Healthcare associated infection (HAI) Self-assessment In February 2015, Healthcare improvement Scotland published the National Standards for Healthcare Associated Infection (HAI) 1. These emphasise the need for all NHS board staff to be involved in infection control initiatives. The prevention and control of infection is everybody s responsibility, with standards being one part of the drive towards a safer NHSScotland. The standards are aligned to the Health Protection Scotland National Infection Prevention and Control Manual (April 2014) 2. The standards and the national infection prevention and control manual are key publications for healthcare organisations to adhere to, to ensure robust HAI practice and policy. We will also refer to national guidance such as Chief Executive Letters (CELs), Health Department Letters (HDLs) and legislation where appropriate. The Healthcare Environment Inspectorate (HEI) will use the self-assessment to inform our inspection activity. We will request that the self-assessment is submitted annually on the first Monday in June. After 6 months, we will contact NHS boards to review the self-assessment and include any substantial changes. NHS boards should provide narrative about how they achieve the desired outcomes for each standard and the methods in place to achieve them. Answers should be kept as concise and as focused as possible. It will also be acceptable to describe the outcomes in a criteria by criteria based narrative. Examples of evidence of achievement have been included for you to consider. However, this is not a compulsory or exhaustive list and other evidence is welcome. Please consider this as a guide, listing the types of evidence you may wish to provide. You should 1 Healthcare Improvement Scotland. Healthcare Associated Infection (HAI) Standards. February 2015 2 Health Protection Scotland National Infection Prevention and Control Manual April 2014 Produced by: HEI Page 1 of 24 Review Date: n/a
provide any evidence you consider supports the outcome. You will not need to submit completed examples of audits, cleaning schedules and individual training records unless you wish to do so, but should include, for example, blank tools. NHS boards can provide alternative examples as they deem appropriate. Please ensure that any policies, guidance, minutes or templates, etc are the current version or the latest document. The completed self-assessment, evidence list and evidence should then be submitted to HEI. Each item of evidence should only be submitted once. NHS boards should provide evidence on an encrypted memory stick and complete the corresponding evidence list provided with the self-assessment template. If the NHS board has published information that it wants to submit, we will accept hyperlinks to that information as part of the evidence, for example to relevant pages of the NHS board s webpage. Please ensure that any updates to the self-assessment are clearly identified in the summary of changes sheet at the beginning of the self-assessment. It is not the intention that the infection prevention and control team complete the self-assessment without input from other departments and services. The self-assessment is to be the collective work of the NHS board and will require input from a variety of disciplines. Please ensure that the self-assessment is signed off using the attached declaration sign-off form. If you require further information, or if you encounter any problems when completing your self-assessment, please contact HEI: tel: 0131 623 4306 in the first instance. Produced by: HEI Page 2 of 24 Review Date: n/a
LEADERSHIP, GOVERNANCE and ACCOUNTABILITY Standard 1: Leadership in the prevention and control of infection The organisation demonstrates leadership and commitment to infection prevention and control to ensure a culture of continuous quality improvement throughout the organisation. Outcome 1: Patients and visitors have confidence that the organisation has effective leadership and governance and the organisation is able to demonstrate achievements in continuous improvement in infection prevention and control Please describe how the NHS board demonstrates effective leadership and governance by reviewing HAI criteria 1.1 1.11 and considering the questions below. Please describe the systems and process in place to support this standard. 1. How does the NHS board demonstrate effective leadership and support to enable the infection prevention and control team to provide a proactive service? 2. Describe the infection prevention and control accountabilities and responsibilities of all staff groups across the organisation? 3. How does the NHS board demonstrate achievements in continuous improvement, including the use of data, in infection prevention and control? Examples of evidence of achievement have been included for you to consider. However, this is not a compulsory or exhaustive list and alternative evidence is welcome. Produced by: HEI Page 3 of 24 Review Date: n/a
Suggested evidence of achievement (further examples of evidence can be found in the HAI standards): Organisational chart showing the management and accountability of infection prevention and control from executive level to frontline care Organisational chart describing the role and structure of the infection prevention and control team Infection prevention and control committee terms of reference and membership Infection prevention and control annual work programme and annual report Two-way reporting structure for infection prevention and control committee Management (leadership/patient safety) walkround schedule, including attendees Infection prevention and control team audit schedule and criteria to target audits Organisational arrangements for the monitoring of implementation of policies and practice, such as senior manger reviews/audits National and local organisational HAI key performance indicators (KPIs) - KPI compliance monitoring, reporting and governance structure Information relating to how the NHS board learns from positive reporting and incidents, outbreaks and adverse events (including the involvement of patients and visitors) Organisational infection prevention and control risk register (or infection prevention and control risks on individual registers, for example directorate/site level risk registers) Policy (if applicable) or detail on what HAI audit information should be displayed on wards Risk assessment template and guidance documents relating to continuity of patient care during periods of service planning and reorganisation NHS board outbreak management plan including preparedness, assessment of patient care and safety, reporting and remedial action plan information [NHS board narrative to be inserted here] Produced by: HEI Page 4 of 24 Review Date: n/a
EDUCATION Standard 2: Education to support the prevention and control of infection Education on infection prevention and control is provided and accessible to all healthcare teams to enable them to minimise infection risks that exist in care settings. Outcome 2: People using the service are assured that staff delivering care are educated and trained in prevention and control of infection. Please describe how the NHS board ensures that staff delivering care are appropriately educated and trained by reviewing HAI criteria 2.1 2.7 and considering the questions below. Please describe the systems and process in place to support this standard. 4. How does the NHS board demonstrate that it carries out routine analysis of training needs for all staff? 5. What are the organisational guidelines on the provision of infection prevention and control training? 6. How does the NHS board monitor staff attendance and completion of infection prevention and control training and education? 7. How is infection prevention and control training and education evaluated? 8. How does the NHS board demonstrate that it responds to national and local HAI-related intelligence to ensure it meets the education needs of its staff? Examples of evidence of achievement have been included for you to consider. However, this is not a compulsory or exhaustive list and alternative evidence is welcome. Produced by: HEI Page 5 of 24 Review Date: n/a
Suggested evidence of achievement (further examples of evidence can be found in the HAI standards): Describe how the NHS board uses data to identify and address gaps in training and education needs An example of a training needs analysis (or similar) for HAI related training and education NHS board s infection prevention and control education programme and governance structure including: - HAI education strategy (including expectations for mandatory HAI induction and update training) - details of roles and responsibilities for ensuring staff are up to date with training (including appraisals, personal development plans, objectives, KSF etc). This should include how and where training is recorded, how non-attendance is addressed, etc - tailored education to meet roles and responsibilities - guidance on infection specific management, including Clostridium difficile and loose stools policies. Describe how the NHS board evaluates training to ensure that HAI training is appropriate Describe how national education programmes are implemented at a local level [NHS board narrative to be inserted here] Produced by: HEI Page 6 of 24 Review Date: n/a
COMMUNICATION Standard 3: Communication between organisations and with the patient or their representative The organisation has effective communication systems and processes in place to enable continuity of care and infection prevention and control throughout the patient s journey. Outcome 3: People receiving care in one or more care setting can expect to receive effective communication on infectionrelated risks and to be involved in care decisions taken to mitigate these risks. Please describe how the NHS board ensures that people receive effective communication and are involved in care decisions by reviewing HAI criteria 3.1 3.10 and considering the questions below. Please describe the systems and process in place to support this standard. 9. How does the NHS board communicate effectively throughout the patient s care journey to ensure effective infection prevention and control continues for the patient in all care settings? Consider the information provided to staff, patients and how this is documented. 10. How does the NHS board ensure that information provided to patients, visitors and carers is in a suitable format and is communicated effectively throughout the patient journey? 11. How are the views of patients, their family and representatives gathered and acted upon and used to change practice, for example patient surveys and complaints data? Examples of evidence of achievement have been included for you to consider. However, this is not a compulsory or exhaustive list and alternative evidence is welcome. Produced by: HEI Page 7 of 24 Review Date: n/a
Suggested evidence of achievement (further examples of evidence can be found in the HAI standards): Patient infection prevention and control risk assessment template and accompanying policies and/or guidance (those used on patient admission and transfers) Policy/guidance for when staff should contact the infection prevention and control team, including where advice is recorded Policies/guidance on staff responsibilities for providing and recording HAI information given to patients and their representatives and how this informs the patients care plan Information supplied to patients, their family and representatives about infection prevention and control, including those patients and their representatives who have a known or suspected infection Guidance on staff responsibilities for providing and recording communication with patient representatives where the cause of death is HAI related NHS board s patient/public engagement strategy, including terms of reference for any HAI-related patient focus public involvement groups Public and staff engagement survey templates and any guidance on how and when the surveys are carried out NHS board s HAI communication strategy [NHS board narrative to be inserted here] Produced by: HEI Page 8 of 24 Review Date: n/a
HAI SURVEILLANCE Standard 4: HAI surveillance The organisation has a surveillance system to ensure a rapid response to HAI. Outcome 4: Patients, visitors and the public can expect to be cared for in an environment where the executive team, infection prevention and control team and clinical teams are effectively working together to monitor, minimise and manage infection risks. Please describe how the NHS board ensures that there is effective team working to monitor, minimise and manage infection risks by reviewing HAI criteria 4.1 4.8 and considering the questions below. Please describe the systems and process in place to support this standard. 12. What local and national HAI surveillance is carried out by the NHS board? 13. How is data from local and national HAI surveillance used to inform the NHS board s response to HAI risks, including emerging risks and outbreaks? 14. How does the NHS board evaluate the effectiveness of its surveillance programmes? 15. Once HAI data has been analysed, how is it communicated in a meaningful way to patients, staff and visitors? Examples of evidence of achievement have been included for you to consider. However, this is not a compulsory or exhaustive list and alternative evidence is welcome. Suggested evidence of achievement (further examples of evidence can be found in the HAI standards): A surveillance programme incorporating mandatory national and local surveillance Three most recent NHS board HAIRT reports Current HAI surveillance annual report(s), including a description of the effectiveness of surveillance activity Produced by: HEI Page 9 of 24 Review Date: n/a
Describe how and where surveillance information is recorded to support real-time surveillance activity Standard operating procedure for trigger alerts including response to variance and outbreaks Describe the system for and governance in place for reports produced by infection prevention and control team from the assessment of surveillance data Examples of action plans resulting from trigger incidences and outbreaks, and any subsequent learning. Communication with patients, staff and visitors on the outcomes of HAI surveillance Describe how the NHS board ensures that those using HAI surveillance have undertaken up to date training with training needs assessed [NHS board narrative to be inserted here] Produced by: HEI Page 10 of 24 Review Date: n/a
PREVENTION AND CONTROL OF INFECTION Standard 5: Antimicrobial stewardship The organisation demonstrates effective antimicrobial stewardship. Outcome 5: Every patient will get the most appropriate antibiotic (type, dose, route and duration) in a timely fashion for their infection, according to local and national policy and/or guidelines. Please describe how the NHS board ensures that patients receive the most appropriate antibiotic in a timely fashion for their infection by reviewing HAI criteria 5.1 5.10 and considering the questions below. Please describe the systems and process in place to support this standard. 16. What mechanisms are in place to ensure that patients get an antibiotic that is appropriate? 17. What governance structures are in place to review antimicrobial use, provision of staff education and staff knowledge, and practice of antimicrobial stewardship? 18. How do staff access advice from local experts and locate guidelines relevant to their wards and departments? 19. What support is available to improve antimicrobial stewardship? 20. How does the NHS board respond to poor antimicrobial stewardship? Examples of evidence of achievement have been included for you to consider. However, this is not a compulsory or exhaustive list and alternative evidence is welcome. Suggested evidence of achievement (further examples of evidence can be found in the HAI standards): Describe the NHS board governance structure for antimicrobial stewardship, detailing staff roles and responsibilities Antimicrobial management team terms of reference, annual work plan/programme Produced by: HEI Page 11 of 24 Review Date: n/a
Audit and governance structure for all antimicrobial stewardship audits in the NHS board, detailing staff roles and responsibilities (including antimicrobial management team and infection prevention and control committee) Antimicrobial policies, for example empirical, prophylaxis, gentamicin/ vancomycin, controls to manage restricted antimicrobials Demonstrate that antimicrobial policies and guidance reviews take place every two years and that changes are communicated to staff Sample audit and surveillance tools for antimicrobial stewardship Examples of antimicrobial stewardship audit results (including national Scottish Antimicrobial Prescribing Group (SAPG), local targeted and point prevalence) and associated action plans Education provided to healthcare workers who are involved in the prescribing, supply and administration of antimicrobials Information provided to patients, their representatives and the public on antimicrobials [NHS board narrative to be inserted here] Produced by: HEI Page 12 of 24 Review Date: n/a
PREVENTION AND CONTROL OF INFECTION Standard 6: Infection prevention and control policies, procedures and guidance The organisation demonstrates implementation of evidence-based infection prevention and control measures. Outcome 6: Every patient receives care in a safe place without unnecessary exposure to infection. Staff providing care demonstrate knowledge of infection prevention and control practices and provide appropriate information to patients, their representatives and visitors on how to prevent infection transmission. Please describe how the NHS board ensures that patients receive care without unnecessary exposure to infection and provides appropriate information to patients on how to prevent infection transmissions by reviewing HAI criteria 6.1 6.11 and considering the questions below. Please describe the systems and process in place to support this standard. 21. Describe the NHS board s audit and governance structures for standard infection control precautions and transmission-based precautions. This should include: 22. What is the process for auditing standard infection control precautions and transmission-based precautions? 23. Who carries out standard infection control precautions and transmission-based precautions audits, for example the infection prevention and control team, ward staff, peer-to-peer system? 24. What is the frequency of standard infection control precautions and transmission-based precautions audit activity? 25. What triggers are in place to carry out audit activity on standard infection control precautions and transmission-based precautions, for example previous audit results, risk rating (RAG) systems, compliance scores etc? 26. How many observations/practice examples are recorded per audit? (for example 20 observations per standard infection control precaution per month) Produced by: HEI Page 13 of 24 Review Date: n/a
27. How are audit results reviewed at ward and senior level and how do they identify areas for improvement, for example action plans, trends analysis? 28. How are audits results quality assured? 29. How do staff challenge and improve practice as a result of audit? 30. How does the NHS board ensure that frontline staff can demonstrate their understanding and compliance with the Health Protection Scotland National Infection Prevention and Control Manual (April 2014) (standard infection control precautions and transmission based precautions)? 31. How does the NHS board implement national evidence-based infection control measures, such as alerts, legislation (CNO, CEL etc) and best practice guidelines? Examples of evidence of achievement have been included for you to consider. However, this is not a compulsory or exhaustive list and alternative evidence is welcome. Suggested evidence of achievement (further examples of evidence can be found in the HAI standards): Audit and governance structures for all standard infection control precautions and transmission-based precaution audits in the NHS board - including staff/team roles and responsibilities and arrangements for audit programme review Sample infection prevention and control audit templates (for all standard infection control precautions and transmission-based precautions audits) Infection prevention and control committee annual programme and report Infection prevention and control audit overview report A summary of audit activity to allow trends to be analysed and areas for improvement identified An overview of the clinical microbiology service, including access arrangements to specialist clinical advice on individual patient treatment Provide examples of (anonymised) condition-specific care plans following an outbreak or incident Produced by: HEI Page 14 of 24 Review Date: n/a
[NHS board narrative to be inserted here] Produced by: HEI Page 15 of 24 Review Date: n/a
PREVENTION AND CONTROL OF INFECTION Standard 7: Insertion and maintenance of invasive devices Systems and processes are in place to ensure the safe and effective use of invasive devices, for example peripheral venous catheters, central venous catheters and urinary catheters. Outcome 7: Every individual with an invasive device is reassured that the staff in the clinical area are competent and committed to providing the safest possible decision-making and care, and display data showing evidence of that commitment. Insertion and maintenance of the invasive device is clearly documented in the patient s record Please describe how the NHS board ensures that individuals are provided with safe and effective management of invasive devices by reviewing HAI criteria 7.1 7.10 and considering the questions below. Please describe the systems and process in place to support this standard. 32. How does the NHS board ensure that invasive devices are safely inserted and maintained? 33. What guidance (assessments, algorithms, posters, etc) is used to assist staff in the decision making process for the safe and effective use of invasive devices, or alternatives to invasive devices? 34. How does the NHS board ensure that staff have the appropriate skills and knowledge to insert and maintain invasive devices? 35. What and how is information provided to patients or their representatives on the use and care of their invasive device? Examples of evidence of achievement have been included for you to consider. However, this is not a compulsory or exhaustive list and alternative evidence is welcome. Suggested evidence of achievement (further examples of evidence can be found in the HAI standards): Information provided by the NHS board to assist staff to make decisions about the use of, and alternatives to, invasive devices NHS board procedures and guidance for the insertion and maintenance of invasive devices, including sample invasive device documentation Produced by: HEI Page 16 of 24 Review Date: n/a
(eg PVC/CVC/urinary catheter care bundles) Governance structure for invasive device monitoring and reporting and responding to data, including staff/ team roles and responsibilities [NHS board narrative to be inserted here] Produced by: HEI Page 17 of 24 Review Date: n/a
DECONTAMINATION AND ACQUISITION OF EQUIPMENT Standard 8: Decontamination The environment and equipment (including reusable medical devices used) are clean, maintained and safe for use. Infection risks associated with the built environment are minimised. Outcome 8: People using the services have confidence that they are being cared for in a clean, safe care environment and that all equipment used will be clean and free from contamination. Please describe how the NHS board ensures that people are cared for in a safe, clean and well-maintained environment and that patient equipment is clean by reviewing HAI criteria 8.1 8.12 and considering the questions below. Please describe the systems and process in place to support this standard. 36. Safe and clean healthcare environments, reusable medical devices and reusable patient equipment are essential so that the risk of infection is minimised. How does the NHS board demonstrate that it can achieve this? 37. What mechanisms are in place for implementation of relevant national policy and guidance about decontamination and the built environment? Healthcare environment and patient equipment: 38. How does the NHS board assure itself that it complies with the outcomes in the NHSScotland National Cleaning Services Specification? 39. How does the NHS board ensure it provides patient equipment and a healthcare environment that is safe and clean? 40. What separate governance systems are in place for the cleanliness of the healthcare environment and the management of reusable patient equipment? For example: 41. Who cleans what and when in terms of the healthcare environment and reusable patient equipment (describe roles and frequency)? 42. Provide examples of cleaning schedules used to record cleaning of the healthcare environment and patient equipment. Produced by: HEI Page 18 of 24 Review Date: n/a
43. Who signs off cleaning schedules (for the healthcare environment and patient equipment?) 44. What quality assurance systems are in place at ward level, for example spot checks/audit? 45. What happens as a result of any non-compliance identified through the assurance systems? 46. What assurance systems are in place above ward level, for example where audits and action plans discussed? 47. How do staff communicate or escalate concerns or issues with the standard of cleanliness? 48. How are the outcomes of cleaning audits consolidated to identify areas of improvement? 49. What governance arrangements are in place for the delivery of domestic services including those delivered by third party contractors? 50. What education is provided for staff to ensure they have the correct knowledge to carry out their specific role in cleaning? 51. How does the NHS board collect the views of patients, visitors and staff about the cleanliness of the care environment and the equipment and use them to improve standards and direct practice? Estates: 52. How are works managed to reduce the risk of infection? 53. What local policies and procedures are in place to involve infection prevention and control teams in the planning, design, commissioning, completion and maintenance of services and facilities? 54. What local arrangements are in place for involving the infection prevention and control team (or other appropriate expertise) in the development of infection control-related estates policies? 55. How does the NHS board comply with the current versions of Scottish Health Facilities Note 30 and HAI-SCRIBE (HAI System for Controlling Risk In the Built Environment)? Produced by: HEI Page 19 of 24 Review Date: n/a
56. Provide details of the governance structure that ensures the whole estate is planned, managed and maintained to minimise risk from infection, including: 57. What communication system is used to report works and keep wards and departments informed of progress of any reported works (repairs/faults)? Can works be tracked? 58. Who is responsible for reporting any required estate works? 59. How are works recorded within estates, including completion of works (is there a computerised system)? 60. Describe the system for prioritising allocated works and timescales. 61. Describe the roles and responsibilities of wards and estates staff for ensuring works are completed. 62. How and where are outstanding works reported or escalated? 63. Describe how contractors and the NHS board manage infection prevention and control risks for works undertaken. Reusable medical devices: 64. How does the NHS board ensure that reusable medical devices are safe for use? 65. How does the NHS board assure itself that decontamination of reusable medical devices complies with relevant technical requirements, legislation and good practice? 66. How does the NHS board review decontamination processes for reusable medical devices in the event of an incident or outbreak (for example using a hospital infection incident assessment tool)? 67. How are these findings shared with staff and external partners? 68. What risk assessments and actions are carried out as part of the decontamination procedure if a near miss, failure or non-conformance Produced by: HEI Page 20 of 24 Review Date: n/a
has been detected? Examples of evidence of achievement have been included for you to consider. However, this is not a compulsory or exhaustive list and alternative evidence is welcome. Suggested evidence of achievement (further examples of evidence can be found in the HAI standards): NHS board policies and procedures for environmental cleaning NHS board assurance system in place for environmental cleaning Evidence of education completed for all relevant staff groups for environmental cleaning NHS board policies and procedures for equipment cleaning NHS board assurance system in place for equipment cleaning Evidence of education completed for all relevant staff groups for equipment cleaning Consider evidence such as bed space checklists and cleaning schedules. Audit and governance structures for the cleanliness of the healthcare environment and patient equipment, and the monitoring and reporting of healthcare environment issues, including staff/ team roles and responsibilities. Describe the governance structure that ensures the estate is planned, managed and maintained to minimise the risk from infection Describe the process and structure for works identified and reported to estates for remedial action Describe how HAI-SCRIBE (HAI system for controlling risk in the build environment) is implemented for repairs, refurbishment or new build works Public and staff engagement survey templates Decontamination policy for reusable medical devices Examples of reusable medical devices audits Three most recent reusable medical devices audits and any action plans for surgical instruments, endoscopes, dental instruments and podiatry instruments Evidence of risk assessments where the decontamination procedure did not produce the desired outcome, or alternative documentation to demonstrate that risks have been assessed Produced by: HEI Page 21 of 24 Review Date: n/a
Infection incident assessment tool used in the event of a decontamination-related incident or outbreak Examples of records kept of decontamination cycles on reprocessing machines and traceability to individual patients [NHS board narrative to be inserted here] Produced by: HEI Page 22 of 24 Review Date: n/a
DECONTAMINATION AND ACQUISITION OF EQUIPMENT Standard 9: Acquisition of equipment All equipment acquired (this being equipment that is procured, loaned, donated, in-house manufactured or for use within a trial or research) for the care environment is safe for use. Outcome 9: Individuals will be confident that all medical devices and communal patient equipment being used by staff and/or in the healthcare setting, meet the required level of safety, quality and performance. Please describe how the NHS board ensures that all medical devices and communal patient equipment is safe for use by reviewing HAI criteria 9.1 9.4 and considering the questions below. Please describe the systems and process in place to support this standard. 69. What system is in place to demonstrate infection prevention and control in the effective procurement of medical devices and communal patient equipment? Examples of evidence of achievement have been included for you to consider. However, this is not a compulsory or exhaustive list and alternative evidence is welcome. Suggested evidence of achievement (further examples of evidence can be found in the HAI standards): NHS board s procurement policy and procedures demonstrating how infection risks are considered when purchasing new equipment for use in the healthcare setting Evidence of involvement of the infection prevention and control team in procuring new equipment for the healthcare setting Examples of evidence of assessment of new equipment to ensure it can be decontaminated in line with manufacturer s instructions and current national guidance [NHS board narrative to be inserted here] Produced by: HEI Page 23 of 24 Review Date: n/a
Additional information Please use this section for any other additional information that the NHS board would like to include that has not already been provided. Please reference any additional evidence submitted. [NHS board narrative to be inserted here] Produced by: HEI Page 24 of 24 Review Date: n/a