MALLOW GENERAL HOSPITAL Quality Improvement Plan 2009 The following QIP was compiled for Hygiene Services at Mallow General Hospital by the Hygiene Services Team It has been amended and approved for implementation by the Senior Management Team Signed: Ms. Mary Owens. Director of Nursing. On behalf of the April 2009
Quality Improvement Plan 2009 Hygiene Services Mallow General Hospital 6 Main Areas to focus on: To maintain our rating of 2008 To look for continuous improvements in all areas Focus on the standards that were rated C in 2008 - aim to improve Focus on the Core Criterion aim to improve these ratings Focus on patient involvement Focus on evaluation Key Targets: Continue to develop documentation processes Improve communication in relation to hygiene outcomes with all stakeholders Continue to self audit against standards Benchmark against other similar hospitals results Visit hospitals in good category Develop Evaluation process 1
REFERENCE The Following are the criterion that were rated C which we aim to improve 2008 2009 RATING GOAL OPPORTUNITY FOR IMPROVEMENT IDENTIFIED GOAL PROGRESS MADE RESPONSIILILTY (TITLE ONLY) TIMEFRAME TO COMPLETION CM 1.1 C B 1. Patient / client 1.To begin process of Training on Public & DON 26 th /27 th consultation patient / client consultation Patient Involvement Multi-Disciplinary Feb2009-2. Development of an Sub group formed to completed by 2. Evaluation of efficacy Evaluation template for use begin patient involvement & in ISQSH of needs assessment by hygiene services and process to level 1 association with 1 year process corresponding KPIs Regional Risk Advisor Sept 2009 CM 3.1 C B 1.Corporate strategic 1. Amend the corporate reviewing Corporate June 2009 plan to include costing plan to include costing for Hygiene Plan 2. Input from patients in hygiene services developing the plan 2. Circulate the plan to all June 2009 stakeholders 3. As above for patient 3. Evaluation of the 3. Involve patients in involvement 1 year Corporate plans goals devising the future plans and objectives 4.Formal evaluation of plan / Regional Risk CM 4.1 C B 1. Authority provisions 1. Clearly define authority Senior Management Team for hygiene not clearly for hygiene. Review of all are clearly identified as as posts defined in org. structure. job descriptions for new having authority for Senior Management arise. 2
competitions and include responsibilities for hygiene hygiene services in Corporate plan Team CM 4.4 C B Policy template to be Policy template to be used Immediate effect used for reviewing by when reviewing hygiene policies. hygiene policies CM 4.5 C B 1.Needs to be Hygiene Team to be Estates documented evidence of involved in capital the hygiene teams development at the involvement in capital planning stage and at development planning implementation written 2. Evaluation of the into terms of reference involvement by the CM 6.1 C A Corporate and Service To include costing in future Senior Management June 2009 Plans need to include plans and to amend Team costings current plans to include Hygiene Services costings. Team CM 6.2 C A Hygiene Team needs to New purchases are Purchasing checklist Hygiene Team Completed April be involved in the assessed from a hygiene completed by hygiene 2009 purchasing of new perspective team and used for equipment / products assessing new purchases 3
CM 7.1 C B 1.Need to track and To minimise risk and to 1.Hygiene Team track Hygiene Team trend internal audit identify hygiene related audit results on a bi- Safety Management results risks monthly basis Team 2. Need annual risk 2. Safety Management management report Team due to produce report for 2009 CM 7.2 C B Need to collate and Ensure timely reports from Hospital Manager feedback information the STARS web system for from the STARS web and system CM 9.1 C B 1.Need to consult 1. Ensure refurbishment Documented process for Infection Control Completed Infection Control prior to work is carried out with Risk assessment by Committee March 2009 refurbishment work infection control measures Infection Control prior to Estates 2. Storage identified as a in place. refurb work now in place Hospital Manager shortcoming in the 2. Improve physical 2.Issue identified to the physical environment environment with. Refer to Estates for additional storage solutions advice and solution CM 9.4 C B Needs to be feedback Ensure Feedback from Training completed on Hospital Manager from the Your Service,Y Your Service, Your say public and patient our Say comment and Review of hygiene related involvement. complaint process & complaints by and Patient Satisfaction Surveys 4
CM 10.1 C B Job description for MTA Recruitment process New job descriptions and HCA needs to adheres to best practice make reference to HR contain specific reference guidelines clearly defined hygiene to hygiene accountability 2. Evaluation of Request evaluation of May 2009 recruitment process recruitment process from HR. CM 10.2 C B 1.Need a documented Human resources are process for reviewing assigned based on changes hygiene services work to work capacity and when capacity and volume volume change Develop an operational tool /HR Sept 2009 2.Evaluation of the for assessment of work review process capacity and volume CM 10.4 C B Contracted services need To ensure that contractors Maintenance / into the hygiene training and are managed effectively Hospital Manager future orientation 5
CM 10.5 C B 1.Hygiene Services Amend the Operational Hygiene Team June 2009 operational plan needs to Plan to reflect human make reference to resource needs human resource needs 2.Hygiene Team needs to Produce Annual Report July 2009 produce an annual report 3.Need a documented Develop Hygiene Services /HR human resource needs Human resource needs assessment process assessment process CM 11.2 C B Staff need training in Provide training in health Medical Gas training Completed Dec health and safety and safety hazards, Health & Safety 08 hazards, conducting risk conducting risk Fire drill assessments and assessments, and handling Fire training planned for Nov 2009 handling of patients patients complaints May and August 2009 complaints Handling Complaints Hospital Manager 1. Evaluation of CM 11.3 C B effectiveness of training Develop PI s to evaluate 2. Need to demonstrate the effectiveness of evidence of resultant education and training actions in response to attendance levels at training provided 6
CM 11.4 C B 1.Needs to be ongoing On going performance On going in-house Catering and performance reviews for evaluation and training/education Household manager staff development of all Hygiene E.g. C difficile Ward managers 2. Evaluate the services staff evaluation process CM 12.2 C B There is a need to To monitor staff /OH evaluate the means by satisfaction and well being which staff satisfaction is monitored CM 13.1 C B Evaluation of process To have a defined process Review of the process in used for data collection, for the evaluation of the place in hospitals who evaluation of data process for collection and had an A rating with a Regional Risk Advisor reliability, accuracy and accessing hygiene related view to sharing best validity information practice There is a need to Ensure the organisation CM 13.3 C B evaluate the mechanisms evaluates the utilisation of used to assess the data collection and appropriateness of data information reporting by collected the Hygiene Team 7
CM 14.2 C B Evaluation of the hygiene Regular evaluation of the On going bi monthly quality improvement quality improvements and audits with resultant system to make improvements action plans where necessary SD1.1 C B 1.Need a documented To ensure that all hygiene Updated hospital cleaning Hygiene Services Completed April process for establishing service policies and guidelines based on best Team 2009 best practice guidelines guidelines are evidenced practice guidelines as set 2.Need to evaluate this based out in NHO Cleaning process Manual and SARI guidelines SD1.2 C B 1. Need a documented New hygiene service process for assessing interventions are assessed new hygiene service interventions. 2.Need to evaluate this process SD 2.1 C B 1. Involvement of Involvement of community Health Promotion community groups in groups, primary health Team hygiene related health teams, and other promotion activities organisations in health 2.Evaluation of activities promotion activities in undertaken relation to hygiene. 8
SD3.1 C B 1. Consultation with Appropriate linkages Established through terms Completed patients regarding between various teams of reference of hygiene services. and committees. committees in hospital 2. Evaluation of multi- Establish formal linkage disciplinary team with Regional Risk structure. Management C A 1. Need for kitchen staff To ensure that kitchens are HACCP training for all SD 4.4 to use PPE s managed in accordance staff updated Catering Dept. Immediate 2. Segregation of with best practice and catering and cleaning current legislation Signage for staff room duties for MTA s OPD Completed 3. Access to kitchens to March 2009 be restricted to designated personnel SD 5.2 C A Need to complete patient To ensure that patients / Sub group updating Multi-Disciplinary /visitor info leaflet. visitors are provided with information leaflet for Evaluation of patient, relevant information patients and visitors to family/visitor regarding hygiene services. include reference to comprehension To evaluate their hygiene. satisfaction with info comprehension 2 day training on Completed Feb provided /satisfaction with same patient/public 2009 involvement 9
SD 5.3 C A Need for staff training in To ensure staff can Hospital Manager relation to complaints. manage complaints in Feedback from Your relation to hygiene services Service, Your Say effectively. SD 6.1 C B Need for greater Patients views are Planned focus groups involvement of patients, considered when Multi-Disciplinary families when the evaluating hygiene services hygiene team is Extend patient comment evaluating its service. cards to all Sept 2009 areas/departments SD 6.2 C B Need to evaluate the To ensure that the team Team benchmarks self Hygiene Team initiatives undertaken by regularly evaluates and audits bi monthly the hygiene team as a benchmarks the quality of result of benchmarking its service and audits. Plan-Do-Check-Act SD 6.3 C B Hygiene Team needs to Team produces a report on Plan to produce an annual Hygiene Team By end of July produce an annual report its annual work. report for July 2009. 2009 10
The Following Criterion were rated an A or B. Aim is to Maintain or Improve Rating CM 1.2 B A Require a process for To ensure that the evaluating developments hygiene services are and modifications in relation to meeting needs of service users developed to meet the needs of the public served CM 2.1 B A Require patient and staff To ensure that the Training on Completed Feb 2009 satisfaction surveys hospital links with all stakeholders with regard to hygiene services patient/public involvement CM 4.3 B B Need to evaluate To ensure that the On going appropriateness of hygiene related research and information available has access to and use best practice information CM 5.1 B A Need to clearly define To have clear roles and End of Sept 2009 reporting relationships for all members of responsibilities throughout Hygiene Services CM 5.2 Core * A A No recommendations Maintain rating On Going CM 8.1 Core * B A Local policy required for establishment & management of contractors Ensure the hospital has a process for managing contractors effectively / Central Contracts 11
CM 9.3 B B Need to involve patients To ensure that the See CM 1.1 in evaluating the hospitals environment and facilities hospital manages its environment and facilities effectively above CM 10.3 A A No recommendations To ensure ongoing On going training in hygiene for all staff CM 11.1 A A No recommendations Maintain rating As Always /Assistant DONs On going Core * CM 12.1 B A Evaluation of the To ensure that staff Request Occ. Health Dept End of Sept 2009 appropriateness of the service provided by Occ Health. well being and occ health is monitored on an ongoing basis evaluation from Occ. Health Dept. CM13.2 B B Evaluation of data To ensure that data On Going presentation methods and evaluation of user satisfaction in relation to the reporting of information and info is reported in a timely, accurate, easily interpreted manner and based on the needs of Hygiene Services CM 14.1 B B Need to coordinate quality improvement activities with other performance monitoring activities To foster a culture of quality improvement throughout the hospital On Going 12
SD4.1 SD4.2 B A 1.Ensure all areas are free from dust. 2.Requirement for additional storage space 3.Ensure alcohol gel is available at all entrances to rooms and wards 4.Require bathroom facilities for A&E To ensure that the physical environment is clean. Maintain excellent compliance with national cleaning standards Provide additional storage space Bi-monthly audits Senior Management Team briefed (03/04/09) on storage requirementsforwarded to Estates Dept. /Estates On Going A A No recommendations Maintain rating Multidisciplinary SD4.3 SD4.5 B B 1.Requirement for additional storage space for cleaning equipment, 2.storage facilities to be kept locked See 4.1 above As 4.1 above Estates Ward managers/multi Task Attendants A A No recommendations Maintain rating Multidisciplinary 13
SD4.6 B A 1.Require additional storage for linen 2.Linen cupboards are not to be used for staff personal belongings To ensure that linen supply is managed effectively. Provide additional storage space. See4.1 above Estates/ SD4.7 A A No recommendations Maintain rating Multidisciplinary SD4.8 B A 1.Need a documented process for the delivery of hygiene services in nonroutine situations SD4.9 B B 1.Evaluation of patient / families satisfaction with participation in service delivery To ensure adverse events are limited and patient safety is maintained To encourage families to participate in improving hygiene Cleaning manual amended to include guideline on nonroutine situations April 2009 As 5.2 above Multidisciplinary 14