OF THE HANDS Skin provides an environment that is acidic, dry; limited in nutrients and that is constantly shed and renewed. There are two types of micro-organisms, which are carried on the skin classified as transient micro organisms and resident microorganisms. 3.1 Transient organisms These organisms live on the surface if the skin and beneath superficial layers of the skin. They are easily acquired via direct contact with people, equipment and other body sites, which result in the transfer of these organisms to and from the hands. Transient organisms can also be transferred via daily activities such as: Touching, lifting and washing patients. Assisting with personal care. Making beds and handling curtains. Wound and respiratory care. Touching any contaminated piece of equipment. Page 5

6 Transient organisms can easily be removed by washing hands with soap and water or with alcohol hand gel. Therefore good hand hygiene is the an important method to help tackle infections. 3.2 Resident organisms These organisms live deep within the skin crevices, hair follicles, sweat glands and also beneath the fingernails, these are also termed as skin flora. These micro-organisms are not readily transferred during routine activities and cannot be eradicated by using soap and water, but their numbers are greatly reduced by antiseptic agents. In order to prevent resident organisms it is important to perform hand hygiene with aseptic agents and also decontaminate hands in order to prevent resident organisms, as resident organisms can cause an infection following surgery or invasive procedures. 4.0 HAND HYGIENE FACILITIES The following facilities are required to perform good hand hygiene: Sinks/wash basin should be specifically allocated to hand hygiene Liquid soap in wall mounted cartridge soap dispensers should be available at each hand-wash basin Good quality paper hand towels in wall mounted dispensers must be available at each hand-wash basin. Sufficient space should be allocated by every hand wash basin for foot operated lidded bins for disposal of hand towels. Alcohol gel should be available for use at the point of care to ensure that compliance is achieved where there is limited access to hand wash basins. 5.0 THE LEVELS OF HAND HYGIENE Level 1 Level 2 Level 3 Social Hand Hygiene Hygienic Hand Hygiene Surgical Scrub Why perform hand hygiene? To render the hands physically clean and to remove microorganisms picked up during activities considered social activities (transient microorganisms) To remove or destroy transient microorganisms. In addition to provide residual effect during times when hygiene is particularly important in protecting yourself and others (reduces resident microorganisms) To remove or destroy transient microorganisms and to substantially reduce those microorganisms which normally live on the skin (resident microorganisms) during times when surgical procedures are being carried out. By following all steps included within the hand hygiene process, e.g. preparation for hand hygiene and complying with the Bare Below the Elbows Policy (Appendix 5), Page 6

7 hand drying and hand care you will ensure potentially harmful microorganisms are not a factor in the spread of infectious agents. The times that hand hygiene should be performed have also been summarised into the Your 5 Moments for Hand Hygiene (Appendix 4) as these are considered the most fundamental times for the levels of hand hygiene to be undertaken during care delivery and daily routines Cleaning hands is important at many times, including on entering and leaving any care environment (e.g. ward or department) and as described below: Level 1 Level 2 Level 3 Social Hand Hygiene Hygienic Hand Hygiene Surgical Scrub When to perform hand hygiene? BEFORE 1) Commencing/leaving work 2) Using computer keyboard (in a clinical area) 3) Eating/handling of food/drinks (whether own or patient/clients) 4) Preparing/giving medications Entering/leaving clinical areas AFTER 1) Patient/client contact 2) Becoming visibly soiled 3) Visiting the toilet 4) Using computer keyboard (in a clinical area) 5) Handling laundry or equipment waste 6)Blowing/Wiping/Touching nose 7) Any contact with inanimate objects (e.g. equipment, items around the patient/client) and the patient/client environment 8) Removing gloves BEFORE/BETWEEN 1)Aseptic procedures 2)Contact with immunocompromised patients/clients AFTER 1)Contact with patients/clients being cared for in isolation or having additional (transmission based) precautions applied due to the potential for spread of infection to others 2) Being in wards/department units during outbreaks of infection 3) Surgical/invasive procedures BEFORE 1) Surgical invasive procedures NB: Specific policies and procedures on surgical preparation should be available at local level. Even if gloves have been worn, hand hygiene must be performed as per recommendations above as hands may still be contaminated beneath gloves, or upon removal of these and, therefore, may pose a risk for transmitting microorganisms Page 7

8 It should also be noted that hand hygiene may have to be performed between tasks on the same patient 6.0 CLEANSING ANGENTS FOR HAND HYGIENE Different solutions and cleansing agents are used for different levels hand hygiene which are explained below: Level 1 Social Hand Hygiene Plain liquid soap. Alcohol based hand rub can also be used for social hand hygiene (where hands have not been soiled) for ease of use where appropriate Level 2 Hygienic Hand Hygiene An approved liquid soap from a dispenser. Alcohol based hand rub can also be used following hand washing. For example when performing aseptic techniques, to provide further cleansing and residual effect. Level 3 Surgical Scrub An approved antiseptic hand cleanser, e.g. 2-4% Chlorhexidine, 5-7.5% povidine iodine from a dispenser. Persons sensitive to antiseptic cleansers can wash with an approved nonmedicated liquid soap followed by 2 application of alcohol based hand rub. Skin problems should be reported to and discussed with GP/Occupational Health and local procedure should be followed. If hands have patient/client contact before or during a procedure, but are not soiled with any body fluids and, therefore, do not require re-hand washing with soap or an antiseptic hand cleanser, alcohol based hand rub can be used, using the same technique/duration (see Performing hand hygiene using alcohol based hand rub). For the situations described for Level 2 (see When to perform hand hygiene) further advice from infection control specialists and/or risk assessment may be required Any soilage/organic matter can inactivate the activity of alcohol and, therefore, rehand washing in these circumstances is essential Where infection with a spore-forming organism e.g. Clostridium difficile is suspected/proven it is recommended that hand hygiene is carried out with liquid soap and water and followed by the application of alcohol gel. Where infection with a viral gastroenteritis e.g. Norovirus is suspected/proven it is important that hand hygiene is carried out with liquid soap and water and then followed by alcohol based hand rub In clinical and communal care settings in particular, it is recommended that solutions be stored within a wall mounted dispenser that can be easily cleaned, have single Page 8

9 use, disposable cartridge sets within the dispenser, and have easy-to-use dispensing systems (e.g. a large lever) Topping up of bottles that contain solutions should never occur as the inside of bottles, even those containing antiseptic solutions, can become a breeding ground for bacteria over time 6.1 DURATION OF HAND HYGIENE Level 1 Social Hand Hygiene Level 2 Hygienic Hand Hygiene Level 3 Surgical Scrub At least seconds At least seconds The first scrub of the day should last for 5 mins and all subsequent scrubs should last 3 mins. Washing for longer than these times is not recommended as this may damage the skin leading to increased shedding of skin scales or increased harbouring of microorganisms. 7.0 HAND HYGIENE PROCEDURE * Preparation Ensure nails are kept short makes it easy to clean beneath the nails as it has been identified that most microbes on the hands originate from beneath the nails and also to avoid glove tears Remove rings - Rings with stones of ridges have been found to present with higher bacterial counts. Additionally they interfere with thorough hand washing and make it more difficult to put on disposable gloves. Do not wear artificial nails as they have a harbour for high levels of microorganisms, as they are likely to discourage vigorous hand washing and are difficult to keep clean. Also can lead to injury of patients if the glove is torn. Bare-Below-the-elbows (please refer to Appendix 5)- Hands and wrists must be decontaminated to the same standard this includes removing watches, wearing short-sleeved shirts or rolling up sleeves. Cuts and abrasions must be covered with waterproof dressings. Washing and Rinsing Wet hands under tepid running water BEFORE applying liquid soap or hand washing agent The hands must be rubbed together vigorously for a minimum of seconds and pay particular attention to the fingertips, thumbs and between the fingers. See Appendix 1 (six step hand washing technique) Rinse hands thoroughly beneath the tepid running water Page 9

10 Drying Dry the hands thoroughly with good quality absorbent, disposable paper towel Dispose the hand towel into a foot operated waste bin in order to avoid recontamination of the hands. 8.0 Skin Care The skin provides a waterproof barrier against micro-organisms, including blood borne viruses, provided it is healthy an intact. Healthcare staff are at increased risk of developing irritant contact dermatitis and eczema due to frequent hand washing. In order to minimise the risk of skin damage it is important that staff: Wet hands prior to washing thoroughly Use a mild liquid soap Apply a water-based emollient before refreshment breaks and at the end of your shift. Cover cuts and grazes with a waterproof dressing Wear Nitrile or latex-free gloves for any activity where blood or body fluids may contaminate the hands Use an alcohol hand gel between patients where appropriate, Avoid contact with irritants. It is important that staff DO NOT: Use oil-based emollients if wearing latex gloves. Latex disintegrates within minutes of contact with petroleum Use communal pots of hand cream Expose your hands to extreme temperatures Forget to wash your hands either with liquid soap and water or alcohol hand gels. Use bar soap. 8.1 Skin Problems If you are experiencing skin problems or if you have a lesion, cut or graze that cannot be adequately covered, contact the Occupational Health Advisor, Ext 3124 Apply an emollient hand cream regularly to protect skin from the drying effects of regular hand decontamination. If a particular soap, anti microbial hand wash or alcohol product causes skin irritation, seek occupational health advice. 9.0 PERFORMING HAND HYGIENE USING ALCOHOL HAND RUB Why use alcohol based hand rub for hand hygiene? Alcohol based hand rubs with a concentration of 70% are generally used as they are effective, cause less skin drying dermatitis and are less costly. Products that also contain emollients can be used to ensure the drying effects of alcohol based hand rubs are minimised It has been shown that alcohol based hand rub used for the hand hygiene process can inhibit microorganisms on hands by filling the crevices in hands and evaporating as it spreads over all areas Page 10

11 When should I use alcohol based hand rub for hand hygiene? Refer to What solution should I use to perform hand hygiene? These products can be useful for performing hand hygiene when sinks are not readily available for hand washing or when hands may be contaminated, but no soilage is present e.g. entering or leaving a ward/clinical/patient area Alcohol based hand rub can also be used following hand washing, e.g. when performing aseptic techniques, to provide a further cleansing and residual effect When should I not use alcohol based hand rub for hand hygiene? Where infection with a spore forming organism e.g. Clostridium difficile is suspected/proven it is recommended that hand hygiene is carried out with liquid soap and water although it can be followed by alcohol based hand rub Where infection with a viral gastroenteritis e.g. Norovirus is suspected/proven it is important that hand hygiene is carried out with liquid soap and water although it can be followed by alcohol based hand rub How should I use alcohol based hand rub to perform hand hygiene? The procedure The amount/volume used to provide adequate coverage of the hands should be indicated in the manufacturers instructions. This is normally around 3 mls The steps to perform hand hygiene using alcohol based hand rub are the same as when performing hand washing (see Appendix 1) The time taken to perform hand hygiene using alcohol based hand rub should be the same as when performing hand washing, e.g. at least 15 seconds is recommended (15-30 seconds is adequate). Manufacturers instructions can be followed (a number of these recommend rubbing for 30 seconds) If the solution has not dried by the end of this process allow hands to dry fully before any patient/client procedures are undertaken (do not use towels to do this) 10. HAND HYGIENE TRAINING Hand hygiene training will be reviewed as part of the annual review of compulsory training for the Hospital Management Board. Attendance on hand hygiene training will be reported to HMB as part of the compulsory training reports and as requested to the Patient, Safety and Security Committee Adherence to the Policy and Associated Sanctions If you see a member of staff in contravention of the Policy you should remind the member of staff of the Policy. Page 11

12 10.2 Roles & Responsibilities All healthcare staff will adhere to the Trust Hand Hygiene policy found within the Infection Control Manual and on the Trust s website. Hand Hygiene training will be carried out by the Infection Control team through compulsory training, Clean Your Hands campaign and targeted training in clinical areas. The Infection prevention and control team is responsible for ensuring appropriate policies and procedures are in place to support hand hygiene practices. Staff are expected to follow Trust policies and procedures; professional codes of conduct/practice accepted standards, statutory requirements and regulations. Staff failing to adhere to the hand hygiene procedures outlined in this policy may be subject to disciplinary action Monitoring All healthcare workers with patient contact must have training in hand hygiene as part of the Trust s Compulsory training programme. The training department will keep records of attendance for Compulsory Training and will follow up non-attenders. Other attendance records on hand hygiene training will be kept by the Infection Control team. Compliance with this requirement will be monitored on a six-monthly basis by the Infection Control Steering Committee and subsequently the Risk Management Committee and Board. Compliance with the policy will be monitored through monthly ward/department audits. These will be undertaken by healthcare workers from the areas and submitted to the Governance Department for collation and analysis. Matrons ensuring data is collected and submitted for their areas of responsibility. Identifying learning and achieving improvement as appropriate. Ward/department manager ensuring individuals are identified and trained to undertake the audit on a monthly basis. Identifying learning and achieving improvement as appropriate. The monthly audit results will be reported by the Infection Prevention and Control Team to the Matrons, individual wards/department managers who will be responsible for communicating to staff within the area. In addition an annual audit of all aspects to the policy will be undertaken by the Infection Control Team. This will also be reported to the Infection Prevention and Control Committee and board. Page 12

13 11 References Bissett L. (2002) Can alcohol hand rubs increase compliance with hand hygiene? British Journal of Nursing, 11 (16): 1072, ; Hand Hygiene Task Force (2001). Draft guideline for hand hygiene in healthcare settings. Hospital Infection Control Practices Advisory Committee, CDC, Atlanta, USA; Infection Control Nurses Association. Hand Decontamination Guidelines; 2002 Available from Fitwise on Larson E. and Kretzer E. K (1995). Compliance with handwashing and barrier precautions. Journal of Hospital Infection, 30: ; Pittet D., Dharan S., Touveneau S. et al (1999). Bacterial contamination of the hands of hospital staff during routine patient care. Arch. Int. Med. 159: ; Pittet D., Hugonnet S., Harbarth S., Mourouga P., Sauvan V., Touveneau S., Perneger T. and members of the Infection Control Programme (2000). Effectiveness of a hospital wide programme to improve compliance with hand hygiene. The Lancet, 356: ; Pittet D (Mar-Apr 2001). Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach. Emerging Infectious Disease, 7: 2; Ward V., Wilson J., Taylor L. et al (1997). Preventing hospital-acquired infection. Clinical guidelines. PHLS, London. Page 13

14 Appendix 1 Hand Hygiene Technique Effective Hand Hygiene Palm to palm 3. Interdigital spaces 5. Thumbs and 2. Back of hands & wrists 4. Fingertips 6. Nails The Ayliffe Technique for hand hygiene Page 14

15 Appendix 2 AREAS MISSED DURING HANDWASHING & APPLYING ALCOHOL GEL Page 15

16 Appendix 3 Hand Hygiene Lewisham Tool NMUH HAND HYGIENE OBSERVATION TOOL Format Monitoring adherence with hand hygiene and providing staff with feedback on their performance is strongly recommended in recent literature. There are a range of tools available for assisting staff in calculating hand hygiene compliance and a number are currently under development. The tool is adapted from the National NPSA Clean Your Hands Campaign. Ward managers are advised to identify staff on the ward who will undertake observations. This could be an infection control link practitioner. The identified person should attend a training session before using the tool (contact Infection Control Team on ext. 3210/3275) Sample Tool: The Lewisham Observational Tool The hand hygiene observation tool is designed to assist staff in observing hand hygiene behaviour and allows for meaningful feedback to staff. It is based on a tool used in one of the largest studies undertaken internationally on hand hygiene, which demonstrated that feedback was a key feature of improvement. The basis of the tool is that it allows you to record over a 20-minute period whether healthcare workers who touch patients have adequately decontaminated their hands in a timely way. The model used here has been adapted by Jeanes (2002) from that used by Pittet et al (2000) and used extensively in University Hospitals Lewisham (UCH); further adaptation took place to include staff groups at Mayday University Hospitals. The tool is based on the principle that when touching patients (or their environment) healthcare staff have hand hygiene opportunities. Hand Hygiene Opportunities The following provides some examples to illustrate opportunities for cleaning hands: Before touching a patient s skin Before doing a sterile procedure After handling body substances After touching a patient All of the above should be followed by hand washing or use of alcohol rub. The observations tool compares hand hygiene opportunities (O) with actual observed hand hygiene (H). Compliance can then be expressed as a percentage. Author: Devinder Kaur, Lead Infection Prevention and Control, Hand Hygiene Policy Draft Version1 16

17 Compliance can be defined as either washing hands with soap and water or rubbing with an alcohol rub in accordance with a hand hygiene opportunity, so Compliance = observed hand hygiene (H) x 100 = compliance % Instructions Hand hygiene opportunity (O) 1. The staff member undertaking observation should undertake a number of practice observations to get familiar with the tool and to minimise the Hawthorne Effect. This also reduces staff on the wards awareness of the presence of the observer. 2. Observations can take place by just one person or with a partner. 3. Identify an area within your ward/department where you can comfortably observe staff. Stay in this place for 20 minutes and observe your window of activity. Do not move from this place during the 20 minutes. If staff walk away without you seeing whether they perform hand hygiene, do not follow them. Do not mark anything down unless you see it. 4. Position yourself so that you do not cause an obstruction but can still see what is happening. It may feel strange and you might think that you are too noticeable. This is normal and the best thing is to just carry on. 5. Observe for 20-minute periods. 6. Using the observation sheet mark an O for a hand hygiene opportunity and an H for an actual hand hygiene activity taking place. If hand hygiene does not take place leave it blank. 7. When you have completed 20 minutes observation, give feedback to the staff a feedback form is included in this pack. When you give verbal feedback try to stress positive findings first and if you give negative feedback give examples and suggestions for improvement. 8. Keep hold of the completed observations and hand to the Senior Nurse for your area. 9. While you are observing you may identify issues which are barriers to hand hygiene, e.g. No soap, obstructed sinks, no alcohol by the bed, alcohol not working, and alcohol empty include this in your feedback. 10. Senior Nurses should compile these results, forward the completed set on to Infection Control and share them at ward managers and the IP&C meetings. 17

18 NMUH Hand Hygiene Observation Sheet Date: Time: Location: Observer: Nurses/Stn Doctors HCAs Others 20-minute period OOO HH OOO H OOOOOO HHH OO H Compliance = observed hand hygiene (H s) = 7 x 100 = 50% Hand hygiene opportunities (O s) 14 18

19 Basic observation chart: NMUH Hospital Hand Hygiene Observation Sheet Date: Time: Location: Observer: Ward manager/junior sister Staff nurses Student nurses Consultants Senior doctors e.g. registrars Junior doctors FY1, FY2 HCAs Allied Healthcare Professionals Others 20-minute period 19

20 Compliance = observed hand hygiene (H s) x 100 = Hand hygiene opportunities (O s) Once competed, please return copy to the IP & C Team situated on the first floor of the Pathology Dept. 20

21 Hand Hygiene Observation Tool - Feedback Form Date Time Ward/unit Observers Score: Observed hand hygiene (H) x 100 Hand hygiene opportunities (O) Score by staff group (if requested) Score compared to last observation Score compared to divisional/unit/directorate average 21

22 Specific feedback Feedback given to: Further action required 22

23 Appendix 4 YOUR 5 MOMENTS OF HAND HYGIENE Hands should be cleaned at a range of times however in order to prevent HAI at the most fundamental times during care delivery and daily routines, when caring for those sick and vulnerable the 'Your 5 moments for Hand Hygiene' should be followed 23

24 Appendix 5 Bare Below the Elbows policy Zero Tolerance Infection Control Bare Below the Elbows In accordance with the new DoH guidelines on prevention of health care associated infections (HCAI s) the Trust is adopting the bare below the elbows policy for all clinical staff Doctors, Nurses and Allied Health Professionals. What does this mean? Following the publication of Uniform and Work wear An evidence base for developing local policy and in accordance with duty 4 of the Health Act (2006) the Trust is implementing the following - 1. Nothing to be worn below the elbows for all clinical activity - short sleeves dress code - no wrist watches or wrist jewellery - rings are to be kept to a single plain band without stones 2. Hand Hygiene principles must be adhered to in line with the existing policies and procedures, these include; - All staff are to use the alcohol hand rub on entry and prior to exit of all wards/ clinical environment - All staff are to use the alcohol rub before and after touching each patient and patient environment - All staff are to wash their hands with soap and water when patients have vomiting or diarrhoea, or when hands are visibly soiled/ dirty 3. Medical equipment that has direct patient contact i.e. stethoscopes, must be cleaned between patients using Alcowipes. 4. Ties are to be tucked in or removed 5. No false/ acrylic nails or nail varnish Areas of high risk/extra measures in place follow the local policy as per the notice at the entrance i.e. Eleanor East, Pymmes and ICU Religious and Cultural beliefs Long sleeves may be worn underneath regular uniform by some members of staff; however, it is imperative that staff wear a clean top every day and that the sleeves are rolled up prior to patient contact. Any further enquiries should be made directly to the Infection Control Team. Remember Hand Hygiene Saves Lives Uniforms and work wear an evidence base for developing local policy G.Jacobs, DOH, September 2007 epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections

25 Appendix 6 Equality Impact Assessment Tool To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval /No Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems No No No No No No No No No 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? N/A No No No 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A If you have identified a potential discriminatory impact of this procedural document, please refer it to the Director of Organisational Development & Human Resources, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact the Deputy Director of Human Resources. 25

26 Appendix 7 Checklist for the Review and Approval of Procedural Document To be completed and attached to any policy document when submitted to the Hospital Management Board for consideration and approval. 1. Title Title of document being reviewed: Is the title clear and unambiguous? Is it clear whether the document is a guideline, policy, protocol or standard? 2. Rationale Are reasons for development of the document stated? 3. Development Process Is it clear that the relevant people/groups have been involved in the development of the document? Are people involved in the development? Is there evidence of consultation with stakeholders and users? 4. Content Is the objective of the document clear? Is the target population clear and unambiguous? Are the intended outcomes described? 5. Evidence Base Are key references cited in full? Are supporting documents referenced? 6. Approval Does the document identify which committee/ group will approve it prior to ratification by Hospital Management Board? 7. Dissemination and Implementation Is there an outline/plan to identify how this will be done? 8. Document Control Does the document identify where it will be held? 9. Process to Monitor Compliance and Effectiveness /No Comments 26

27 Title of document being reviewed: Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document? Is there a plan to review or audit compliance with the document? 10. Review Date Is the review date identified? Is the frequency of review identified? If so is it acceptable? 11. Overall Responsibility for the Document /No Comments Is it clear who will be responsible for coordinating the dissemination, implementation and review of the document? Executive Sponsor Approval If you approve the document, please sign and date it and forward to the author. Policies will not be forwarded to HMB for ratification without Executive Sponsor Approval Name Signature Date Hospital Management Board Approval The Deputy Chief Executive signature below confirms that this policy was ratified by Hospital Management Board. Name Joe Harrison Date August 2008 Signature Responsible Committee Approval only applies to reviewed policies with minor changes The Committee Chair s signature below confirms that this policy was ratified by the responsible Committee Name Name of Committee Signature Date Name & role of Committee Chair 27