Improvement Action Plan NHS Tayside, Perth Royal Infirmary Healthcare associated infection inspection Inspection date: July 2017

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1 Improvement Action Plan Declaration It is the responsibility of the NHS board Chief Executive and NHS board Chair to ensure the improvement plan is accurate and complete and that the s are measurable, timely and will deliver sustained improvement. Actions should be implemented across the NHS board, and not just at the hospital inspected. By signing this document, the NHS board Chief Executive and NHS board Chair are agreeing to the points above. A representative from Patient/Public Involvement within the NHS should be involved in developing the improvement plan. NHS board Chair NHS board Chief Executive Signature: Signature: Full Name: Professor John Connell FMedSci FRSE Full Name: Ms Lesley McLay : 5 September 2017 : 5 September 2017 Produced by: HEI//NHS Tayside Page: Page 1 of 6 Review : - 1

2 taking Requirement: Standard 6: Infection prevention and control policies, procedures and guidance Req 1 NHS Tayside must ensure that in accordance with Health Protection Scotland s National Infection Prevention and Control Manual, personal protective equipment should be removed and disposed of immediately after use and hands should also be decontaminated after the completion of each task (see page 9). 1.1 An assessment of all theatre practitioners practice to be undertaken by Senior Charge Nurse and a training needs analysis completed. 1.2 The Infection Control team plan to deliver training/ education which will consist of hand hygiene, use of personal protective equipment, standard and transmission based precautions on 14/09/2017 as part of the education programme on the Clinical Effective Session. Additional sessions to be scheduled in October and November A record of attendance will be used at all sessions to evidence training. 1.3 Monitoring will be on a daily basis by the Theatre Team Leader and spot checks undertaken by the Senior Charge Nurses and Head of Nursing to provide assurance that practice is consistent and maintained. TEACH tool will be completed for audit purposes. Failures and compliance will be observed, discussed recorded by Head of Nursing in new clinical effectiveness monitoring template for standards of practice in theatre 27/09/2017 Head of Nursing / Managers/Senior Charge Nurses 27/09/2017 Infection Control Team On target to complete initial session focused on PPE and hand hygiene on 14/09/ /09/2017 Head of Nursing / Managers/Senior Charge Nurses 04/09/2017 Template complete to support Head of Nursing in recording s and observations. In progress on target for 14/09/2017 Produced by: HEI//NHS Tayside Page: Page 2 of 6 Review : - 2

3 1.4 In addition the monthly Hand Hygiene audits in the recovery areas and operating theatres will ensure that Standard 6 is met as referenced in the Ninewells Hospital Improvement Action Plan (Requirement 1.1 and 1.2). Test of Change to audit Hand Hygiene practice within the operating theatres was completed in June Requirement: Standard 8: Decontamination Req 2 taking 27/09/2017 Head of Nursing / Managers/Senior Charge Nurses August 2017 Monthly audits commenced in August 2017 for each of the theatres in Perth Royal Infirmary. The data is entered on GDet; a national system where data such as Hand Hygiene is recorded. Results are displayed on QlikView on a monthly basis and discussed as part of SCN 1to1s and local Clinical Governance meetings. NHS Tayside must ensure that all positioning pieces are stored in a clean way away from potentially contaminated areas to reduce the risk of cross contamination and infection of patients (see page 10). 2.1 A designated area in each theatre has been identified to store all positioning pieces/table attachments within the Day Surgery Unit Theatres, the Gynaecology Theatre and the five theatres in the Main suite on the Perth Royal Infirmary site. 27/09/2017 Senior Charge Nurses This will ensure that equipment is stored in a clean environment free from potentially contaminated areas and thus reduce the risk of cross contamination and patient infection. Complete July Produced by: HEI//NHS Tayside Page: Page 3 of 6 Review : - 3

4 2.2 Monitoring on a daily basis by the Theatre Team Leader and spot checks will be undertaken by the Senior Charge Nurses and Head of Nursing to provide assurance that this change is sustained. TEACH tool will be completed for audit purposes. Failures and compliance will be recorded by Head of Nursing in new clinical effectiveness monitoring template for standards of practice in theatre in order to provide assurance. taking 27/09/2017 Theatre Team Leader/ Senior Charge Nurses/ Head of Nursing Recommendation: Standard 6: Infection prevention and control policies, procedures and guidance Clean equipment is observed daily to be stored consistently separate from potentially contaminated areas A NHS Tayside should review the storage of sterile instrument trays, instruments and packs in line with Health Facilities Scotland s Management of reusable surgical instruments during transportation, storage and after clinical use (see page 9). A.1 Following the theatre inspection in Ninewells Hospital on the 21/03/2017 and 22/03/2017 and the requirement 3, 3.1, 3.2. highlighted in the Improvement Action Plan, a preliminary assessment of the current storage facilities was undertaken in Perth Royal Infirmary on 17/05/2017 by the Sterile Supplies Department Manager and the Senior Charge Nurse. 27/09/2017 Senior Charge Nurses/Operational Theatre Manager Manager/Senior Charge Nurse to confirm the additional storage facilities required in each of the theatre areas in Perth Royal Infirmary. Medical Equipment Group (MEG) bids to be completed by 27/09/17. Produced by: HEI//NHS Tayside Page: Page 4 of 6 Review : - Manager (OTM) will take cognisance of recent procurement for additional storage facilities within theatres in Ninewells Hospital, (Requirement 3.1 and 3.2 of Ninewells Hospital Improvement Action Plan). In progress on target to complete by 27/09/

5 A.2 The Sterile Services Department Manager will deliver a training/education session to staff representatives from theatres in Perth Royal Infirmary, Ninewells Hospital and Stracathro Hospital to support and evidence knowledge referenced by Health Facilities Scotland s Management of reusable surgical instruments during transportation, storage and after clinical use. Record of attendance will be completed to evidence training. Staff trained will cascade to all other theatre staff members. Recommendation: Standard 8: Decontamination B taking 27/09/2017 Sterile Services Department Manager Sterile Services Department Manager to deliver training programme on Clinical Effectiveness Session on 21st November. In progress on target to complete 21 st November NHS Tayside should review theatre cleaning practices to ensure that theatres are cleaned in a systematic way to reduce the risk of cross infection (see page 11). B.1 An assessment of current cleaning practice is being undertaken by Senior Charge Nurses within theatres in Perth Royal Infirmary and a training needs analysis completed. B.2 The Infection Control team will provide training/education specific to decontamination on the 14/09/2017 as part of the education programme on the Clinical Effective Session. 27/09/2017 Senior Charge Nurses/Head of Nursing To ensure standardisation and consistency of practice the same assessment will be undertaken by the Senior Charge Nurses in the theatres in Ninewells Hospital and Stracathro Hospital. 27/09/2017 Infection Control Team On target to complete initial session 14/09/2017. Produced by: HEI//NHS Tayside Page: Page 5 of 6 Review : - 5

6 B.3 A Standard Operating Practice (SOP) to be developed for all staff to reference during theatre cleaning practice to ensure standardisation and consistency of practice by theatre staff. taking 27/09/2017 Senior Charge Nurses/Head of Nursing Draft SOP to be circulated to to SCNs for comment by 29/09/2017 B.4 Monitoring of practice on daily basis by the Team Leader in each theatre, and the Senior Charge Nurses. The Head of Nursing will undertake spot checks in all theatres and on each of the hospital sites. 27/09/2017 Theatre Team Leader/ Senior Charge Nurses/ Head of Nursing Practice of all members of the theatre team is observed to be consistent. Produced by: HEI//NHS Tayside Page: Page 6 of 6 Review : - 6