Author: Improvement Programme Review Team Version: 1.00 Date: Finalised 18 04 07

1. MRSA/HCAI Improvement Programme Gloucestershire Hospitals NHS Foundation Trust Report Author: Improvement Programme Review Team Version: 1.00 Date: Finalised 18 04 07

2. Contents • Section 1 • 1.1 Executive summary • 1.2 Your key message & immediate priorities • 1.3 Data analysis • 1.4 Suggested target milestones • 1.5 Actions for recovery & improvement • 1.6 Encouraging signs • Section 2 • 2.1 Key themes • Findings and recommendations • 2.2 People • 2.3 Performance • 2.4 Process • 2.5 Practice • Section 3 • 3.1 Recommended performance reporting • 3.2 Recovery plan • Section 4 • 4.1 Data Pack Links: Acknowledgements Section 1 Section 2 Section 3

3. Contents • Section 1 • 1.1 Executive summary • 1.2 Your key message & immediate priorities • 1.3 Data analysis • 1.4 Suggested target milestones • 1.5 Actions for recovery & improvement • 1.6 Encouraging signs • Section 2 • 2.1 Key themes • Findings and recommendations • 2.2 People • 2.3 Performance • 2.4 Process • 2.5 Practice • Section 3 • 3.1 Recommended performance reporting • 3.2 Recovery plan • Section 4 • 4.1 Data Pack Links: Content Page Acknowledgements Section 2 Section 3

4. 1.1 Executive summary • Your MRSA enhanced data shows that you have remained above trajectory but are demonstrating positive signs of reducing numbers. You have invited the Improvement Review Team to the organisation to seek their guidance and the team recognised there are many examples of good practice and encouraging signs, and that you have recently galvanised action to achieve the required improvement. You now need to direct focus for recovery and sustainability to aim to reach trajectory and deliver the target. • from October 06 to January 07 you have eliminated variance and continue to reduce your bacteraemias month on month • the biggest challenge you have is identifying the root cause of your bacteraemias and this requires your immediate attention. Immediately carry out root cause analysis empowering the clinical teams to ascertain source and cause of all MRSA bacteraemias within 24 hrs. • your data shows that 65% of your bacteraemias occur after 48 hours, of which 9% are within Augmented Care. You need to ensure there are no avoidable MRSA bacteraemias in Augmented Care • you need to demonstrate a 50% improvement in General Medicine and Surgery in the next 3 months and continue with your focus on Nephrology. • your data suggests that 35% of your bacteraemias occur pre-48 hour. Work with partners to understand cause, and reduce number of pre-48 hour cases. Reduce by at least 20 % by July 07 • ensure month on month improvements in all areas • The organisation as a whole needs to own the challenges to reduce healthcare associated infections. The infection control team will undoubtedly provide guidance and focus with the Director of Nursing providing drive and motivation but the most gains will come from ownership and impetus within the wards and divisions for reducing risks and leading improvement. • Whilst you clearly have frameworks in place, you may gain benefit from strengthening the performance framework to enable timely feedback and monitoring of actions and interventions particularly with the results and actions following from Root Cause Analysis. • Achieving the target is not about working harder but using robust data and information to focus attention and a robust root cause analysis process at ward level is key. Only then will you be in the position to focus attention on the “hot spots” and to continue to re focus as you surmount each challenge. • There is a need for the sense of importance and urgency held by the Directors to be translated to all levels of the organisation and requires a cultural shift in ownership. There is a need to ensure medical, clinical leads are nominated for all specialties, supported by the ICT. Ensuring everyone understands their role, responsibility and accountability is also fundamental. Utilisation of the HIIs in specific and focused areas as highlighted by the improved RCA will lead you to make progress faster. • We have highlighted a number of areas in this report which should improve your performance towards reducing the levels of MRSA bacteraemia. The review team has included in this report key performance improvement statements with timescales for specific improvement outcomes.

5. 1.2 Your key message and immediate priorities Your key message is : Focus, Feedback Follow-through Turning knowledge into improved patient care to know what you do is working Immediate implementation of the following 4 actions will start you on your journey of reducing your MRSA bacteraemias (please see the embedded document in section 1.5 for your further actions) • commence root cause analysis with verbal feedback within 24 hours of bacteraemia identification • develop and share performance information that is understood by all levels of the organisation • identify medical clinical leads with clearly identified roles and responsibilities • put Infection Prevention and Control as a standing item on all key agendas

6. 1.3 Data analysis Data in the following slides are from your submitted MESS data October 2005 to January 2007

7. What is the direction of travel? The challenge is significant to be where you need to be in March 2008

8. What is the scale of your challenge Your MRSA figures are consistently above trajectory. Recovery needs to be sustained and the pace increased Trajectory (T) Actual (A) You need to put a recovery plan in place to ensure you are meeting your agreed monthly trajectory

9. No of MRSA cases split by Pre- and Post-48 Hours You have 35% pre 48 hours which is more than the national average (28%) Suggestion – look at your pre 48 hour patients and see if they have been to hospital in the previous 3 months from when their MRSA Bacteraemia was identified

10. No of MRSA cases split by Specialty - A look at your problem areas • Areas to target short term are: • General Medicine (including Geriatric Medicine) • Surgery

11. No of MRSA cases split by Augmented Care & Non-Augmented Care You have 9% of cases in Augmented Care which is less than the national average (24%) You need to achieve zero in augmented care.

12. No of MRSA cases by Age Band The breakdown of your MRSA cases by age band. You have most cases in the 85-89 category. Suggestion – look at your age profile in conjunction with your actual admissions in those age bands. You may find as a proportion of bacteraemias to attendances you have an issue.

13. A look at the time between bacteraemias The longer the gap between MRSA Bacteraemias (over the upper limit) the more confidence you can have regarding practice around avoidable infections.

14. Next Steps for you • Root Cause analysis empowering the clinical teams to ascertain source and cause of all MRSA bacteraemias within 24 hrs. Where are the sources of your bacteraemias • body site and cause (e.g. leg wound, PVC lines etc) • which wards are your hotspot areas • are there any workforce issues or trends Where do you need to focus your efforts • Implement High Impact Interventions with clinical staff within your “hot spot” areas and commence fortnightly audit of them, with weekly audit of PVC’s, share the audit outcomes and learning • Use the enhanced facilities on the MESS database to analyse your problem areas

15. 1.4 Suggested target milestones

16. 1.5 Actions for recovery and improvement • The attached planning and action matrix will be started by your programme manager around the Improvement Team findings and quick areas to target • You have agreed a date to jointly expand this as appropriate These are based on our key findings during our 2 day review. You may wish to further expand on these as you develop this action plan locally for the medium to long term and consider the wider findings in section 2 of this report Double Click to Launch Gloucester Action Plan updated 17 04 07 This will continue to be work in progress owned by Gloucester Hospitals NHS Foundation Trust

17. 1.6 Encouraging signs • there is strong top executive engagement and clear corporate responsibility for infection control with key appointments made to drive forward this agenda • the trust has set a challenging target of a reduction of 40% for C Diff • there is a clear organisational message to not let process impede progress • the Governors and Non Executive Director/Chair appear well informed and placed to challenge • the organisation has a strong focus on patient safety and improving the patient experience • cohort wards have been established the team acknowledged the trust has acted quickly and effectively • the Medical Director demonstrated how he reiterates to frontline staff the relationship between patient experience and organisational systems (or failure of) by using a real patient story • there is a very dedicated infection control team, members of which are valued and respected across the Trust. continued/…

18. 1.6 Encouraging signs …/continued • there is a Deep Clean Programme in place • the review team found ward Managers had a positive attitude to driving the Quality agenda • there were some shining examples of good clinical practice in some areas with some excellent clinical champions and good medical leadership • there is evidence of some surveillance and early root cause analysis being undertaken across the Trust despite the challenges. Reporting and monitoring of MRSA incidence is improving

19. Contents • Section 1 • 1.1 Executive summary • 1.2 Your key message & immediate priorities • 1.3 Data analysis • 1.4 Suggested target milestones • 1.5 Actions for recovery & improvement • 1.6 Encouraging signs • Section 2 • 2.1 Key themes • Findings and recommendations • 2.2 People • 2.3 Performance • 2.4 Process • 2.5 Practice • Section 3 • 3.1 Recommended performance reporting • 3.2 Recovery plan • Section 4 • 4.1 Data Pack Links: Content Page Acknowledgements Section 1 Section 3

20. 2.1 Key themes Performance People Performance frameworks Use of data Performance data Audit Pre-48 hour cases Leadership Divisional responsibilities and ICT Roles and responsibilities MRSA bacteraemia reduction Processes Practices Hand hygiene High impact interventions Screening / decolonisation Antibiotics Root cause analysis Renal

21. 2.2.1 People Leadership Findings • there is clear and effective leadership at executive level within the organisation in relation to infection control but the review team was not convinced that the sense of urgency and importance and ownership is embedded at all levels of the organisation • there is a belief that that audit is onerous and does not relate to improving care, in pockets of the organisation • there are no medical clinical leads for infection control, although the review team recognized clinical champions for I&C in some areas Recommendations

22. 2.2.3 People Divisional responsibilities and ICT Findings • the review team was unable to find widespread evidence of responsibility and objectives for infection prevention and control at divisional level • there are many dedicated lead nurses and link nurses however the ICT is attempting to drive this largely on its own Recommendations

23. 2.2.4 People Roles & responsibilities Findings • whilst there is evidence of infection control responsibilities within many job descriptions and objectives, individuals and teams did not always appear to understand what that meant for them, what they had to do differently, and where responsibilities were shared or individual • ward staff did not openly relate IP&C activity to improving the patient experience • roles and responsibilities were are not always fully understood in relation to priority of other Trust targets Recommendations

24. 2.3.1 Performance Performance frameworks Findings • MRSA bacteraemia data is embedded in the board performance reporting arrangements. However, the review team was not convinced that targets are set to a specific tolerance for each division to deliver against and are own/embedded within core business • all clinicians/multidisciplinary teams do not currently have a meaningful forum or mechanism to individually review relevant data in a safe environment • the ICC is viewed as not being proactive with little input from the many representatives • IP&C is not a standing item on some key agendas Recommendations

25. 2.3.2 Performance Use of data Findings • reporting back of root cause analysis findings is neither robust nor timely. However the Medical Director has piloted a case study format with some inclusion of the patient journey timeline. • RCA does not yet enable comprehensive identification of themes, trends and sources. Follow up action is not always identified nor monitored • High Impact Interventions are not implemented or audited by the “hot spot” wards and so there is no feedback loop on improvement in practice • the plan for IP&C audit it not frequent and focused Recommendations

26. 2.3.3 Performance Performance data Findings • your data shows that 65% of bacteraemias occur after 2 days • hotspot areas are General Medicine including geriatrics(37%), Nephrology (18%), and General Surgery (18%) Recommendations

27. 2.3.4 Performance Pre-48 hour cases Findings • 35% of bacteraemias were diagnosed within 48 hours of admission, this is above the national average (28%) • there are fortnightly IC steering group meetings attend by the PCT Recommendations

28. 2.3.5 Performance Audit Findings • whilst the review team was informed of some audits that had been conducted, managed by the IC Steering Group, there were numerous ward staff who were unaware of the audit and of the results • there did not appear to be a mechanism for sharing learning from the audits within/across specialties nor with future induction/education and training, personal development plans and performance monitoring frameworks Recommendations

29. 2.4.1 Process Renal Findings • a care bundle approach to care is adopted in renal but audit is reactive and sporadic • HII 2c has just been introduced • there is thirst to embrace improvement in the unit and many good ideas • there is currently no screening in Renal Dialysis patients on admission Recommendations

30. 2.5.1 Practice Hand hygiene Findings • infrequent audits of hand hygiene have shown a variable rate of compliance across the organization • the perception amongst clinical staff is that medical staff were the least compliant. This was confirmed in the small amount of audit data available which showed compliance as low as 10% • aseptic non-touch technique practice standards are not fully met Recommendations

31. 2.5.2 Practice High impact interventions Findings • whilst a start has been made, the review team found many staff that were not as aware of the High Impact Interventions as expected. • the HIIs are not owned widely across the Trust and are not always being implemented in response to the RCA, and could therefore be more focused • the review team found evidence that the Trust guidelines for peripheral and central lines and urinary catheters were not always followed • documentation was often lacking, especially in the areas of line insertion and management • a recent focus on cannulae care has shown improvement with removal if not used within 24hrs Recommendations

32. 2.5.3 Practice Screening/ decolonisation Findings • there is confusion in some areas around who and when to screen • there is a lack of consistency in applying decolonisation for high risk patients • a revised screening policy is awaiting sign off • screening in renal dialysis is not yet in line with national policy • there is a clear organisational message to not let process impede progress Recommendations

33. 2.5.4 Practice Antibiotics Findings • The antimicrobial pharmacist and medical microbiologist do not have a visible profile on the medical and renal wards but are approachable and get involved when required Recommendations

34. 2.5.5 Practice Root cause analysis Findings • root cause analysis is currently undertaken but is not as timely or robust as future requirements dictate. It is not always disseminated to the clinical teams in a timely manner, therefore it is not always owned by the divisions and clinical teams • RCA is undertaken by named individuals who are not from the clinical team. RCA is presented to clinical teams with no clear time frame for input or completion. • appropriate and timely action is not always taken as a result of the analysis of each MRSA bacteraemia Recommendations

35. Contents • Section 1 • 1.1 Executive summary • 1.2 Your key message & immediate priorities • 1.3 Data analysis • 1.4 Suggested target milestones • 1.5 Actions for recovery & improvement • 1.6 Encouraging signs • Section 2 • 2.1 Key themes • Findings and recommendations • 2.2 People • 2.3 Performance • 2.4 Process • 2.5 Practice • Section 3 • 3.1 Recommended performance reporting • 3.2 Recovery plan • Section 4 • 4.1 Data Pack Links: Content Page Acknowledgements Section 1 Section 2

36. 3.1 Recommended performance reporting Report on actions for recovery and improvement through: • the use of the MRSA improvement programme actions for recovery and improvement template to track progress and report performance into existing governance structures • population of the non-mandatory enhanced facilities on the HPA MESS reporting system to track and analyse key problem areas • undertake robust root cause analysis and share widely- where are the sources of your bacteraemias? • body site and cause, eg leg wound, CVC lines etc • which wards are your hotspot areas? • are there any trends with specific clinicians? • where do you need to focus your efforts? • Monday morning sign off (with sit rep) of all your previous week’s bacteraemias and upload to MESS every Monday afternoon • call or meet with the SHA, MRSA programme manager, implementation lead and others from your organisation as appropriate (weekly to begin with) • three month review with members of the PCT, SHA, Department of Health and Trust to demonstrate grip and delivery • this report needs to be tabled at your open Trust Board meeting

37. Acknowledgements The review team would like to acknowledge all staff within Gloucestershire Hospitals NHS Foundation Trust for their time, honesty and hospitality during this intensive two day review and its preparation Links: Content Page Section 1 Section 2 Section 3