The Scottish Patient Safety Programme

1. The Scottish Patient Safety Programme HAI – Leadership in Infection Prevention and Control NHS GG&C

2. Three Key Leadership Elements in Infection Prevention and Control • Directorate accountability • Performance management • Surveillance and Clinical incident reporting

3. What are our underlying leadership principles within the Infection Control Service ? • Patient focused • Data driven • Evidence based (and prepared to formulate evidence where none exists) • Closely linked into Management and Clinical Governance structures • Responsive to targets

4. SAB HEAT Target Target: 15% reduction by March 2011 GG&C Aim: 20% reduction by March 2011 Issue: How do we develop a system to manage this?

5. SABs Project Plan 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.

6. Develop Reporting Structure SPSP

7. Utilise Infection Control Staff Resource MRSA Screening Project Team: • Utilised as there was a gap in policy decision for screening. • Project Nurses were already aligned to directorates. • Provided a formal reporting and monitoring structure. • Were responsible for hosting local action group meetings (meetings chaired by directorate Head of Nursing) • Facilitation by Project Team: Rolling action plans, research etc. Infection Control Leads: • Lead Nurses provided expertise to local groups • Lead Surveillance Nurse coordinated data • Consultant Microbiologist, Assistant Head of Nursing and Infection Control Manager visibly supported process.

8. Utilising our Data 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.

9. Directorate

13. Directorate Led Action Groups

14. Key Workstreams – Infection Control Enhanced SAB Surveillance Leads ICNs and Lead Surveillance Nurse reviewed current documentation and database. An enhanced form was launched in July 2010. Enhanced Reporting In addition to directorate reports, all directorates will now be receiving an enhanced summary of the above SAB surveillance.

15. Key Work streams – Emergency Care and Medical Services 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).

16. Poster

17. Observations so far…. Benefits noted: • Joint working • Shared ownership of target • Project management facilitation is helping push actions • Evidence based approach is helping to engage clinicians – they are leading the direction of travel.

18. SABs Pareto and SPSP Implementation

19. Observations so far….(2) 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.

20. Creating a Combined Approach SOLUTION: Needs to be combined process linked to board governance based on performance indicators from multiple areas. Continuous Improvement Targeted Improvement

21. Thank you Any Questions?