INFECTION CONTROL POLICY
Responsible Directorate:
Public Health
Date Approved:
9 April 2008
Committee
Governance Committee
Signature of Accountable Director: Print Name:
Dr Judith Hooper
Version Control
Document Title Document number Author Contributors Version Date of Production Review date Postholder responsible revision Primary Circulation List Web address Restrictions
Infection Control Policy Jane O’Donnell 1 13.2.2008 February 2010 for Assistant Director Infection Control
Standard for Better Health Map
Domain
First Domain Safety Sixth Domain Care Environment and Amenities Core / Development Standard C4a, C4d, C4e, C21 Reference Performance Indicators 1. To reduce incidence of healthcare associated infections.
Contents Section 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Introduction Associated Policies & Procedures Aims & Objectives Scope of the Policy Accountabilities & Responsibilities Equality Impact Assessment Training Needs Analysis Monitoring Compliance with this Policy References Key stakeholders Appendices
Appendices Appendix 1 – Equality Impact Assessment Tool Appendix 2 – Training Needs Analysis
Page 1 1 1 1 1 3 3 3 4 4 4
5 6
Policy Statement
Kirklees PCT is committed to delivering a safe, effective and efficient infection control service that is fit for purpose and is able to discharge its duties in accordance with the Health Act 2006. The policy will establish ownership of infection prevention and control at all levels in the organisation from PCT Board to individual clinicians.
1.
Introduction
All NHS organisations must ensure that they have effective systems in place to control healthcare associated infection as part of its responsibilities to keep patients and staff safe. This is reflected in Government policy; •
The 2006 Health Act.
•
The NHS Operating Framework.
2.
Associated Policies and Procedures
This Policy should be read in accordance with the following PCT policies, procedures and guidance. • • • 3.
Infection Control Policies Health and Safety Policies Incident Reporting Policy. Aims and Objectives
To ensure that infection prevention and control is embedded into the culture of the PCT and that there is ownership at all levels. To ensure that the organisation is compliant with the standards for Better Health and NHSLA risk management standards. To ensure that there is robust governance reporting arrangements and lines of accountability for infection prevention and control. To ensure that there are clear monitoring and reporting arrangements for all commissioned services. 4.
Scope of the Policy
This policy must be followed by all PCT employees and staff on temporary or honorary contracts as well as pool staff and students. This policy should be considered and included in services that are contracted and commissioned. 5.
Accountabilities & Responsibilities
Chief Executive The Chief Executive is the accountable officer regarding all infection prevention and control arrangements but delegates the responsibility to the PCT Board and the Director of Infection Prevention and Control. Board The Board ensures that the arrangements which the PCT has in place to prevent and control infection are effective. Systems are implemented to ensure that the Board gains assurance that all risks are being managed. The Board will use the Assurance framework to achieve this aim. Page 1 of 11
Director of Infection Prevention and Control (DIPC) The DIPC is responsible for the Infection Control team. Development and implementation of infection control policies. The DIPC reports directly to the Chief Executive and the Board. The DIPC has the authority to challenge inappropriate clinical hygiene practice as well as inappropriate antibiotic prescribing decisions. The DIPC assesses the impact of all existing and new policies and plans on healthcare associated infections and make recommendations for change The DIPC is an integral member of the PCTs Clinical Governance and Patient safety structures. The DIPC produces an annual report on the level of healthcare associated infections in the PCT and will ensure available in the public domain. Infection Control Committee The Infection Control Committee meets quarterly. The chair of the committee is the Director of Public Health/DIPC. The committee reports to the Governance committee, which reports to the Board. The infection control committee identifies and priorities actions based upon national guidance, Board directives, external reports and internal incident reports, trends and patterns from the risk management reporting system. The infection control committee approves and monitors the annual infection control programme, infection control policies and supports the work of the infection control team. The infection control committee receives the annual infection control report which is then submitted for approval to Governance Committee required by the Health Act 2006. Infection Control Team The Infection Control Team develops an annual infection control programme, with clearly defined objectives. •
Development of key policies and procedures implemented and reviewed in collaboration with clinical service leads.
•
Education and training on infection prevention and control to all clinical and non clinical staff.
•
Works closely with clinical governance, risk management, provider and contracted services, to ensure that the risks of healthcare associated infection are identified and assessed.
•
Provide timely reports to relevant committees and produce an annual infection control report.
•
Implement the decontamination policy.
•
React in a timely manner to outbreaks of infection.
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•
Ensure that root cause analysis investigation is undertaken for every pre 48 hour MRSA bacteraemia by the clinical teams in conjunction with the infection control team.
•
The team works with PCT Estates and facilities to ensure that the environment is fit for purpose and maintained in order to provide environments for patients, visitors and staff which are safe and clean.
The team consists of a number of key staff who are suitably qualified and directly managed by the Assistant Director of Infection Control who reports to the DIPC. The team is supported by the Consultant Microbiologists through an agreement with MYHT and CHFT. This includes 24 hour advice and support. The Infection Control team will ensure information on infection prevention and control to the public and patients is available. This is communicated to the public and patients by the leaflet“What is Infection control”. Healthcare Professionals Local responsibility for infection prevention and control is not limited to the DIPC and infection control team but to everyone in the organisation, all professional groups, clinical specialities and directorates. The Hygiene code duty 11f requires that responsibility for infection prevention and control is reflected in all job descriptions and appraisal and personal development plans. All staff has a mandatory responsibility to undertake infection prevention and control training, to ensure that infection control policies are effectively implemented in their area of work, and to report infection control incidents and risks to their line manager and or Infection Control team via the PCT incident reporting mechanism. 6.
Equality Impact Assessment
All public bodies have a statutory duty under the Race Relation (Amendment) Act 2000 to “set out arrangements to assess and consult on how their policies and functions impact on race equality.” This obligation has been increased to include equality and human rights with regard to disability age and gender. The PCT aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. In order to meet these requirements, a single equality impact assessment is used to assess all its policies/guidelines and practices. This Policy was found to be compliant with this philosophy. 7.
Training Needs Analysis
The PCT is committed to the training and continuing development of all staff including independent contractors on all relevant issues around infection prevention and control. All induction and mandatory infection prevention and control training will include how the organisation manages the risks of infection prevention and control. 8.
Monitoring Compliance with this Policy
The PCT will have key indicators to monitor infection prevention and control that will be included in all PCT performance processes including the Assurance Framework. The performance indicators will be: •
PEAT assessment scores for cleanliness. Page 3 of 11
9.
•
The Percentage of clinical and non clinical healthcare workers, undertaking annual mandatory infection control training. Line managers are responsible that all clinical and non clinical healthcare workers undertake mandatory annual infection prevention and control training. This will ensure that individual accountability for infection prevention and control is identified through personal development plans, appraisals and job descriptions. The Assistant Director of Infection Control and the Head of Knowledge are responsible to ensure a rolling programme of education.
•
The percentage of incident reports associated with healthcare associated infections. Incident reports on healthcare associated infection will be reviewed and actioned by Infection Control Committee and the Risk management Operational Group.
•
Audit findings from Essential Steps to Safe Clean Care to ensure key infection prevention and control practices are being implemented. The audits will be on a rolling programme agreed by the Infection Control Committee. The audits will be carried out by Provider Services and follow the national template for Essential Steps to Safe Clean Care. Results will be reported to Infection Control Committee and PCT Provider Board. The Director of Infection Prevention and Control and Director of Provider Services are the accountable Directors to ensure these audits are completed. References
The Health Act 2006. Code of practice for the prevention and Control of Health Care Associated Infections. HMSO London Department of Health 2003 Winning Ways: Working Together to Reduce Healthcare Associated Infection in England, Chief Medical Officer HMSO London Department of Health 2002 Getting Ahead of the Curve, A strategy for Combating Infectious Diseases. HMSO London Department of Health 2006 Essential Steps to safe Clean Care. HMSO London National Institute for Clinical Excellence 2003 Prevention of Health Care Associated Infections in Primary and Community Care HMSO London
10.
Key Stakeholders consulted/involved in the development of the policy. •
Assistant Director of Corporate Services and Risk Management
•
Kirklees PCT Infection Control Committee
11.
Appendices
1
Equality Impact Assessment Tool
2
Training Needs Analysis
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APPENDIX 1 Equality Impact Assessment Tool To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Insert Name of Policy / Procedure Yes/No 1.
Does the policy/guidance affect one group less or more favourably than another on the basis of:
NO
• Race
NO
• Ethnic origins travellers)
(including
gypsies
and
• Nationality
NO NO
• Gender
NO
• Culture
NO
• Religion or belief
NO
• Sexual orientation including lesbian, gay and bisexual people • Age
NO NO
• Disability - learning disabilities, physical disability, sensory impairment and mental health problems
NO
2.
Is there any evidence that some groups are affected differently?
NO
3.
If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?
NO
4.
Is the impact of the policy/guidance likely to be negative?
NO
5.
If so can the impact be avoided?
6.
What alternatives are there to achieving the policy/guidance without the impact?
NO
7.
Can we reduce the impact by taking different action?
NO
NO
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Comments
APPENDIX 2 Training Needs Analysis Infection Control
It is a legal requirement that all staff receive training on infection prevention and control as part of their mandatory training. Infection control training is to be undertaken annually. This training forms part of the Trust Mandatory training programme and training courses are held at regular intervals throughout each year organised through the Trust Training Department.
Who needs to attend?
All Clinical staff
All non-Clinical staff, including temporary, bank and contractor staff.
All new employees, including bank, temporary and contractor staff.
How can the training be delivered?
Level 3 In-depth for clinical staff
Level 2 40-minute training course 40 minute training presentation for non-clinical staff – part of the Trust Mandatory training Programme to be undertaken annually.
Level 1 Basic Awareness 30-minute session for all new starters provided within the Trust Induction Programme for all new starters.
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Delivered by infection control team
Delivered by infection control team
Delivered by infection control team
Who is responsible for delivering this training:
Infection Control staff
(Assistant Director of Infection Control) Jane O’Donnell Training needs assessment It is estimated that there are approximately 1223 staff (as at 11.02.08) employed by the Trust who require this training annually. This is broken down as follows: Level 3 – Clinical All clinical staff including District Nurses, Community Nurses, HCAs, AHPs, Health Visitors, School Nurses, Nursery Nurses and Dental Staff. Clinical staff total = 664. Level 2 – Non Clinical All non-clinical staff including administration, management and support. Non-clinical staff total = 559 (as at 11.02.08). Level 1 - Induction - Basic awareness All new employees to the Trust. The learning aims and objectives for the 3 levels of training are as follows:
Overall Aim: That the staff and Trust operate a safe environment in compliance with regulations and guidance and that the management of infection control is inherent in all systems and processes. Objectives for the learner Level 1 – Induction all new staff Basic understanding and knowledge of Infection control. Level 2 – non-clinical staff This course explains roles and responsibilities in infection prevention, the importance of personal and environmental hygiene, how to care for your own health, and how the correct use of personal protective equipment helps to maintain a safe environment for patients and staff. Level 3 – Clinical staff Standard Precautions, outbreaks and reporting of incidents, management of high risk needlestick injuries, decontamination, safe disposal of waste, use of sterile equipment, use of cleaning equipment and chemicals, blood borne viruses, MRSA, Scabies, fleas. Reducing the risk of infection. .
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Levels 1 and 2 - Links to KSF Profile/Outlines
Core:
Level:
Examples of KSF indicators that this course/programme may contribute to
1. Communication
3 – Develop and maintain communication with people about difficulty matters and/or in difficult situations.
e) communicates in a manner that is consistent with relevant legislation, policies and procedures
2. Personal and people development
2 – Develop own knowledge and skills and provide information to others to help their development
b) takes an active part in the development review of own work against the KSF outline for the post with their reviewer and suggests areas for learning and development in the coming year.
3. Health, Safety & Security
4. Service improvement
5. Quality
2 – Monitor and maintain health, safety and security of self and others
a) identifies and assesses the potential risks involved in work activities and processes for self and others. b) identifies how best to manage the risks. c) undertakes work activities consistent with: - legislation, policies and procedures - the assessment and management of risk f) supports others in maintaining health, safety and security
2 – Contribute to the improvement of services.
f) constructively identifies issues with direction, policies and strategies in the interests of users and the public
2 – Maintain quality in own work and encourage others to do so
a) acts consistently with legislation, policies, procedures and other quality approaches and encourages others to do so.
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Level:
Examples of KSF indicators that this course/programme may contribute to
HWB4
2
c) effectively prepares for and undertakes activities to enable people to meet their ongoing needs consistent with the care plan, legislation, policies and procedures.
IK1
1
inputs data and information accurately and completely: using the correct formats, consistent with legislation, policies and procedures.
Specific Dimension:
Level 3 – Links to KSF Profile/Outlines Core: Level:
Examples of KSF indicators that this course/programme may contribute to
1.
Communication
3 – Develop and maintain communication with people about difficulty matters and/or in difficult situations.
e) communicates in a manner that is consistent with relevant legislation, policies and procedures
2.
Personal and people development
2– Develop own knowledge and skills and provide information to others to help their development
b) takes an active part in the development review of own work against the KSF outline for the post with their reviewer and suggests areas for learning and development in the coming year.
3.
Health, Safety & Security
2 – Monitor and maintain health, safety and security of self and others
a) identifies and assesses the potential risks involved in work activities and processes for self and others. b) identifies how best to manage the risks. c) undertakes work activities consistent with: - legislation, policies and procedures - the assessment and management of risk F) supports others in maintaining health, safety and security
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4. Service improvement
2 – Contribute to improvement of services.
the
f) constructively identifies issues with direction, policies and strategies in the interests of users and the public
5. Quality
2 – Maintain quality in own work and encourage others to do so
a) acts consistently with legislation, policies, procedures and other quality approaches and encourages others to do so
6. Equality and Diversity
2 – Support equality and value diversity.
a) recognises the importance of people’s rights and acts in accordance with legislation, policies, procedures.
Dimension:
Level:
Examples of KSF indicators that this course/programme may contribute to
HWB3
3
Prepares for and undertakes the protective interventions that s/he is responsible for as part of the protection plan in a manner that -
is consistent with evidence-based practice, legislation, policies and procedures.
-
is appropriate to the people concerned.
-
is appropriate for the setting.
-
Maintains health and safety.
HWB4
2
c) effectively prepares for and undertakes activities to enable people to meet their ongoing needs consistent with the care plan, legislation, policies and procedures.
IK1
1
a)
inputs data and information accurately and completely: using the correct formats, consistent with legislation, policies and procedures.
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