The Scottish Patient Safety Programme. HAI – Leadership in Infection Prevention and Control NHS GG&C. Three Key Leadership Elements in Infection Prevention and Control. Directorate accountability Performance management Surveillance and Clinical incident reporting.
HAI – Leadership in Infection Prevention and Control NHS GG&C
Target: 15% reduction by March 2011
GG&C Aim: 20% reduction by March 2011
Issue: How do we develop a system to manage this?
Develop Reporting Structure
Develop a formal sub-group of AICC
Develop local action groups with rolling action plans
Utilise Our Infection Control Staffing Resource
Existing project team (MRSA Screening) tasked with facilitation of groups
Utilise Our Data (Using Improvement Methodology)
Target interventions in areas of highest prevalence
Monitor progress towards target
Review surveillance of SABs
Promote Local Ownership
By identifying areas specific to directorates, interventions will be targeted, appropriate and locally owned
Ensure an Inclusive Approach
Consideration will be given to work already being progressed by SPSP, practice development and directorates.
MRSA Screening Project Team:
Infection Control Leads:
Pareto charts focused our attention:
At Board Level
At Directorate Level
Trajectories reminded us of the goal:
The GG&C Target
The Directorate Target
Ad hoc reports:
Were produced on directorate request. E.g. HAI only, source of SAB.
Enhanced SAB Surveillance
Leads ICNs and Lead Surveillance Nurse reviewed current documentation and database. An enhanced form was launched in July 2010.
In addition to directorate reports, all directorates will now be receiving an enhanced summary of the above SAB surveillance.
Blood Cultures: Developing NHS GG&C Blood Culture Policy
Evidence based approach
Blood Culture contamination audit
PVCs: Production of poster ‘Pause. Think….’
Surveillance snapshot of PVC use (approx 30% unused in first 24 hours).
Areas of uncertainty:
Unable to link SABs rate with SPSP ward performance/scores
SPSP is not mandated to deliver HEAT targets
SPSP rollout is not correlated with areas of high HAI prevalence
SPSP is focused on process and relies on reliability to drive outcomes which are not measured.
SOLUTION: Needs to be combined process linked to board governance based on performance indicators from multiple areas.