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

HUMBER NHS FOUNDATION TRUST INFECTION PREVENTION AND CONTROL STRATEGY 2015-2017 1. Introduction Healthcare associated infections (HCAI) continue to be a major cause of patient harm and although nationally there have been significant reductions achieved in the number of patients developing serious infections such as MRSA (Meticillin Resistant Staphylococcus aureus) bacteraemia and Clostridium difficile, the rates of other HCAI have risen due to the emergence of resistant organisms in healthcare settings. It is therefore important that the reduction of HCAI remains a high priority on any patient safety agenda. The provision of an Infection Prevention and Control Strategy is an essential requirement for any organisation. Its purpose is to; Clarify the outcomes that they wish to achieve; Determine the broad priorities that will be adopted to achieve those outcomes; Identify the ways that progress will be measured. This strategy aims to set out the direction of all infection prevention and control activity undertaken within or on behalf of Humber NHS Foundation Trust over the next two years. It also is designed to ensure compliance to Care Quality Commission (CQC) Outcome 8 (Regulation 12), Cleanliness and Infection Control standards and to achieving local and national targets. 2. The Trust Vision Caring, Compassionate, Committed As outlined in the Humber NHS Foundation Trust Organisational Plan 2015-2019 the trust affirms its commitment to being a leading provider of integrated health services. It also aims to be recognised for the care, compassion and commitment of all staff. In order to support the delivery of this vision and to prevent any avoidable harm to any patient due to infection we aim to focus on 6 main areas of improvement as highlighted below. The proposed objectives are intended to focus on the continuing requirement to reduce HCAI and to firmly embed infection prevention in to everyday practice to keep patient, visitors and staff safe. 3. Strategic Priorities Priority 1: Patient Safety The safety of every patient we care for is our number one priority We are proud to report that we have an excellent track record on preventing HCAI and continue to perform well against both national and locally agreed targets. Achievements over the last year have included; 0 patients reported as developing a trust apportioned MRSA blood stream infection. Prevention and Control Strategy 2015-2017 Page 1

0 trust apportioned Clostridium difficile infection. An improvement in staff hand hygiene compliance (98% compared to 95% in 2013-2014). In line with the NHS Operating Framework 2015-2016, we want to ensure that the incidence of serious HCAI continues to remain within or better than agreed thresholds and that cleanliness in our healthcare premises meets the highest standards. We acknowledge that the public rightly expect healthcare environments to be clean and safe. Service users need to be confident that all our premises and equipment used in the delivery of healthcare will exceed minimum standards of cleanliness and be appropriate for purpose. Over the next 2 years we aspire to; Comply fully with all requirements of the Code of Practice on the prevention and control of infections and related guidance. Provide a patient environment that is clean and acceptable to patients, visitors and staff. Achieve all national and locally agreed infection prevention and control targets. Develop a multi-disciplinary approach to antimicrobial stewardship. Priority 2: Quality & Clinical Governance We are committed to developing a robust governance framework which monitors the quality of all our infection prevention and control activity Sustainable reductions in HCAI like MRSA and Clostridium difficile require the proactive involvement of every member of staff working across all healthcare settings. All staff have a role to play in reducing HCAI and making that contribution is crucial. To ensure that all staff are aware of their individual responsibilities it is extremely important to ensure that there are effective structures, processes and systems in place to monitor the quality of all infection prevention and control activity, providing assurance to the public about the quality of care that is being delivered and the improvements that are being made. A trust wide review of operational structures has recently been undertaken and have now entered the final stages of implementation. We are committed to ensuring that teams at all levels within the organisation are able to define their specific roles and responsibilities, outcome measures and infection performance indicators across their workforce. To support this over the next 2 years we will; Ensure there is corporate ownership of the infection prevention and control agenda. Prevention and Control Strategy 2015-2017 Page 2

Develop a robust infection prevention and control governance reporting structure in line with local and national requirements. Improve clinical and managerial engagement in infection prevention and control improvement work by establishing and managing an operational framework which monitors and assures improvement on HCAI. Priority 3: Patient Experience We are committed to keeping patients and the public informed about all aspects of their care and ensuring they are involved whenever possible in key decisions Engaging with patients, users and carers is essential in the planning, designing and delivery of any care. Benefits include a more responsive service, improved patient outcomes, improved patient experience and shared decision making. We would like to increase the level of patient and public involvement in infection prevention and control matters in order to share ideas and become more patient focused, improving the overall patient experience. Over the next 2 years we will; Improve the quality and availability of patient information available. Create opportunities to hear patients and family members describe their perspective of infection prevention and control practice within the hospital care experience in order that improvements can be made. Promote patient involvement in all national infection related patient safety initiatives such as World Hand Hygiene Day. Priority 4: Clinical Effectiveness We are committed to improving the care we provide by continually striving for excellence As a trust we are committed to developing excellence in the quality of care we deliver to our patients. We want to deliver care that is evidence-based and consistently applied in all areas across the trust. To do this we need to measure how consistent and reliable our care is throughout all areas. We aim to identify any variations in infection prevention and control practice and address any areas or issues where improvement is needed. Over the next 2 years we will; Ensure that staff continue to have access to infection prevention and control policies and guidance that reflects current national policy, statutory requirements and best evidence based guidance. Ensure that a robust infection prevention and control audit programme is in place. Develop a quality improvement programme aimed at minimising the risk of urinary catheter related infections. Prevention and Control Strategy 2015-2017 Page 3

Priority 5: Partnership working We are committed to working in partnership to improve the care we provide by being open, transparent and inclusive Working collaboratively across organisational boundaries is essential in the reduction of HCAI and achieving infection prevention targets. Benefits include; The ability to improve decision making due to a broader understanding of the bigger picture. The access to increased capacity and expertise providing the opportunity to achieve more for less. An increase of responsiveness through economies of scale and availability of more resources. Work has commenced in the strengthening of partnership working with all providers and Commissioners to drive forward a further reduction of HCAI across the whole health care economy. Over the next 2 years we will; Continue to share learning with regional partners and learn from others by the continued attendance at regular local and regional meetings. Continue to participate in the development of policies and procedures across the whole health economy to guarantee a unified approach to delivering high standards of infection prevention and control. Remain committed to supporting national initiatives and innovations in order to improve the patient journey. Complete a rigorous investigation of all episodes of any HCAI and evidence learning from them. Priority 6: Providing leadership in infection prevention and control We are committed to ensuring that exemplary infection prevention and control principles are firmly embedded within every staff members daily practice Infection control and the prevention of all infection remains a major goal within all healthcare settings and ultimately is the responsibility of everyone who works within the trust. Exemplary care should be delivered by staff who understand and effectively discharge their roles and individual responsibilities for the prevention and treatment of HCAI. To support staff the Infection Prevention and Control Team (IPCT) currently deliver an evidence-based educational programme for all members of trust staff. Prevention and Control Strategy 2015-2017 Page 4

An organisational review of the Trust Statutory and Mandatory Training Programme has recently been completed and is expected to provide the IPCT with an opportunity to develop a wider range of options for staff to fulfil development and training needs. Over the next 2 years we will; Aim to develop a wider range of options for staff to fulfil development and training needs. Review and refresh the infection prevention and control training programme to ensure it remains responsive to both national requirements and staff needs. Sustain and enhance the infection prevention and control link practitioner programme. 4. Strategy Delivery How will we achieve all the priorities highlighted within this strategy? The strategy will be delivered though; The formulation and delivery of a Trust Infection Prevention and Control Quality Improvement Plan (Appendix 1). Visible and strong trust board leadership; the strategy is approved by the Board and will be supported and overseen by members of the Executive Team. Clear lines of responsibility and effective performance management of all Care Group s. The formulation of infection prevention and control policies which reflect national recommendations, statutory requirements, latest guidance and local need. The inclusion of infection prevention and control issues in all business planning processes as a matter of course. A varied trust infection prevention and control training programme. Local and trust performance management; performance against HCAI targets are reported through the Trust key performance indicators. A programme of infection prevention and control assurance reporting; including progress with audit action plans, environmental issues and observation of clinical practice utilising the Infection Prevention Society s (IPS) Quality Improvement Tool (QIT) framework. Rigorous investigation of all episodes of HCAI and evidence of learning from them. Regular monitoring and reporting of HCAI in accordance with Department of Health and Trust approved reporting requirements. Performance managing areas where problems are identified. Sustaining a motivated engaged workforce. Improved engagement with all patients and the public. 5. Strategy Implementation, Monitoring and Review The Trust Board is responsible for ensuring the trust has appropriate infection prevention and control systems and resources in place to enable delivery of all the Prevention and Control Strategy 2015-2017 Page 5

infection prevention and control objectives. This strategy and the Trust Infection Prevention and Control Quality Improvement Plan will be approved and reviewed by the Trust Board. Progress made against the strategy will be monitored bi-monthly by the HCAI Group. A quarterly briefing report will be prepared and presented to the Quality and Patient Safety Committee. This will highlight any achievements made as well as escalating any areas of concern. An Annual Infection Prevention and Control report will be produced and presented to the Trust Board. Other reports will be produced by exception. 6. Dissemination of Strategy The strategy will be available on the trust intranet. Awareness of the strategy will be raised through education and training, staff briefing and the IPCT newsletter. Prevention and Control Strategy 2015-2017 Page 6

Appendix 1 Infection Prevention and Control Quality Improvement Plan April 2015 April 2016 Priority 1. The safety of every patient we care for is our number one priority No. Development area Action Performance 1.1 Ensure compliance with Develop and implement an Work plan produced all requirements of the Annual Infection with measurable Code of Practice on the Prevention and Control outcomes included. prevention and control of Work Plan for 2015- infections and related guidance ensuring all statutory duties are effectively discharged. Bi monthly briefing report presented at the Quality and Patient Safety 1.2 Strengthen approach to the delivery of a trust-wide environmental audit programme ensuring all trust properties meet the fundamental standards of cleanliness and safety. Develop and implement a robust multidisciplinary environmental infection prevention and control audit programme. IPC/ Head of Estates and Environ mental Services Committee. A multidisciplinary infection prevention and control environmental audit programme agreed and completed in all trust owned premises Date 31 st July 30 th March Quarter 1 Annual Infection Prevention and Control Work Plan developed. Draft produced and presented to the IPCC 14.7.15. First briefing repot presented at the inaugural meeting 9.9.15 Quarter 1 Agreement in principle received from Stephen Dale/ Rob Atkinson. Multi- disciplinary audit programme commenced with extremely positive feedback received Prevention and Control Strategy 2015-2017 Page 7

No. Development area Action Performance 1.2 cont A report and improvement IPCT. Evidence produced plans to be produced for that any gaps in all areas audited. compliance have been escalated to the appropriate Care Group Triumvirate to 1.3 Maintain the delivery of a zero tolerance approach to MRSA apportioned infection. Undertake continuous surveillance of all alert organisms eg MRSA. action. To have Zero trust apportioned cases of MRSA bacteraemia. Date 30 th March from both the matrons and estates personnel involved. Defects are logged and actioned in a more timely manner. Action plans produced for each area audited Quarter 1 No cases reported- Remains within agreed threshold. No cases reported- Remains within agreed threshold. 1.4 Maintain progress against the delivery of contractually agreed trajectories for MSSA (meticillin sensitive staphylococcus aureus), Clostridium difficile, and E.coli bacteraemia. Undertake continuous surveillance of all alert organisms eg MSSA, C. difficile, and E.coli bacteraemia. To remain within the annual contractually agreed trajectory 30th March Quarter 1 No cases reported- Remains within agreed threshold. 1 trust apportioned C. difficile reported. (Cumulative position for the year 1 Remains within annual trajectory (4 ) Prevention and Control Strategy 2015-2017 Page 8

No. Development area Action Performance 1.5 Promote antimicrobial stewardship. Support the ongoing monitoring of antibiotic prescribing practice in the Trust in-patient units. Chief Pharmac ist Compliance data produced and improvement noted. Date 1st October Compliance data produced and shared with the HCAI group. Antibiotic choice noted to be appropriate in all cases where the indication was highlighted. 1.6 To review the Scottish Antimicrobial stewardship programme package for potential utilisation within the Trust. Nurse/ Medicine Manage ment Nurse. An appraisal completed and outcome shared with HCAI Group members. 1 st November Meeting date arranged for Debbie Davies and Julie Moore to discuss the potential roll out within the organisation 1.7 Maximise the approach to learning from infection acquisition and incidents to improve patient safety and experience. An RCA / PIR investigation to be completed for any trust apportioned infection or incident e.g. C.difficile infection / MRSA and MSSA bacteraemia. Nurse Investigation completed within specified PHE time frames and report produced to highlight learning. Quarter 1 1 st August 2015 No alert organisms currently identified. RCA analysis currently underway for Trust apportioned C. difficile. Prevention and Control Strategy 2015-2017 Page 9

Priority 2. We are committed to developing a robust governance framework which monitors the quality of all our infection prevention and control activity No. Development area Action Performance Date 2.1 Ensure there is corporate ownership of the trust infection prevention and control agenda. Production of an Annual Infection Prevention and Control 2014-2015 report. D Report received and approved by the Trust Board. May Action completed. Presented and approved by the Trust Board 22.5.15. 2.2 Ensure there is a robust infection prevention and control governance reporting structure in place which fulfils local and national requirements. Infection Prevention and Control Strategy 2015-2017. Develop an internal infection prevention and control governance framework to ensure board to ward reporting in relation to infection prevention and control. D D Strategy received and approved by the Trust Board. Framework produced and approved by the Trust Board. October Infection Prevention and Control Strategy 2015-2017 produced. to the Trust Board agenda for 4.11.15 October 2015 HCAI Group Tor reviewed and amended. Presented at the Quality &Patient Safety Committee 9.9.15 2.3 Robust processes are in place to ensure all infection prevention and control activities are monitored and performance managed. Annual Infection Prevention and Control Quality Improvement Plan to be developed for 2015- Annual Infection Prevention and Control Quality Improvement Plan completed. Plan approved by the Quality and Patient Safety Committee. October Annual Infection Prevention and Control Quality Improvement Plan developed and agreed. Prevention and Control Strategy 2015-2017 Page 10

No. Development area Action Performance 2.4 Robust processes are in The infection prevention D Infection Prevention place to ensure all and control service and Control Team infection prevention and requirements to be service requirements control activities are reviewed. determined. monitored and performance managed. 2.5 Develop and adopt an Infection Prevention and Control Dashboard to ensure early warning indicators are robust. Infection Prevention and Control Dashboard developed and approved at the Quality and Patient Safety Committee. Date 1 st January 30 th October Current arrangements reviewed. IPC to extend contact until March A full review will commence in December Draft dashboard presented at the HCAI Group 22/10/15. Circulated for wider consultation prior to adoption Priority 3. We are committed to keeping patients and the public informed about all aspects of their care and ensuring they are involved whenever possible in key decisions 3.1 Strengthen patient and family engagement in all aspects of infection prevention and control practice. Key themes identified for learning and action plan produced. 1 st January Dates requested and received for the IPCT to attend the Quality Circle meetings. Create opportunities to hear patients and family members describe their experience of infection prevention and control practice within the healthcare setting. Patient Carer Experience Group ToR membership amended to include Infection Prevention and Control representation. Prevention and Control Strategy 2015-2017 Page 11

No. Development area Action Performance 3.2 Strengthen patient and The IPCT to attend the unit IPCT Evidence of family engagement in all Quality Circle meetings attendance and a plan aspects of infection of action produced to prevention and control address any issues practice. raised. 3.3 Ensure all patients, service users and carers are provided with suitable information on all infection concerns. The Nurse to become an active member of the Patient carer Experience Group Review all patient and public information leaflets currently utilised within the Trust. Review all comments received by staff following completion of the East Riding Consortium infection control audits. Produce or sign post the patients and public to good quality patient information This to include materials from national or local antimicrobial awareness campaigns. IPC IPC Evidence of attendance at the Patient Carer Experience Group Good quality patient information is readily available to both staff and patients on the Trust website. Date Quarter 1 1st January 1st January 15 th November 2015 1st January 1st January Inaugural meeting arranged for 9th November 2015 A review of all patient information available on the intranet has commenced. An analysis of all staff comments made and areas for improvement have been identified. Prevention and Control Strategy 2015-2017 Page 12

Priority 4. We are committed to improving the care we provide by continually striving for excellence No. Development area Action Performance 4.1 Provide evidence about Refresh the infection An improvement plan the quality of care in a prevention and control produced in each service to establish audit programme to area. Progress confidence amongst staff, measure compliance with Modern monitored by the Care patients. trust infection prevention Matron. Group. Exception and control policies. reports required against any gaps in compliance. Date Quarter 1 + 2 1 st Audit programme September refreshed and in place. 4.2 Provide evidence about the quality of care in a service to establish confidence amongst staff, patients. 4.3 Ensure all policies in place are reviewed to ensure they reflect national policy, statutory requirements, latest guidance and local need. An infection prevention and control dashboard to be developed for all in patient and community areas Review all the Infection Prevention and Control policies in place. Modern Matron. An improvement plan produced in each area. Progress monitored by the Care Group. Exception reports required against any gaps in compliance. All policies reviewed and re approved. 1 st October 2015 1 st October Draft Infection prevention and control dashboard developed. To be presented at the Health Care Group Infection meeting 22.10.15 Hand Hygiene Policy/ Cleaning and Disinfection of Medical Devices and MRSA policy all reviewed and out for consultation. Prevention and Control Strategy 2015-2017 Page 13

No. Development area Action Performance 4.4 Develop a quality Baseline Trust wide improvement programme urinary catheter to minimise the infection associated infection risks associated with rate identified. urinary catheter infections. 4.5 Sustain improvements made in hand hygiene compliance. Produce an improvement work plan which includes a timetable for the completion of; i) A Trust wide baseline prevalence audit of urinary catheter usage and management to determine associated infection rate. iii) An assessment of staff urinary catheter management knowledge. Review and refresh the Trust Hand Hygiene statement pertaining to bare below the elbow. D Briefing report produced and findings reviewed by Care Groups. Action plan produced to determine future training needs Statement completed and circulate to all Trust staff Date Quarter 1 + 2 30 th September 1 st November 1st November 1 st September Urinary catheter prevalence completed. Data currently being analysed. Staff questionnaires underway. Quarter 1 Hand Hygiene Statement amended and cascaded in the Global Newsletter August The Hand Hygiene Policy has been amended to reflect the changes. Endorsement has been received from the HCAI Group 22.10.15. Prevention and Control Strategy 2015-2017 Page 14

No. Development area Action Performance 4.5 cont Sustain improvements made in hand hygiene compliance. The Trust will participate and promote the World Health Organisation (WHO) Hand Hygiene Day. Evidence of participation and update of activities cascaded. Date Quarter 1 + 2 Committee meeting agenda for 13th November 2015 5 th May Priority 5. We are committed to working in partnership to improve the care we provide by being open, transparent and inclusive 5.1 Participate in the development of unified policies and procedures across the whole health economy to guarantee a single approach to delivering high standards of infection prevention and control. Work in partnership with the Yorkshire branch of the Infection Prevention Society to develop a selection of regionally approved policies. Participation and development of policies and the cascade of work completed. 1 st April Quarter 1 Meeting arranged for 22.9.15 Meeting held as arranged. Planned work programme has been agreed. 5.2 Support national patient safety initiatives and innovations in order to minimise the risk of infection and raise awareness. The Trust will participate and promote International Infection Prevention Week. Evidence of participation and outcomes achieved. 25 th October All link practitioners informed of the IP week. A global email cascaded to all areas with a variety of resources to support the planned activities. Hand hygiene Prevention and Control Strategy 2015-2017 Page 15

No. Development area Action Performance 5.3 Improve communication channels with regional health care providers and Commisioners. To be an active participant and member of the Humber HCAI Group. DIPC Evidence of attendance at the meeting. The production of joint work projects. Date Quarter 1+2 competency assessment dates to be arranged for all Directors The last 2 regional group meetings have unfortunately been cancelled by the CCG Awaiting confirmation of a further date. Meetings have taken place with colleagues across the patch to discuss HCAI issues and the development of future project work development. A Yorkshire and Humber Network event is planned for Novemeber to share learning, discuss initiatives, showcase best practice and offer peer review and support opportunities. This will take place in November The Nurse Prevention and Control Strategy 2015-2017 Page 16

No. Development area Action Performance Date Quarter 1 + 2 continues to attend the regional infection prevention society network meetings quarterly to share practice with IPCT colleagues across the Yorkshire region. Priority 6. We are committed to ensuring that exemplary infection prevention and control principles are firmly embedded within every staff members daily practice 6.1 Deliver exemplary care by professionals who are aware of their responsibility and accountability for the prevention and treatment of HCAI. 6.2 Sustain a motivated engaged workforce. 6.3 Maintain and strengthen the Link Practitioner programme. Review and refresh the infection prevention and control training programme in line with the Trust Board approved Training Programme 2015- Develop a newsletter detailing HCAI news and initiatives. Sustain a motivated engaged Link Practitioner workforce. Nurse. IPC Training programme reviewed and refreshed. Training figures to be monitored. Positive staff evaluation. Launch first edition of newsletter and continue to produce quarterly. Measure meeting attendance rate. Produce meeting evaluations and evidence of changes 1 st October 1 st September Training programme reviewed and refreshed. Mandatory requirements amended. Additional bespoke sessions have commenced at various bases and locations 1 st staff newsletter produced and circulated August March Quarter 1 Link practitioner training sessions completed. Link practitioner Prevention and Control Strategy 2015-2017 Page 17

No. Development area Action Performance 6.3 cont. made at unit / department level. Date Quarter 1 + 2 training sessions completed Evaluations reviewed positive feedback received. Attendance rate data to be included in the proposed infection prevention and control dashboard. All link practitioners currently commencing a 1.1 supervision programme to develop /enhance performance Prevention and Control Strategy 2015-2017 Page 18