OPERATIONAL POLICY INFECTION PREVENTION AND CONTROL POLICY NO.1 Applies to: All employees of Wirral Community NHS Trust Group for Approval Infection Prevention and Control Group Date of Approval 25 January 2012 Committee for ratification Quality and Governance Committee Date Ratified 27 February 2012 Review Date: April 2013 Name of Lead Manager Head of Infection Prevention & Control UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION
CONTENTS Paragraph 1 Introduction 2 Statement of intent 3 Equality impact assessment 4 Duties/Responsibilities 4.1 All Staff (clinical and non-clinical) 4.2 Board of Directors 4.3 Chief Executive Officer (CEO) 4.4 Director of Infection Prevention and Control (DIPC) 4.5 Medical Director 4.6 Director of Operations and Performance 4.7 Head of Infection Prevention and Control (HIPC) 4.8 Quality and Governance Committee 4.9 Infection Prevention and Control Group (IPCG) 4.10 Role of Infection Prevention and Control Service (IPCS) 4.11 Head of Estates 4.12 Heads of Service/Managers 5 Patient/Public engagement and support 6 Process for monitoring effective implementation Appendices Appendix 1 Organisational Chart Appendix 2 Monitoring tool 1
1. INTRODUCTION Reducing the risk of infection through good infection control practice is the key priority for Wirral Community NHS Trust (WCT). This is achieved by developing a culture whereby patient, staff and visitor safety is ensured through the promotion of excellence in all aspects of Infection Prevention and Control practice, which is embedded throughout the organisation. The Trust s goal as an organisation is to eliminate all avoidable infections that occur as a result of care provided by WCT. Our philosophy centres on the WCT mission statement that aspires us To be the outstanding provider of high quality, integrated community care services in Wirral and beyond and reflects the corporate objectives of WCT with specific reference to; Improving quality outcomes & patient satisfaction Improving patient safety and risk management 2. STATEMENT OF INTENT There is a legal requirement on all NHS organisations to demonstrate compliance with The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance (Department of Health, 2010). The aim of this policy is to ensure that the Trust maintains effective arrangements for Infection Prevention and Control (IPC) and outlines the collective responsibilities and lines of accountability across the organisation for IPC. This policy applies to all staff employed by the Trust and to staff working in a contracted capacity and should be read in conjunction with the Trust Health and Safety policies, and supporting IPC policies which are available on the Trust intranet site. 3. EQUALITY IMPACT ASSESSMENT As part of its development, this policy and its impact on equality have been reviewed using the Policy Equality Impact Assessment Screening tool. The purpose of the assessment is to minimise and if possible remove any disproportionate impact on employees on the grounds of race, sex, disability, age, sexual orientation or religious belief. No detriment was identified. 4. DUTIES/RESPONSIBILITIES 4.1 Trust Board The Trust Board has a collective responsibility for Infection Prevention and Control throughout the Trust. The Chief Executive and Trust Board are accountable for establishing and maintaining adequately resourced infection prevention and control arrangements throughout the Trust. The Board provides support for the Director of 2
Infection Prevention and Control (DIPC) and takes a position on any recommendations and advice that are provided. The Trust Board will receive; Minutes of the Infection Prevention and Control Group; Annual Infection Prevention and Control Work plan; DIPC annual Infection Prevention & Control Report; Written reports outlining key issues in relation to infection prevention and control activity four times per financial year; Exception reports where indicated; 4.2 Chief Executive Officer (CEO) The Chief Executive is accountable to the Board for achieving the Trust s goal in relation to infection prevention and control. As the accountable officer the CEO has ultimate responsibility for ensuring that there are adequate structures, effective control mechanisms and clear lines of accountability for infection control throughout the organisation. 4.3 Director of Infection Prevention and Control (DIPC) The Director of Quality and Governance also fulfils the role of DIPC. The DIPC is responsible to the Chief Executive and the Board for the achievement of the Trust s goal for infection control and to ensure that a robust infrastructure is in place for Infection Prevention and Control within the organisation. The DIPC is a member of and is responsible for the Infection Prevention and Control Service (IPCS) and reports directly to the Chief Executive Officer and the Board. Their role includes being an integral member of the Trust's Governance and Patient Safety systems and the Trust Decontamination Lead. The DIPC is the Chair of the Infection Prevention and Control Group and responsible for ensuring strategies, policies and procedures are in place to ensure evidence based infection prevention and control practice and that their implementation effectively monitored. 4.4 Medical Director The Medical Director supports the DIPC on issues relating to Infection Control. The Medical Director is responsible for compliance with Infection Control by all medical and dental staff within the Trust. 3
4.5 Director of Operations and Performance The Director of Operations and Performance is responsible for the performance of clinical services in relation to infection prevention and control including financial planning and the identification and management of risk. The Director of Operations and Performance is also the Executive Nurse of the Board. 4.6 Head of Infection Prevention and Control (HIPC) The Head of Infection Prevention and Control provides support to the DIPC and takes responsibility for leading and developing the strategic direction of IPC throughout the Trust. The HIPC manages the IPCS and provides clinical and professional leadership to the nursing members of the IPCS and is accountable to and managed by the DIPC. 4.7 Quality and Governance Committee The primary function of the Quality and Governance Committee is to provide assurance to the Board of overall compliance with all statutory and regulatory obligations and will ensure the effective management of incidents, complaints, and subsequent dissemination of lessons learnt. The Quality and Governance Committee is responsible for ratifying Infection Prevention and Control policies. The Board receives the minutes of the Quality and Governance Committee. 4.8 Infection Prevention and Control Group (IPCG) The Infection Prevention and Control Group meets bi-monthly and is chaired by the DIPC or HIPC. The minutes of the Infection Prevention and Control Group (IPCG) go to the Quality and Governance Committee. The IPCG will: Support the Infection Prevention and Control Service; Review Service Assurance Reports; Approve and recommend implementation of all IPC policies; Approve and recommend Trust wide protocols and initiatives; Review and disseminate shared learning from IPC related incidents; To monitor and review the IPC assurance framework; Provide a forum for staff/services to discuss areas of concern and share excellence in practice; Review antimicrobial prescribing within the Trust and promote prudent antimicrobial stewardship; Discuss relevant national recommendations, directives and statutory guidelines for infection control; Assure the Trust that the appropriate systems are in place to enable it to meet its statutory requirements in respect of infection prevention and control; 4
4.9 Role of Infection Prevention and Control Service (IPCS) The IPCS provides a clinical advisory service for the prevention, surveillance, investigation and control of infection within the Trust. The IPCS will: Develop relevant infection prevention and control policies and protocols; Provide assurance to the Trust board regarding activity in infection prevention and control within the Trust. Written reports are submitted four times per financial year; Contribute to the Trust wide work programmes and strategic plans; Initiate, develop and lead in delivering Infection prevention and control education; Develop and lead the WCT infection prevention and control audit programme; Provide expert advice to all WCT staff; Report all Serious Untoward Incidents (SUI) and other relevant incidents through the Trust s reporting system and to the Health Protection Agency (HPA) as necessary; Lead root cause analysis investigations where required to promote learning and practice improvement; Provide specialist advice to key committees, groups, departments or individual staff members in relation to Infection Prevention and Control practices; Work closely with the Occupational Health Department and other relevant stakeholders to develop Policies and Guidelines for the protection of Health Care Workers (HCW) from exposure of communicable infections during the course of their work; Develop and produce an annual infection prevention and control programme; 4.10 Employees (clinical and non-clinical) Responsibility and accountability for reducing the risk of Healthcare Associated Infection (HCAI) rests with every member of staff within the organisation. All staff are accountable to the Board for achieving the Trust s goal in relation to IPC; All staff are responsible for ensuring that they follow good infection control practice at all times; All Staff must comply with Trust policies and that they are familiar with Infection Control policies, procedures and guidance relevant to their area of work. Failure to comply with or act in accordance with a Trust policy may result in disciplinary action; Staff have a duty to challenge and report breaches in good practice by others, take corrective action as appropriate and are responsible for ensuring they 5
undertake relevant infection prevention and control training as set out in the Trusts training matrices. 4.11 Head of Estates The Head of Estates is responsible for ensuring the provision and maintenance of a clean and appropriate environment within the Trust. This includes; Management of the service level agreement for cleaning services; Ensuring contracted services work to the National Patient Safety Association (NPSA) Specifications for Cleanliness in the NHS; Waste management (including clinical waste); 4.12 Heads of Service/Managers Heads of Service/Managers will be responsible for ensuring the implementation of Infection prevention and control protocols and policies. Where action is required following assessment, audits or inspections they will ensure action plans are completed within the designated timescales and identify resources from within service budgets as required. Heads of Service must also ensure that Service Assurance Reports are submitted to the IPCG and that infection prevention and control advice is sought at the earliest stages of service change and development. 5. PATIENT/PUBLIC ENGAGEMENT AND SUPPORT WCT is committed to seeking the support and engagement of patients and general public on matters relating to Infection prevention and Control. The Trust recognises that collaborative partnership working with partners across the Health Economy is key in the reduction of HCAI s. Working in partnership supports interventions for reducing infection throughout the patient journey and improves quality. 6
References Department of Health (2010). The Health and Social Care Act 2008: Code of practice on the prevention and control of infections and related guidance. London DH. Crown Copyright Department of Health (2011). Safe Management of Healthcare Waste. London Crown copyright. National Patient Safety Association (2009). Specifications for Cleanliness in the NHS. Department of Health (2008). Clean, Safe Care: Reducing Infections and Saving Lives. London DH Crown copyright. Department of Health (2008). Going Further Faster II: applying the learning to reduce HCAI and improve cleanliness. London. DH. Crown copyright. Department of Health (2006). Essential steps to safe, clean care: Reducing healthcare associated infection. London. DH Crown copyright Department of Health (2005, 2010). Saving lives: a delivery programme to reduce healthcare associated infection (HCAI) London. DH Crown copyright. Department of Health, December (2003). Winning Ways. Working together to reduce Healthcare Associated Infection in England. London DH Crown Copyright. Department of Health (2002). Getting Ahead of the Curve. A strategy for combating infectious diseases (including other aspects of health protection). London: DH Crown Copyright. 7
APPENDIX 1 IPC Structure - Wirral Community NHS Trust Trust Board Quality & Governance Committee Director of Infection Prevention and Control (DIPC) Infection Prevention & Control Group Infection Prevention & Control Service Risk & Governance Learning & Development Medicines Management Clinical Policy & Procedure Health Safety & Wellbeing 8
Appendix 2 Process for Monitoring Compliance with Organisational Infection Control Policy Minimum requirement to be monitored Process for monitoring (e.g. audit) Responsible individual / group/ committee Frequency of monitoring Evidence Responsible individual for development of action plan Responsible committee for monitoring of action plan and Implementation Process for monitoring duties across the organisation Minutes from Infection Control Group IPC work programme (work plan) Infection Prevention & Control Group Bi-monthly IPCG Minutes & Service Assurance reports Minutes Director Infection Prevention & Control Quality & Governance Committee Service Assurance Reports Service Assurance Reports Assurance framework for infection prevention and control and HCAI Monthly Service and Corporate risk registers 9