Healthcare Environment Inspectorate Framework: Update to NHS QIS Board

1. Healthcare Environment Inspectorate Framework: Update to NHS QIS Board NHS Quality Improvement Scotland April 2009

2. Context for the Healthcare Environment Inspectorate Scotland (HEIS) Healthcare Associated Infection Focus of Last Six Weeks • Hospital acquired infections are a serious issue in Scotland with high HAI prevalence in comparison to EU countries* • The Vale of Leven incident prompted a review of HAI in Scotland that identified a number of shortcomings in governance and leadership • The Cabinet Secretary announced the creation of the Healthcare Environment Inspectorate (HEIS) to • Carry out site visits of every Scottish acute hospital • Ensure highest standards of infection prevention, control and cleanliness • NHS QIS has been : • Defining the scope and purpose of the inspectorate • Developing an inspection framework • Testing and refine the inspection framework with key stakeholders • Outlining the implications of HEIS for relationships with stakeholders in NHSScotland • Outlining the organisational implications of the inspectorate for NHS QIS *Annual epidemiological report on communicable diseases in Europe 2008 SOURCE: Team analysis

3. Purpose of HEIS • Provide assurance to the public, NHS Boards, and the Scottish Government that healthcare associated infection (HAI) standards in acute hospitals are high and that any HAI issues are being tackled • Assurance • Catalyse improvement in infection prevention measures across Scotland through an inspection framework leading to a decrease in HAIs and their consequences over time, • Build on and contribute to the existing improvement agenda • Improvement SOURCE: Team analysis

4. HEIS will primarily support the assessment element of the improvement cycle, though it will inform the whole integrated cycle QIS Integrated cycle for improvement • Implementation • support • Guidance • Assessment

5. Risk based • The frequency and intensity of monitoring and inspection proportionate • and risk based Impact focused • Resources will be focused on areas that will yield the greatest improvement in performance and provide the most assurance to the public, NHS Boards and the Scottish Government Maintaining board accountability • Boards will remain accountable for HAI performance and for fulfilling any statutory requirements Transparent and open • The inspectorate will use a transparent method for inspecting hospitals, involving the public in inspections and publishing the results of inspections shortly after they are completed • The inspectorate will not disclose confidential information without prior agreement (unless it has a statutory obligation to do so) Minimising duplication • The inspectorate will use data already collected to the greatest extent possible in its operations and will not request information that a Board should not already be reviewing as part of its operations • The inspectorate will collaborate with a range of organisations (inc scrutiny and regulatory bodies) to minimise duplication of activity and will evolve over time to ensure it remains efficient and effective Supporting improvement • The Inspectorate will actively contribute to, and enhance, the broader quality improvement agenda Six principles of the inspectorate philosophy SOURCE: Team analysis

6. HEIS inspection framework has five components HEIS Role • Monitors quantitative and qualitative data to support risk assessment and overall inspection cycle, using analysis of self assessment • Monitoring The inspectorate will also inform the setting of HAI standards /policy • Visit hospital sites to validate self assessment and gather first hand feedback on HAI performance (visits hospitals at least once every three years) • Inspections may be announced or unannounced and may be focused on specific themes • Site visits • Following visits, requires Boards to update improvement plan to address any identified deficiencies • Monitors progress against updated improvement plan • Follow-up development and intervention • Publishes reports on: • Monitoring • Hospital inspections • Board performance • National performance • Reporting • Escalates to SGHD performance managers or regulators where necessary • Escalation SOURCE: Team analysis

7. Proposed monitoring metrics (1/2) Primary metrics – reviewed by HEIS • Number of MRSA positive patients/% of patients MRSA positive • Number of MRSA bacteraemias/% of patients with MRSA bacteraemias • Number of C. diff positive patients/% of patients C. diff positive • Bed occupancy • Weekly • Quarterly • Deaths per infection • Time to treatment for infected patients • Antibiotic prescribing compliance • % MRSA positive patients isolated • % C. diff positive patients isolated • Cleanliness compliance • Handwashing compliance • Patient complaints • Staff complaints/staff survey results Source: Team analysis

8. Proposed monitoring metrics (2/2) Primary metrics – reviewed by HEIS • Time from outbreak triggers to management starting emergency procedures (e.g., declaring outbreak to HPS, ward closures) • % patients receiving HAI risk assessment on admission • Age of infrastructure • Capital investment per bed per year • Maintenance spend per bed per year • Number of beds per 1000 sq ft ward floorspace • Patient age and case mix by specialty • % nurses completed HAI training in last 3 years • % staff screened for MRSA in last year • Annually Source: Team analysis

9. Inspection team • HEIS employees • Lead inspector • Inspector • Project manager • Other inspectors • Associate inspector: Public representative1 • Expert inspector: Ventilation expert2 • Observer • Chief Executive from Board X What could an announced initial site visit look like? … • Example topics to cover Introduct-ions and objectives • Day 1 • 9am • 10am • 11am • 12pm • 1pm • 2pm • 3pm • 4pm • 5pm • Team A Team B • Walk round and general review • Inspect ward 15 Inspect ward 16 • Inspect operating theatres • Lunch (inspection team only) • Inspect ward 26 Inspect ward 12 • Staff/patient open session • Staff/patient open session • Inspection team meeting • Give informal feedback to Chief Executive • Day 2 • 9am • 10am • 11am • 12pm • 1pm • 2pm • 3pm • 4pm • 5pm • Team A Team B • Staff interviews Patient interviews • Patient interviews Staff interviews • Staff interviews Patient interviews • Lunch (inspection team only) • Inspect ward 2 Inspect ward 5 • Inspect ward 4 Inspect ward 8 • Inspect maternity Inspect ITU • Inspection team meeting • Informal close and feedback with Chief Executive and senior team Evidence of good practice Antibiotic prescribing Ongoing concerns Bed spacing Ccleanliness Staff attitudes Ventilation Initial findings/ immediate concerns Findings and next steps 1 HEIS will draw from a permanent pool of associate inspectors. Permanent pool will allow HEIS to train inspectors in inspection methodology 2 Experts will be invited as required (e.g., will join this team from 3-4pm on day 2 because of recent concerns about airborne spread of infections in ITU) 3 Inspection team may take photos, record video, inspect documents, or speak to patients and staff at any stage of the site inspection Source: Team analysis

10. 3 • 4 • 2 • 1 • 5 Proposal for post site visit process • HEIS/Board Meeting • Inspection report published • Updated improvement plan published • Immediate escalationto relevant body • Serious issue identified • Feedback to hospital following visit • Internal HEIS review of draft report • Draft report presented to Board for review • Board circulates draft internally and prepares responses if needed • Formal mediation session with Board to review accuracy • Board updates improve-ment plan in response to Report • Formal meeting between HEIS and Boardto test improvement plan “fit for purpose” • Follow-up by HEIS • Site visit • complete • Within 4 weeks of inspection • Immediate • 1 week • 1 week • 2 hr • meeting • 2 weeks • 3 hr meeting • Within • 16 weeks • Depends on severity of issues

11. Site visit cycle • Board • National Proposed reporting and frequency • Still to be finalised • Report • Content • Distribution • Frequency • Quarterly • HEIS monitoring metrics with Board commentary (including self-assessment) • Electronic/internet • Monitoring • Summary of inspection findings • Recommendations for action • Grading • Inspectees • Electronic/internet • Local healthcare providers • Boards • Scottish Government • Final report published within 6 weeks of site inspection • Every hospital will be inspected at least twice every 3 years • Summary of inspection findings by board • Recommendations for action • Boards • Electronic/internet • Scottish Government • Annual • Summary of inspection findings • Recommendations for national HAI framework • Scottish Government • Electronic/internet • Annual Source: Team analysis

12. When will escalation be triggered? Trigger points throughout post-inspection process will ensure issues are resolved within a reasonable time-frame • Scottish Government • HSE • Procurator Fiscal • Governance and support organisations (e.g. QIS) • Scottish Government • Scottish Government • Governance and support organisations (e.g. QIS) • Scottish Government • HSE • Procurator Fiscal • Escalation to: • Inadequate implementation of action plan poses threat to public health • Trigger rationale • Serious issue identified during inspection • Board improvement plan inadequate or not produced within required time-frame • Implementation of improvement inadequate or not within required time-frame • Feedback to hospital following visit • Internal HEIS review of draft report • Draft report presented to Board for review • Board circulates draft internally and prepares responses if needed • Formal mediation session with Board to review accuracy • Board prepares improve-ment plan in response to Report • Formal meeting between HEIS and Board to test improvement plan “fit for purpose” • Follow-up by HEIS • Site inspection • complete Source: Team analysis

13. 1 • 2 • 3 • 4 • 5 There are a number of important HEIS design decisions that the board should consider • Open design issues • Should the inspectorate focus on understanding current compliance with HAI standards or make a judgment of ability to maintain compliance in the future? • How should the inspectorate approach its monitoring role? • What role should the inspectorate seek to play in the broader Scottish quality improvement agenda? • Should the inspectorate explicitly grade hospitals? • How could the promise of public involvement in HEIS be best delivered?

14. 1 • 2 • 3 • 4 • 5 Next steps in relation to HEIS • Current Activity • Test framework with key stakeholders • Test and finalise details of inspection framework through scenario testing • Monitoring • Site visits • Follow-up • Reporting • Draft Concordat proposal and test with HAI related bodies • Prepare for and run prototype inspection regime in two pioneer sites in June • Full implementation by September