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EEAST: Annual Quality Report 2016-17
June 2017
EEAST: Annual Quality Report 2016-17
June 2017
Contents
Introducing the East of England Ambulance Service NHS Trust…………………………………………………………………………………………4
IPC Team statement…………………………………………………………………………………………………………………………………………………..6
Introduction………………………………………………………………………………………………………………………………………………………………7
What is the Director of Infection, Prevention & Control annual report?............................................................................................7
CQC Report……………………………………………………………………………………………………………………………………………………………….8
Significant Progress in 2016/17…………………………………………………………………………………………………………………………………….10
Trust IPC Infrastructure………………………………………………………………………………………………………………………………………………11
IPC Reporting and Assurance groups…………………………………………………………………………………………………………………………….12
IPC Auditing and Quality Assurance……………………………………………………………………………………………………………………………...13
IPC Vehicle Audit Results…………………………………………………………………………………………………………………………………………….14
IPC Vehicle Decontamination………………………………………………………………………………………………………………………………………15
IPC Station Audit Results…………………………………………………………………………………………………………………………………………….16
IPC Staff Audit Results………………………………………………………………………………………………………………………………………………..17
Untoward IPC related incidents……………………………………………………………………………………………………………………………………19
IPC activities……………………………………………………………………………………………………………………………………………………………..20
IPC Programme 2017/18………………………………………………………………………………………………………………………………………………21
EEAST: DIPC Annual Report 2016-17
August 2017 3
Welcome to the East of England Ambulance Service NHS Trust Director of Infection, Prevention & Control Annual Report for 2016/17. This document has been approved by the Trust Board and is an accurate account of the Trust’s infection, prevention and control activities. In developing this annual report, we have set out a summary of achievements for 2016/17, and goals for 2017/18.
Where can you get hold of this document?
This Annual Report is available on the East of England Ambulance Service website from www.eastamb.nhs.uk or write to: East of England Ambulance Service NHS Trust Headquarters, Whiting Way, Melbourn, Cambridgeshire SG8 6EN Tel: 0845 601 3733
EEAST: DIPC Annual Report 2016-17
August 2017 4
Introducing the East of England Ambulance Service NHS Trust
Our Trust provides emergency and urgent care services throughout Bedfordshire, Cambridgeshire, Essex, Hertfordshire, Norfolk and Suffolk.
We also provide non-emergency patient transport services for patients needing non-emergency transport to and from hospital, treatment centres and other similar facilities within Cambridgeshire, Great Yarmouth and Waveney, north, south and west Essex and Suffolk.
We cover an area of approximately 7,500 sq miles with a resident population of almost six million people.
We employ over 4000 staff operating from 130 sites and are supported by more than 1000 dedicated volunteers.
There is an emergency operations centre (EOC) at each of the three locality offices in Bedford, Chelmsford and Norwich, and the Trust Headquarters building is situated in Melbourn, Cambridgeshire.
EEAST: DIPC Annual Report 2016-17
August 2017 5
The eastern region is made up of both urban and rural areas with a diverse population. As well as a resident population of nearly six million people, several thousand more tourists enjoy visiting our area in peak seasons each year. Our area also contains major airports including London-Luton and London-Stansted which increase the number of people in our region on a daily basis. We have four main areas of service provision:
Response to 999 calls as an emergency and urgent care service
In 2016/17, our emergency operations centre received 1,140,394 contacts from the public. On average, nearly 3,200 emergency 999 calls come into the ambulance service every day and are answered and managed in our emergency operations centre (EOCs). The call handler records information about the nature of the patient’s illness or injury using sophisticated software to make sure they get the right kind of medical help. This is known as triaging, and allows us to ensure that the most seriously ill patients can be prioritised and get the fastest and most appropriate response. Once this key information is established, the response will be selected from a range of care providers including a single clinician in a fast response car, a double staffed emergency ambulance dispatched on blue lights, a clinical assessment conducted over the phone by an appropriate clinician for patients with conditions that do not require an ambulance service response. This response would include advice over the phone from a paramedic or a referral to their GP, pharmacist or local walk-in centre. Scheduled Care Service – Patient Transport Service
We provide a non-emergency Scheduled Care Service, more commonly known as the Patient Transport Service (PTS) to and from home to outpatient appointments at hospitals or other care centres around the region to help people who need assistance because of their medical condition or age. Special and partnership operations
The Trust operates two hazardous area response teams and has a resilience and emergency planning department who work closely with critical care charities and community volunteers to respond to a variety of emergency situations. Commercial services
We operate a number of services which generate income for the Trust. These include training for blue -light drivers and first aid at work. In addition there is a contact centre and a medical service which cover events, festivals and medical repatriation.
EEAST: DIPC Annual Report 2016-17
August 2017 6
IPC Team statement
2016/17 has been good year for IPC in EEAST, despite some setbacks and challenges good progress has
been made in raising the standards and developing assurance across the Trust. There have been
significant steps made to improve the levels of reporting and the completion of actions where issues are
found, although further work is required in reporting on the completion of the actions. This has been
worked into the team work plan for 2017/18.
The regular decontamination of vehicles is an area which has been highlighted as requiring improvement
and the team has begun to undertake a substantial quality improvement project to review this process
and develop a model that delivers the highest levels of patient safety. The work undertaken in this
project is part of a national project to contribute to a standardised approach for all UK ambulance Trusts.
Throughout 2016/17 the team has been expanded and developed wider networks of IPC lead roles
throughout the Trust operational teams, this has worked well to develop good levels of local ownership
and improve staff access to IPC information. Further work is planned for 2017/18 to revitalise the IPC
Champions role and develop them as part of the wider IPC team to help support the operational staff and
local management teams.
Along with the re-launch of the IPC Champion role additional funding has been allocated to recruit an
additional IPC Specialist Practitioner to address the capacity gap within the team. This will be a great
addition to the team and increase the capacity of the team to allow them to provide a higher level of
support to all service lines and provide a higher level of assurance to the Trust.
EEAST: DIPC Annual Report 2016-17
August 2017 7
The Trust puts infection control and basic hygiene at the heart of good
management and clinical practice, and is committed to ensuring that
appropriate resources are allocated for effective protection of patients,
their relatives, staff and members of the public. In this regard, emphasis is
given to the prevention of healthcare associated infection,
and the sustained improvement of cleanliness of our
vehicles and stations.
The issues that the Trust must
consider include:
The number and type of
procedures carried out across
the Trust and the systems in place to
support infection control and decontamination.
The different activities of staff in relation to the
prevention and control of infection.
The policies relating to infection prevention control and
decontamination.
The staff education and training programs.
The accountability arrangements for infection prevention and
control.
The infection prevention and control advice received by the Trust.
The integration of infection prevention and control into all service
delivery and development activity.
What is the Director of Infection, Prevention & Control annual report?
The annual Director of Infection, Prevention & Control (DIPC) report is a
mandatory report for NHS healthcare trusts, and is required to be
completed in line with the Health and Social Care Act (2012).
It gives an account of infection, prevention and
control activities within the East of England
Ambulance Service NHS Trust during
April 2016 to March 2017.
The DIPC annual report covers:
The Infection, Prevention & Control (IPC) team infrastructure and
Trust progress against this current objectives
How IPC standards and compliance is monitored
Sets out the goals and objectives for the coming year
How IPC standards and compliance is monitored
Introduction
EEAST: DIPC Annual Report 2016-17
August 2017 8
Overall compliance for hand
hygiene in Bedfordshire and
Hertfordshire was 96.6% CQC Report
The Care Quality Commission carried out an inspection of the Trust on the 4th to 8th April 2016 with an
unannounced inspection on the 19th April 2016. The final report was published on the 19th August and is available
through the CQC website (www.cqc.org.uk) or via the link on the Trusts website (www.eastamb.nhs.uk). The
overall rating for the Trust was “Requires Improvement” and the Trust complete overall Trust action plan is
available on the website. There is a specific action plan relating to all the areas for improvement found during the
visit which is reviewed at the bi-monthly IPC Group meetings and is also available on the Trust website.
With the changes to the way CQC inspections are performed the rating gives
an overall view of the findings from the visit in relation to the key lines of enquiry
questions and does not give a defined view on individual elements e.g. Infection,
prevention and control.
There were a number of positive points found regarding IPC during the visit and also some areas for improvement
highlighted, one of the key points highlighted was in relation the vehicle decontamination. This was found to be good for
the emergency vehicles but there were concerns highlighted within the non-emergency vehicles. in that they were not being
thoroughly decontaminated to the standards set out within the Trust’s policies. And, furthermore did not always have the full
level of PPE available for the staff.
Although these points were specific to the non-emergency vehicles a full review was performed for
both emergency and non-emergency vehicles and areas of improvement found. Measures were put
in place for an immediate quick resolution of the issues and also for the longer term improvement
of the standard.
Advice regarding IPPC was available in prominent places at all ambulance stations
All equipment within vehicles was visibly clean
EEAST: DIPC Annual Report 2016-17
August 2017 9
Other areas for improvement found during the inspection were:
Lack of assurance that reliable systems were in place to protect patients from the risk o infection in non-emergency vehicles
Low levels of uptake on mandatory training including IPC and hand hygiene training
Not all non-emergency vehicles had a full range of personal protective equipment available for staff
Not all areas had complete or consistent action plans when areas for improvement were highlighted during audits
Although most staff were found to be compliant with the Trust ‘bare below the elbows’ policy and followed good hand hygiene practice,
this was not the case in all areas
In some areas there were some out of date disinfectants found
Throughout the remainder of the year following the release of the CQC report there have been a number of measures put in to address and
improve the issues highlighted. The key measures put in place are:
Introduced the central recording of vehicle decontamination to increase visibility and highlight discrepancies.
The Trust has begun a quality improvement project alongside the National ambulance service IPC Group to review vehicle cleaning
procedures and frequencies against impact on patient safety.
Review of the practice and requirements of the non-emergency staff roles with regards to PPE and implementing a process with
additional monitoring to ensure consist availability of PPE to staff
Introduction of including exceptions reports and actions taken within the IPC Monthly report
Ongoing review and increased monitoring of staff compliance with ‘Bare below the elbows’ incorporated with staff awareness notices.
Changes to the Trust IPC assurance database, which enables the management teams to record steps taken to address issues and record
appropriate evidence. This helps to raise the awareness of the local teams and also continually keeps the focus on these areas so they are
not overlooked.
EEAST: DIPC Annual Report 2016-17
August 2017 10
Significant Progress in 2016/17
The approach within the Trust is that Infection Prevention and Control is
everyone’s business and without the efforts of every member of staff the
Trust would not have made the significant progress with the IPC agenda that
it has.
During 2016/17 there has been progress made in the following key areas:
The IPC team has taken a more strategic and supportive role,
promoting local management ownership and accountability
Increased levels of quality assurance audits
Improved audit system to enable easier recording, monitoring and
reporting of IPC audits with live data available to all areas
Improvements in the recording and compliance of vehicle “Deep
cleaning”
Improvements in the reporting, monitoring and management of IPC
occupational exposure incidents
Production of an easy access guide to infectious disease for operational staff
The IPC team resourcing has been reviewed and vacancies filled, with additional funding agreed for a second IPC Specialist role
EEAST: DIPC Annual Report 2016-17
August 2017 11
Trust IPC Infrastructure
NHS organisations are required to have in place systems to manage and
monitor the prevention and control of infections, which should include all
parts of the organisation from the front line to the board.
Within EEAST everybody plays a part in the reducing the risk of infection for
patients, staff and the public. The trust has a dedicated IPC team which
provides specialist IPC advice and guidance.
The main IPC team consists of:
Director of IPC
Head of IPC
IPC Administrator
IPC Auditor
The Trusts Director of Nursing and Clinical Quality performs the duties of the
Director of IPC role, so has an integral part in developing and guiding the Trusts
clinical governance and patient safety strategies. He is responsible for providing
oversight and assurance on all aspects of IPC to the Trust Chief Executive and
the Board.
The Head of IPC is an experienced Emergency Care Practitioner with eight
years’ experience of working within IPC in the emergency care environment.
The IPC team provide expert knowledge, direction and education in IPC issues
across the Trust. The team liaise with clinicians, service line and directorate
managers together with managers who have responsibility for estates, clinical
governance, risk management, health and safety, occupational health, medical
devices, procurement and waste management.
.
EEAST: DIPC Annual Report 2016-17
August 2017 12
IPC Reporting and Assurance groups
The IPC Group is the main forum for discussion concerning changes to policy or practice relating to infection prevention and control. The membership of the
group is multi-disciplinary and includes representation from all directorates and senior management. The Gr oup is chaired by the DIPC and currently meets bi-
monthly.
There are multiple groups which feed into the Infection Prevention & control group, which in turn reports into the Clinical Quality Safety Group, who report to the
Quality Governance Committee, which is a sub-group of the board.
Trust Board
Quality Governance
Committee
Clinical Quality & Safety
Group
IPC Group
Estates Group
Waste Management
Cleaning Contractors
Locality IPC Group
Infection Control
Champions
Vehicle Working
group
Occupational Health
Medical Devices &
safety Group
EEAST: DIPC Annual Report 2016-17
August 2017 13
IPC Auditing and Quality Assurance
The Trust has a comprehensive audit schedule which is reviewed annually; this incorporates audits for emergency and non-emergency vehicles, operational
stations, and staff uniform and IPC procedure compliance audits.
Three levels of audit are carried out as recommended by the NPSA (2009) these are
technical, managerial and external audits. Technical level audits are carried out by
operational staff at a local level. Managerial audits are carried out by members of the local
senior management team, IPC team or Clinical Quality team managers at a Trust, rather
than local level. The aim of carrying out the managerial audits is to verify the results of the
technical level audits and identify trends and areas of concern. External audits are carried
out by the Trust User Group throughout the year, with the aim being for each station/ area
received two unannounced visits per year. All of the Trusts clinical commissioning groups
are invited to perform unannounced external audits throughout the year.
During 2016/17 the Trust has developed an additional level of assurance level of quality
assurance by introducing Locality IPC meetings, which primarily focus on reviewing and
comparing the result of the different levels of audits completed. This not only helps to
promote local ownership and improve standards but also ensures that issues highlighted
during the audit process are picked up and addressed.
The Trust utilises an online audit system for recording and analysing audit data, this system
is live and allows for all central and local monitoring of the latest data, as well as comparison against
previous results to establish trends and progress. It also has the capability to include pictures taken during the audit
to help visualise any issues or elements of good practice.
The IPC team produce a comprehensive Monthly IPC report which includes details of all of the audit activity, results and exception reports; this is
available on the Trust website www.eastamb.nhs.uk from the 15th of each month.
EEAST: DIPC Annual Report 2016-17
August 2017 14
IPC Vehicle Audit Results The Trust target is to audit 85% of the operational vehicles (Emergency
and Non-emergency) each month. During 2016/17 the overall average
audit submission level was 92% and the 85% target was achieved every
month except August. The drop in submissions levels during August were
primarily related to an increase in operational pressures.
The audits primarily focus on vehicle cleanliness, but also include elements
relating to waste, equipment servicing and availability, medicines
management.
.
The National recommendations for compliance levels is 85%, however the
Trust has set an aspirational target of 95%, and managed to achieve this in
every month of 2016/17, with an overall average of 97% The results are
generally consistent with no major areas of concern highlighted.
The cab interior was predominately found to have the lowest compliance
level consistently throughout the year; although the cab interior is
highlighted as the area with the lowest compliance it still achieved a year
end average of 95% compliant. This is not a patient treatment area.
Both the vehicle saloon (patient treatment area) and the medical
equipment had the highest results consistently throughout the year with
both elements achieving an overall average of 97% compliance.
Throughout the year there are regular quality assurance audits performed,
the results of these are variable and generally a few percent lower than the
local audits, the average results have been consistently above 90% for the
entire year, as shown the in chart below.
The main areas for improvement highlighted throughout the audits
relates to the following:
Cleanliness of vehicle cab areas
Cleanliness of some equipment brackets
Management of sharps containers, primarily relating to assembly
and documentation
Staff awareness of Occupational exposure incident management
EEAST: DIPC Annual Report 2016-17
August 2017 15
IPC Vehicle Decontamination
The Trust has a vehicle cleaning program in place which ensures that the vehicle are decontaminated at key points , the key points from the program are:
Between patient cleans- Between patient clean- this is a clean of the frequently touched surfaces following patient
care and includes any equipment used by the clinicians during the patient care episode. It is primarily carried out
during the hospital turnaround time utilising Clinell universal sanitizing wipes by the crew.
Daily clean- this is a more thorough clean of the vehicle surfaces and floor, this clean does not cover the inside of the
cupboards (unless required) and includes the vehicle exterior and cab as required. This clean is primarily carried out on
station utilising a detergent and hot water mix with disposable cloths by either the vehicle cleaning teams or crew.
Deep clean- this is a full clean of the vehicle whereby all equipment and consumables are removed and cleaned, the
vehicle interior and exterior is fully cleaned and disinfected if required prior to all the equipment and consumables
being replaced. The schedule being for all patient carrying vehicles to be deep cleaned every six weeks. Where
required in addition to a general purpose detergent a chlorine based disinfectant is used.
Emergency Decontamination clean- this is similar to the deep clean but is performed following incidents where the
vehicle is heavily contaminated or has conveyed a highly infectious patient and requires full decontamination. This is
performed as a two-stage clean first using a general purpose detergent followed by a chlorine based disinfectant.
The recording of the vehicle deep cleaning was moved on to the Trust central reporting system part way through 2016, to help raise awareness
and improve the central monitoring. The records of the deep cleans are shown live on the system and give a snap-shot of the compliance level at the
time of viewing. When records first began to be recorded on the system in August the recorded compliance level was 41%, there was an element of
reporting issues noted during the first few months of recording as the vehicle cleaning teams became familiar with the system. The compliance level
gradually improved over the following months to 62%.
There is still a considerable improvement required in the overall compliance to achieve the Trust target of 90% of vehicles deep cleaned every six weeks.
However, although there is improvement required the vehicles continue to be cleaned after each patient care episode and regularly through the daily
cleaning process.
EEAST: DIPC Annual Report 2016-17
August 2017 16
IPC Station Audit Results The Trust schedule is for all operational stations to be audited every
month; this does not include response posts or standby points*. The
rationale for this is that the response posts and standby points are smaller
sites and do not hold clinical stores or dirty utility areas. As with the
vehicle audits the NPSA compliance standard is set at 85%, however the
Trust has set the aspirational target of 95% compliance.
The station audits focuses on key areas within the station for compliance
with cleanliness standards and Trust procedures. It includes:
Medical consumables stores
Dirty utility
Handling and management
of linen
IPC notices/ information
availability
Management of clinical waste
and sharps
Management of medical
equipment
Kitchens
Toilets
The result of the audits were found to be consistently above the 95%
aspirational target for the entire year , the medical consumables store was
found to have the lowest compliance results with an average of 95%, this
was closely followed by the kitchen and IPC notice/ information elements
at 96%. These areas consistently achieved compliance levels above 94%.
The quality assurance audits results were found to be a true reflection of
the local audits in the majority of cases, although generally found to be 5-
10% lower than the local audit results. With the exception of a dip in May
the quality assurance results are around 90% and consistently above the
National recommendations of 85%. The number of quality assurance
audits varied throughout the year (10-65% completed), primarily due to
geographical and staffing issues, the monthly average was 40% of stations
receiving a quality assurance audit.
The main areas for improvement highlighted throughout the audits
relates to the following:
Cleanliness of medical consumables stores
Cleanliness of dirty utility areas
Updating of IPC notices, particularly monthly audit results
Cleanliness of kitchen areas, primarily appliance e.g. microwaves
Staff awareness of Occupational exposure incident management
*No patient care is provided on any of the Trusts premises.
EEAST: DIPC Annual Report 2016-17
August 2017 17
IPC Staff Audit Results The Trust audits staff compliance with IPC procedures and practice
through three different audit types:
Uniform compliance- primarily relates to compliance with bare
below the elbows policy
IPC practice- this is a theory based audit whereby staff are asked
question relating to IPC practice and procedures
QA10-this is carried out during a clinical ride-out observing
compliance with IPC practice and procedures
Due to the fact that clinical staff work individually or in pairs and cover
a large geographical area it is not realistic for high numbers of
observational audits to be performed.
Uniform audits were increased to monthly submission for 2016/17
following feedback from management teams and to simplify the audit
and reporting schedule. For 2016/17, there was an initial drop in
submission levels as some areas adapted to the change to the schedule;
the compliance level was consistently above 95% for the entire year.
The numbers of IPC practice and QA10 audits completed throughout
the year is limited due to the availability of clinical staff and the
logistical and geographical challenges of the trust.
The IPC practice audit is carried out through a discussion with the
clinical staff whereby they are asked a series of questions regarding
their understanding and compliance with IPC practices and procedures.
A total of 170 IPC practice audits were completed during 2016/17. The
average overall compliance level for the IPC practice audits was 75.3%.
This is below the target level set by the Trust and the main areas for
improvement relate to:
Understanding and compliance with Trust wrist watch policy,
staff are permitted to wear a washable wrist watch (in line with
DH guidance) providing it is removed for hand hygiene
Bare below the elbow compliance regarding wrist and hand
jewellery
Recognition of the “Five moments of hand hygiene”
Awareness of Occupational exposure incident management
EEAST: DIPC Annual Report 2016-17
August 2017 18
The QA10 audits are carried out during clinical ride-outs with
operational staff, primarily on ambulances to allow for the observation
of the complete patient care episode. There were a total of 133 QA10
audits performed during 2016/17, the average overall compliance level
for these was 96%.
The main areas for improvement relate to:
Compliance with the aseptic non-touch technique for
cannulation, primarily relating to the recording of ANTT/
Emergency cannulation on patient record
Uniform compliance, primarily due to compliance with bare
below the elbows due to wrist/ hand jewellery
The IPC practice audits highlighted that recognition of the “five
moments of hand hygiene” was an area requiring improvement
however this was found to be an area with consistently high results in
the QA10 audits which achieved above 95% every month, with the
exception of May.
.
EEAST: DIPC Annual Report 2016-17
August 2017 19
Untoward IPC related incidents
The Trust records incidents through the online reporting system, Datix to
ensure ease of access staff are able to submit incident reports either
online or via a single point of contact phone number. The IPC related
incidents are split into two main themes and reported on through the
monthly IPC report, they area classed as:
Occupational exposure incidents
o Contaminated needle stick injuries
o Splashes of blood or bodily fluids to mucous membranes
o Exposure to highly infectious patients
Incidents which cause or have the potential to cause harm to staff,
patients or the public
o Clean sharp injuries
o Poor practice
o Waste compliance
During 2016/17 there were a total of 222 incidents
48 contaminated needle stick injuries
o 23 relating to intravenous needles
o 6 relating to intravenous needles
o 1 relating to an intraosseous needle
o 7 relating to patients own devices
o 4 relating to razors
o 7 relating to others e.g. broken glass, bites etc.
42 splashes of blood or bodily fluids
12 exposures to potentially highly infectious patients
29 clean sharp injuries
92 other incidents* e.g.
o Poor practice relating to decontamination and preparation
of equipment and vehicles
o Wrong waste disposal/ segregation
*There were 50 incidents relating to decontamination declaration on the defective equipment
form. This was as a result in a change to practice and failure of areas to adopt change in
practice in July.
EEAST: DIPC Annual Report 2016-17
August 2017 20
IPC activities
Seasonal Flu vaccinations
As a responsible healthcare provider the Trust promotes and
encourages its entire staff group to get the seasonal flu vaccination. The
vaccination, although recommended and acknowledged as the most
effective method of reducing the spread of flu, is not mandatory. All
NHS Trusts face challenges in delivering the flu vaccinations and this is
particularly challenging within ambulance Trusts due to the large
geographical areas and logistical issues. During the 2016/17 flu
campaign a total of 46.2% of EEAST staff were vaccinated, the national
uptake for all ambulance Trusts was 53.1%. Which although the level of
uptake was below the desired level it is an increase of almost 10% on the
previous year and 20% increase in the past three years.
Outbreaks
The Trust was not involved in any significant outbreaks
or infection control incidents during 2016/17.
Training
IPC training is cover with all staff in multiple formats. All clinical staff
receives specific IPC training relating to their role and clinical level, this
is covered through all clinical training courses.
Non-clinical staff also receives IPC awareness training through the Trust
induction upon joining the Trust.
Further to this IPC is included within the regular mandatory training for
all staff; this is delivered as mixture of classroom sessions and
eLearning/ workbooks. A total of 76% of clinical staff completed their
mandatory training during 2016/17, and 67% of new starters (non-
clinical) had completed their induction training at the end of 2016/17
(new starters have a six month period to complete induction training).
1005 of new clinical staff received IPC training as part of their clinical
course.
The Trust also supports local universities with delivery of IPC training to
paramedic science students prior to operational placements.
EEAST: DIPC Annual Report 2016-17
August 2017 21
IPC Programme 2017/18
The Trusts IPC programme and annual plan are maintained within a
dynamic governance and assurance framework program. This is utilised to
monitor Trust compliance with regulatory requirements and compliance.
This system supports the local management teams in having clearer
visibility of their requirements and supports local ownership.
During 2016/17 there was still a degree of under resourcing to the IPC
Team which has limited some of the work capacity of the team. This is
being addressed for 2017/18 by the allocation of addition funding for an
IPC Specialist Practitioner within the team, which will be recruited during
the year. This will allow for greater focus on improving standards and
reviewing the audit and quality assurance results. It will also allow for the
development and training of the IPC Champion network and local IPC
leads.
Priorities for 2016/17 include:
During 2017/18 the IPC team will continue to take a strategic role
and further support the development of local ownership in all
areas, to increase the local focus and compliance of IPC issues.
Recruit to the new IPC Specialist Practitioner role
Review the Trust Quality Assurance process and develop areas for
improvement, to maximise the available resources
Review and improve the recording and monitoring of the actions
taken elements of the audit cycle
Work in conjunction with the National Ambulance Service IPC
group to develop consistency across all UK Ambulance Trusts.
Continue to improve networking and communications across all
aspects of healthcare economy.
Carry out a complete review of the IPC annual programme and
associated policies to ensure compatibility with the new Trust
structure and compliance with the recent changes to the CQC
monitoring process and standards.
Continue to monitor and quality assure the Trust third party
providers e.g. Independent private ambulance services, Air
ambulance providers
Review, improve and update the Trust training presentations for all
clinical grades to ensure high standard training is provided to all
clinical staff
Review the IPC related products in use within the Trust to ensure
practicality, efficiency and suitability.
Increase participation and networking across the wider healthcare
environment and the National Ambulance Service IPC group,
including Health Protection England and local CCGs