author: improvement programme review team version: 1.00 date: finalised 18 04 07

MRSA/HCAI Improvement Programme

National Orthopaedic Project National Orthopaedic Project

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Author: Improvement Programme Review TeamVersion: 1.00Date: Finalised 18 04 07

MRSA/HCAI Improvement ProgrammeGloucestershire Hospitals NHS Foundation TrustReport



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Contents

Section 1 1.1 Executive summary1.2 Your key message & immediate priorities1.3 Data analysis1.4 Suggested target milestones1.5 Actions for recovery & improvement 1.6 Encouraging signs

Section 22.1 Key themes

Findings and recommendations2.2 People2.3 Performance2.4 Process2.5 Practice

Section 33.1 Recommended performance reporting3.2 Recovery plan

Section 44.1 Data Pack

Section 1

Section 2

Section 3

Links:

Acknowledgements



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Content Page

Links:

Acknowledgements

Section 3

Section 2

Contents








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1.1 Executive summaryYour 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.



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Your key message is :

Focus, Feedback Follow-throughTurning 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 organisationidentify medical clinical leads with clearly identified roles and responsibilitiesput Infection Prevention and Control as a standing item on all key agendas

1.2 Your key message and immediate priorities



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1.3 Data analysis

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



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MRSA Bacteraemias. 12 month rolling total.

0

10

20

30

40

50

60

70

80

90M

ar-0

6

Apr

-06

May

-06

Jun-

06

Jul-0

6

Aug

-06

Sep

-06

Oct

-06

Nov

-06

Dec

-06

Jan-

07

Feb

-07

Mar

-07

Apr

-07

May

-07

Jun-

07

Jul-0

7

Aug

-07

Sep

-07

Oct

-07

Nov

-07

Dec

-07

Jan-

08

Feb

-08

Mar

-08

Tar

get

What is the direction of travel?

The challenge is significant to be where you need to be in March 2008



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0

1

2

3

4

5

6

7

8

9

10

Feb-06 Mar-06 Apr-06 May-06 J un-06 J ul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 J an-07

What is the scale of your challenge

Trajectory (T)

Your MRSA figures are consistently above trajectory. Recovery needs to be sustained and the pace increased

Actual (A)

You need to put a recovery plan in place to ensure you are meeting your agreed monthly trajectory



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=<48hrs, 35%

>48hrs, 65%

No of MRSA cases split by Pre- and Post-48 Hours

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

You have 35% pre 48 hours which is more than the national average (28%)



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No of MRSA cases split by Specialty

- A look at your problem areas

5%

37%

18%

7%

1%

7%

11%

4% 3%1%3%

1%

1%

1%

A&E

Cardiology

Clin. Oncology

C.C. Med

Gen. Med

Gen. Sur

Geriatric Med

Haematology

Med.Oncology

Nephrology

Unknown

Obstetrics

T&O

UrologyAreas to target short term are:•General Medicine (including Geriatric Medicine)•Surgery



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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.

9%

91%

Augmented Care

No Augmented Care



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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.

No of MRSA cases by Age BandThe breakdown of your MRSA cases by age band. You have most cases in the 85-89 category.

0

2

4

6

8

10

12

14

16

18

25 -29

30 -34

35 -39

40 -44

45 -49

50 -54

55 -59

60 -64

65 -69

70 -74

75 -79

80 -84

85 -89

90 -94

95+



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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.

0

5

10

15

20

25

30

35

01/1

0/05

01/1

1/05

01/1

2/05

01/0

1/06

01/0

2/06

01/0

3/06

01/0

4/06

01/0

5/06

01/0

6/06

01/0

7/06

01/0

8/06

01/0

9/06

01/1

0/06

01/1

1/06

01/1

2/06

01/0

1/07

Date of sample

Day

s si

nce

las

t b

acte

raem

ia d

etec

ted

Mean Lower limit Upper limit Time between bacteraemias

Gloucestershire Hospitals NHS Foundation Trust

Time in days between MRSA bacteraemias - Gloucestershire Hospitals NHS Foundation Trust



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Next Steps for you

Root Cause analysisempowering 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



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Actions Milestones

A robust recovery plan is required immediately to prioritise and focus activity to deliver agreed monthly trajectory

Immediately carry out root cause analysis empowering the clinical teams to ascertain source and cause of all MRSA bacteraemias within 24 hrs.

Revise RCA process to include action points and learning

Feed back collated information from RCA and HII audit to clinical teams

You can make significant improvement in MRSA bacteraemia by at least 50% in General Medicine, Nephrology, Geriatric Medicine and General Surgery by end of July 2007

Carry out bespoke analysis of pre-48 hour MRSA bacteraemias and determine how many of them have had previous hospital admissions in the previous three months

Work closely with partner organisations to reduce number of pre-48 hour MRSA bacteraemias. Instigate joint root cause analysis to uncover source.

Avoidable MRSA bacteraemia in Augmented Care should have been zero by December 06 in line with national target

To get on trajectory and sustain improvement

Continue to reduce MRSA bacteraemias in General Medicine, Geriatric Medicine and Renal to achieve your monthly run rate or less

Reduce the number of < 48hr bactereamias in line with the improvement for >48hr bacteraemias

Ensure you have zero avoidable cases in Augmented Care continuing monthly

1.4 Suggested target milestones



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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

Microsoft Excel Worksheet

Gloucester Action Plan updated 17 04 07This will continue to be work in progress owned by

Gloucester Hospitals NHS Foundation Trust



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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/…



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1.6 Encouraging signs

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

…/continued



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Acknowledgements

Section 1

Section 3

Links:

Content Page

Contents








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PeoplePeople PerformancePerformance

ProcessesProcesses PracticesPractices

2.1 Key themes

MRSA bacteraemia

reduction

Leadership Divisional responsibilities

and ICTRoles and responsibilities

Renal

Performance frameworks Use of data

Performance data Audit

Pre-48 hour cases

Hand hygieneHigh impact interventionsScreening / decolonisation

AntibioticsRoot cause analysis



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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

Leadership

Recommendations

Ensure MRSA target delivery is of equal importance to other key targets and translated to divisions, teams and individuals accordingly, to ensure delivery and then performance managed

Reducing infection must be seen to be everyone’s business with clear responsibly, accountability and performance management

Appoint medical clinical leads within each specialty and performance manage

Play a key role in the DH MRSA Programme Performance Improvement Network. Disseminate timely, accurate and appropriate information to all staff to encourage a culture of continuous learning, improvement and sharing of best practice

2.2.1 PeopleFindings



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Divisional responsibilities

and ICT

Recommendations

The focus of activity must be based around divisions, with the ICT enabling rather than undertaking the bulk of activity. Clinical leads within each speciality will be key to successful implementation, supported by clear objectives and outcome measures

Ensure that clinical leadership is engaged at divisional level, with clear responsibilities and accountabilities for engagement, reporting and delivering improvements. Responsibilities need to be explicit in clinical director job descriptions

Achieving the target needs to be everyone’s business. Clear responsibilities and accountabilities must be underpinned with focused objectives for all members of the directorate including clinical directors, lead nurses and link nurses

2.2.3 PeopleFindings

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



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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

Roles &responsibilities

Following a series of new appointments, staff changes and changing priorities and workload, re consider the role of the DIPC and review in light of ’Winning ways: Action Area 6’

Ensure that consultants are aware of their accountability/responsibility for the IC practice of their juniors and are appropriate role models. Escalate their engagement in clinical governance to deliver updates and key messages

Re state the roles and responsibilities and accountabilities of the consultants, ICT and lead nurses to ensure understanding of individual and shared responsibilities and performance manage through regular 1:1s

Implement High Impact Interventions to change behavior and to measure improvement

2.2.4 People

Recommendations

Findings



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Performance frameworks 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

Set divisional tolerance levels and display recent data at ward level to ensure all members of the team are aware of baseline and their personal responsibility

Divisions to be held accountable through performance frameworks for their performance against the MRSA bacteraemia reduction target

Each MRSA bacteraemia over and above the monthly trajectory should be treated as a breach and performance managed

Review the current meeting structure and expedite plans to merge the Infection Control Committee and the Saving Lives Group review membership to include key clinicians and terms of reference, incorporate specific action points with named individuals as an output from each meeting.

2.3.1 Performance

Recommendations

Findings



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Use of data 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

Review the current RCA approach used and consider using the newly developed NPSA RCA tool or components of it to be able to identify trends in individuals, teams, environmental issues, sources, case mix issues, collective training and development needs, etc. Ensure timely reporting of RCA findings and appropriate feedback, across the health economy where appropriate. Performance manage and monitor and ensure interventions are targeted

Implement appropriate HII’s in ‘hot spot’ areas with weekly audit undertaken by Link Nurses. Use the Compact Disk from Saving Lives to ensure this is done easily and quickly. Produce and circulate data to monitor improvement in practice

2.3.2 Performance

Recommendations

Findings



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Performance data 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%)

Understand sources of your bacteraemias both pre- and post-48 hours to enable focus on the hot spots. Provide basic information and key/simple messages to staff on MRSA and mechanism of transfer. Adopt more rigorous and evidence based approaches in using data in order to provide the required focus, create the sense of importance and urgency required. Gain greater engagement across the Trust and provide assurances to the Board

Use robust and timely enhanced surveillance data to identify which wards/departments have the greatest numbers of bacteraemias and interrogate own Trust data to understand sources. Use clinical leads to overcome any data credibility issues. Ensure a fit for purpose IT system is in place which supports IC activities in respect of providing information for surveillance/monitoring.Use rigorous methods to identify which areas in General Medicine and Geriatrics and General Surgery require focus in addition to the attention that renal services are already receiving

Using the HIIs within these areas should enable faster progress to be made. Set local reduction targets, dates for attainment and owners. Focus on your hotspots

Complete, sign off and submit MESS data weekly with sit reps and share across the organisation for early use in learning and performance management

2.3.3 Performance

Recommendations

Findings



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Pre-48 hour cases 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

The pre-48 hour group of patients would suggest that some of this group are readmissions or frequent attenders with chronic conditions. Use the RCA tool to identify the source and any contributing factors

Work with the PCTs on further engagement and management of those cases identified. You should address specific issues in Nephrology that may relate to efficiency or permanent vascular access or other dialysis practices, including screening and preventing colonisation

Once the the source of the pre-48 hour bacteraemias has been identified, review screening and decolonisation protocols in light of the findings. Your figures are suggestive of re-admissions and may require a health economy approach with support from the SHA

Escalate and increase the pace of action as a result of the work with the health economy partners at the fortnightly meetings to reduce the pre-48 hour cases

2.3.4 Performance

Recommendations

Findings



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Audit 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

Use the RCA and hot spot areas to focus work for HIIs and audit

Feed the results of audit into directorate performance management to ensure actions are monitored and owned

Establish a mechanism for sharing/spreading good practice and learning across the Trust

Link the results of audit into future induction/education and training, personal development plans and performance monitoring frameworks

2.3.5 Performance

Recommendations

Findings



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Renal 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

2.4.1 Process

Implement screening policy see recommendation 2.5.3

Introduce other appropriate HII’s and audit compliance, weekly at first until improvement is achieved and sustained

Process map the renal patient pathway and refine the steps in the journey.

Recommendations

Findings



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Hand hygiene 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

2.5.1 Practice

Restate the message to all staff that improved compliance with hand hygiene is a priority for the Trust and work towards a target for compliance of 95% across the Trust. Ensure all relevant staff understand the rationale behind the need to use gloves, when to wash hands, and when to use gel or rub. Audit through the HII and performance manage to ensure all staff, whether touching a patient or not, decontaminate their hands on entry and exit to clinical areas and always at the point of care

Increase the frequency of hand hygiene audits to be undertaken by clinical lead nurses, publish the results and take any appropriate action. Promote the use of alcohol hand rub as the gold standard for routine hand hygiene when appropriate

Escalate the education and awareness, training and auditing, particularly in areas identified by the RCA as the main areas of focus

Continue with the recent focus on hand hygiene and re launch the ‘Clean Your Hands campaign’ use the opportunity of appointing medical clinical champions to re enforce the message

Recommendations

Findings



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2.5.2 Practice

Undertake robust root cause analysis and prioritise the implementation of the HIIs for relevant areas accordingly

Ensure the utilisation of the HIIs are owned by the directorates, with clear responsibility and accountability and linked to governance and performance. Ensure the Trust guidelines are implementedfor the insertion and management of CVCs. Audit documentation and performance manage

Observational audit at point of insertion to become everyday practice. Speed up the implementation of VIP scoring, audit HII 2b weekly and focus on ‘hot spot’ areas first

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

High impactinterventions

Recommendations

Findings



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2.5.3 Practice

Use national evidence and the DH guidance to review and re-launch the screening and decolonisation policies. Provide consistent clarification to staff in relation to screening of all high risk patients (surgery, critical care, elderly care, regular or repeat admissions and admissions from nursing home/residential care homes) as recommended in national guidance (Guidelines for the Control and Prevention of MRSA in Healthcare Facilities by BSAC, HIS, ICNA working party on MRSA)

Implement revised screening policy as a pilot and audit compliance, sign off can come later supported by evidence of effectiveness

Ensure the policies are interpreted and adhered to appropriately and audit compliance. Performance manage and feed back to divisions/departments

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

Screening/decolonisation

Recommendations

Findings



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2.5.4 Practice

Formalise contact of antimicrobial pharmacist and medical microbiologist within renal and general medicine to promote policy compliance and best practice in these hot spot areas

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

Antibiotics

Recommendations

Findings



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2.5.5 Practice

Each relevant consultant to report to their divisional governance group on the findings of RCA and action taken to support learning. Performance manage through existing governance structures

Review the current RCA approach used and develop a more robust approach. Consider using the newly developed NPSA RCA tool or components of it to be able to identify trends in individuals, teams, environmental issues, sources, case mix issues, collective training and development needs, etc. Commence RCA within 24 hours of confirmation of an MRSA bacteraemia.

Once a more robust approach has been developed, assign responsibility for undertaking RCA to an individual within the relevant clinical team who has the time, skills and status to investigate, action and follow-up all cases supported by infection control/DIPC and the risk management team

Ensure timely reporting of RCA findings and appropriately feed back across the health economy where appropriate. Performance manage and monitor and ensure interventions are targeted

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

Root causeanalysis

Recommendations

Findings



35

Acknowledgements

Section 1

Section 2

Links:

Content Page

Contents








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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



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Acknowledgements

Section 1

Section 2

Section 3

Links:

Content Page

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

author: improvement programme review team version: 1.00 date: finalised 18 04 07

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