100%
6A *
100%
100%
5D*
Theatres**
100%
100%
100%
98%
89%
69%
85%
90%
0
0
0
90%
0
0
0
1
0
0
100%
0
0
0
0
0
0
% shifts 'at risk
staffing'
100%
85%
0
% shifts 'minimum
staffing'
CTW *
92%
0
13
% shifts 'agreed
staffing'
96%
4 & 20
SIRIs Not Incl
Pressure Ulcers
97%
91%
1
Single Sex
Breaches
100%
100%
5
Compliance with
Nutritional
Assessments
100%
CTCC / CCU**
4
Pressure Ulcers
Grade 2/3/4 / Skin
Integrity
Cardiology *
4
Compliance with
Track and Trigger /
EWS
91%
4&9
Medication errors
causing harm
100%
Antimicrobial
4
Falls causing
harm
100%
Ward
8
% End date
included
National Cleaning
Overall Score
8
ANTT Injectables
8
Hand Hygiene
8
CAS **
Directorate
Medicine
Surg &
Vasc
PP
Cardiac, Vascular
and Thoracic (3)
Division
CQC Outcomes
C, V & T Quality Scorecard Board
% Correct
prescription
July Data
0
0
14%
86%
0%
100%
0
0
70%
30%
0%
100%
0
0
50%
49%
1%
0
100%
0
0
25%
67%
8%
90%
0
100%
0
0
94%
1%
3%
100%
0
100%
0
0
0
41%
100%
56%
0%
3%
0%
Action Plan
National Cleaning scores: CAS - Re-audit by Matron and infection control. All failures related to Carillion with exception of BP cuffs. At the time of re-audit, no
rectifications had been made so escalated through Carillion management structure and monitored by unit Sister.
6A: On re-audit almost all failures had been corrected. All failing items were Carillion responsibilities and may be due to the ward’s usual cleaner being on annual
leave. The Matron has written to Carillion, highlighting the importance of this ward having a regular replacement cleaner.
Antimicrobial prescribing: Discussion held at CSU Directorate and Divisional meeting and reinforced to new F1s during induction.
Pressure Ulcers: Community acquired grade 2 pressure ulcer which developed into grade 3 in a high risk patient.
At risk staffing: staff moved across the division and temporary staff used to ensure patient safety.
National Cleaning Specification (%)
Key
1
Antimicrobial Prescribing
Poor
V. High Risk
**
>95
90-95
<90
Green
Fair
High Risk
*
>92
87-92
<87
Amber
80% or more
70 - 79%
Good
Significant Risk
>85
80-85
<80
Red
69% and below
July Data
C & W Quality Scorecard Board
% shifts 'minimum
staffing'
% shifts 'at risk
staffing'
100%
0
0
93%
85%
85%
0
0
100%
0
95%
0
0
100%
0%
0%
100%
94%
0
0
91%
82%
82%
0
0
100%
0
90%
0
0
96%
4%
0%
Childrens Ambulatory Care
95%
100%
0
0
92%
0
0
N/A
0
0
0
50%
50%
0%
HGH Childrens W *
Bel / Dray *
Kamrans **
Melanies *
NNU**
SCBU**
PHDU**
PICU**
100%
95%
0
0
95%
92%
100%
0
0
90%
Catheter on
going care
100%
Ward
Catheter
Insertion
% shifts 'agreed
staffing'
13
SIRIs Not Incl
Pressure Ulcers
4 & 20
Single Sex
Breaches
1
Compliance with
Nutritional
Assessments
5
Pressure Ulcers
Grade 2/3/4 / Skin
Integrity
4
Compliance with
Track and Trigger /
EWS
4
Total No of
medication errors
that did harm
4&9
Total No of
Accidents that did
harm
4
% End date
included
8
% Correct
prescription
8
National Cleaning
Overall Score
8
C-Diff post 72 hrs
8
MRSA / MSSA post
48 hrs
8
Saving Lives Catheter
Care
ANTT Injectables
8
Hand Hygiene
8
Toms *
Robins *
Directorate
Paediatrics
Paediatric
Critical
Children's
Division
CQC Outcomes
Antimicrobial
87%
87%
0
0
80%
0
100%
0
0
100%
1%
0%
0
0
100%
0
100%
0
0
96%
4%
0%
98%
99%
0
0
95%
n/a
n/a
0
0
100%
0
90%
0
0
84%
16%
0%
100%
97%
0
0
92%
100%
100%
0
0
80%
0
100%
1
0
94%
6%
0%
100%
99%
0
0
91%
100%
100%
0
0
n/a
0
0
0
99%
1%
0%
100%
100%
0
0
96%
100%
100%
0
0
n/a
0
0
0
100%
0%
0%
95%
98%
100%
100%
0
0
0
0
95%
95%
100%
100%
100%
100%
0
0
0
0
n/a
n/a
0
0
0
0
0
0
100%
100%
0%
0%
0%
0%
Action Plan
Staffing : Ambulatory Care - staffing optimal for 50% of the time and staff moved from other areas in CHOX as part of Summer Plans to manage safety at all other times
Key
Poor
Fair
Good
National Cleaning Specification (%)
V. High Risk
High Risk
Significant Risk
Page 2 of 9
**
*
>95
>92
>85
Antimicrobial Prescribing
90-95
87-92
80-85
<90
<87
<80
Green
Amber
Red
80% or more
70 - 79%
69% and below
% shifts 'agreed
staffing'
% shifts
'minimum
staffing'
% shifts 'at risk
staffing'
SIRIs Not Incl
Pressure Ulcers
13
Single Sex
Breaches
4 & 20
Compliance with
Nutritional
Assessments
1
Compliance with
Track and Trigger
/ EWS
5
Total No of
medication errors
that did harm
4
Total No of Falls
That did harm
4
% End date
included
4&9
% Correct
prescription
4
National Cleaning
Overall Score
8
ANTT
Injectables
8
Hand Hygiene
8
JR Gynae*
100%
100%
89%
100%
100%
0
0
100%
100%
n/a
100%
0%
0%
HGH Gynae*
100%
96%
0
0
n/a
100%
0%
0%
Gynae Scrub
87%
94%
0
0
n/a
100%
0%
0%
Gynae A & R
Maternity Theatres
91%
94%
94%
0
0
0
0
n/a
100%
100%
0%
0%
0%
0%
Delivery Suite / Obs
100%
94%
0
0
100%
0%
0%
95%
0
0
100%
0%
0%
0
0
100%
0%
0%
0
0
100%
0%
0%
0
0
100%
0%
0%
0
0
0
0
100%
100%
0%
0%
0%
0%
Directorate
Gynae
8
Ward
Spires Midwifery Led
Maternity
Gynae and Maternity
Division
CQC Outcomes
Pressure Ulcers
Grade 2/3/4 / Skin
Integrity
Gynae and Maternity Quality Scorecard Board
July Data
100%
Level 5
66%
96%
Level 6
100%
93%
Level 7
Antimicrobial
NA
NA
93%
HGH Delivery Suite
HGH Post Natal Ward
90%
Action Plan
JR Gynae: fortnightly cleaning and inspection rounds have commenced with Carillion fully engaged in the process. Supervisor presence has been increased.
Women's Theatres: great improvement in hand hygiene but still under target. Daily audits are to continue.
Falls: One recorded fall (but no harm) occurred at the HGH and was the partner of the patient who was taking painkillers and had not eaten.
Hand hygiene audit on Level 5 - Small number of staff involved [ 1 midwife] this was addressed with individual concerned
Key
Poor
Fair
Good
New Structure Metrics V.2
Final November 2011 SY
V. High Risk
High Risk
Significant Risk
National Cleaning Specification (%)
**
*
>95
>92
>85
90-95
87-92
80-85
<90
<87
<80
Green
Amber
Red
Antimicrobial Prescribing
80% or more
70 - 79%
69% and below
EMTA Quality Scorecard Board
4&9
4
4
5
1
4 & 20
0
0
100%
0
100%
0
0
100%
0
100%
91%
1
0
100%
94%
82%
82%
1
0
91%
80%
80%
0
100%
ND
91%
82%
100%
92%
85%
69%
100%
na
PAU *
100%
Oak *
0
93%
7%
0%
0
0
73%
27%
0%
0
0
100%
0%
0%
100%
0
0
68%
32%
0%
0
100%
0
0
57%
37%
6%
100%
1
100%
0
0
72%
27%
1%
0
100%
0
100%
0
0
71%
19%
10%
1
0
100%
0
100%
0
0
63%
27%
10%
0
0
100%
0
100%
0
0
70%
30%
0%
94%
0
0
0
0
78%
14%
8%
0%
92%
0
0
0
0
80%
15%
5%
100%
89%
93%
93%
93%
1
0
96%
0
100%
0
0
93%
7%
0%
Laburnam *
100%
100%
ND
90%
80%
0
0
92%
0
100%
0
0
88%
12%
0%
Juniper *
100%
100%
ND
0
0
100%
0
100%
0
0
69%
31%
0%
Level 4 *
100%
100%
95%
0
100%
0
100%
0
0
85%
15%
0%
ASU *
92%
100%
91%
0%
John Warin **
95%
100%
Geoffrey Harris *
100%
Treatment Centre
Dermatology
National Cleaning
Overall Score
0
100%
ANTT Injectables
% shifts 'at risk
staffing'
0
% shifts 'minimum
staffing'
0
100%
% shifts 'agreed
staffing'
100%
0
SIRIs Not Incl
Pressure Ulcers
0
1
Single Sex
Breaches
0
13
Compliance with
Nutritional
Assessments
Hospital acquired
Pressure Ulcers
Grade 2/3/4 / Skin
Integrity
4
Compliance with
Track and Trigger /
EWS
8
Total No of
medication errors
that did harm
8
Total No of Falls
that did Harm
8
JR ED **
86%
75%
96%
JR EAU *
100%
100%
ND
HGH ED **
92%
100%
94%
HGH MAU *
100%
100%
ND
100%
7A *
100%
100%
93%
7B *
100%
100%
7C *
100%
100%
7D *
100%
7F*
100%
5A *
% End date
included
Ward
Antimicrobial
% Correct
prescription
Directorate
Emergency Medicine
Ambulatory, Chest, ID
Division
Emergency Medicine, Therapies & Ambulatory (7)
8
Hand Hygiene
July Data
CQC Outcomes
82%
45%
100%
94%
0
0
0
92%
0
94%
2
0
95%
5%
95%
100%
86%
0
0
100%
0
96%
0
0
57%
34%
9%
100%
92%
100%
100%
0
0
80%
0
100%
0
0
10%
75%
15%
100%
100%
83%
0
0
0
100%
0%
92%
0
0
0
0
Immunology
100%
100%
NA
0
0
0
0
OCDEM Endocrine
100%
0%
NA
0
0
0
0
OCDEM Diabetes
N/A
0%
NA
0
0
0
0
Sleep Physiology
N/A
0%
NA
0
0
0
0
GUM
Genetics
0
0
100%
0%
NA
0
0
0
0
N/A
0%
NA
0
0
0
0
Action Plan
Clinically Justifiable Single sex breachs: Stroke Unit (5B) - 2 single sex breaches affecting 8 patients to ensure patients received care in appropriate environment to receive specialist care
care.
Antimicrobial: EAU JR, Antimicrobial medical prescribing issue low end date data - To be reviewed in medical directorate and at medical governance, that ward manager has identified an audit error that would account for
low scoring. 7F -This issue will be highlighted to the Clinical Lead and the next Unit meeting.
Pressure ulcers: 7B - 1 patient developed a pressure ulcer, grade 2 despite all pressure relief management in place
Key
Poor
Fair
Good
New Structure Metrics V.2Final November 2011 SY
National Cleaning Specification (%)
**
>95
V. High Risk
*
>92
High Risk
>85
Significant Risk
90-95
87-92
80-85
<90
<87
<80
Green
Amber
Red
Antimicrobial Prescribing
80% or more
70 - 79%
69% and below
5
1
4 & 20
13
% shifts 'minimum
staffing'
4
94%
100%
100%
0
0
100%
0
100%
1
0
100%
0%
0%
100%
84%
100%
100%
1
0
100%
0
100%
0
0
82%
15%
3%
not done
% shifts 'at risk
staffing'
100%
100%
% End date
included
80%
Neurosciences IP *
Ward
% Correct
prescription
% shifts 'agreed
staffing'
National Cleaning
Overall Score
4
SIRIs Not Incl
Pressure Ulcers
ANTT Injectables
4&9
Single Sex
Breaches
Hand Hygiene
Combined
4
Compliance with
Nutritional
Assessments
8
Antimicrobial
Pressure Ulcers
Grade 2/3/4/ Skin
Integrity
8
Compliance with
Track and Trigger /
EWS
8
Total No of
medication errors
that did harm
8
NICU **
Directorate
Neuro
Trauma
Specialist
Surgery
Neuro, Trauma, Specialist
Surgery (3)
Division
CQC Outcomes
Total No of Falls
that did harm
NTSS Quality Scorecard Board
July Data
Neurosciences OPD
100%
0
100%
0%
0%
2A *
100%
100%
not done
100%
100%
0
0
100%
2
96%
0
0
59%
32%
9%
3A *
100%
100%
92%
100%
100%
0
0
100%
4
90%
0
0
56%
42%
2%
Trauma OPD
98%
0
80%
20%
0%
F Ward *
95%
100%
96%
70%
90%
0
0
96%
5
90%
0
0
81%
17%
2%
SSIP *
100%
100%
97%
100%
100%
0
0
100%
0
90%
0
0
96%
4%
0%
Lichfield *
100%
n/a
88%
0
98%
2%
0%
SSOPD
100%
no audit
0
90%
10%
0%
OPD Eye
OMFS OPD
100%
100%
90%
not done
0
0
80%
14%
20%
36%
0%
50%
not done
Action Plan
Neurosciences - Fall - this is being investigated as an orange incident and a meeting has been arranged to review the case and this will be reported to the
September Clinical Governance Committee.
Pressure Ulcers Trauma wards - 1 category 4 ulcer which patient was admitted with. All other ulcers were category 2, of which 5 were discovered on admission and
5 developed whilst admitted. Trauma Tissue Viability Nurse has reviewed the cases and is incorporating them as case studies into the Trauma teaching Schedule.
Staffing OMFS OPD - this is a small team, whilst they are waiting for recruited staff to start Sister is monitoring closely and will report back any concerns to Matron.
Cleaning audits are discussed in the infection control section of the quality paper. The Divisional Nurse attended the latest audit on neurosciences and is monitoring
closely with Carillion and infection control. Matron is addressing concerns with Carillion managers regarding Lichfield.
One clinically justified single sex breach on NICU due to delay in discharge to the ward and patient acutiy improved
Key
Poor
Fair
Good
Metrics V.2
Final SYNov 11
National Cleaning Specification (%)
V. High Risk
High Risk
Significant Risk
**
*
>95
>92
>85
Antimicrobial Prescribing
90-95
87-92
80-85
<90
<87
<80
Green
Amber
Red
80% or more
70 - 79%
69% and below
Directorate
Division
Metrics V.2
Final SYNov 11
8
8
National Cleaning
Overall Score
Antimicrobial
4&9
4
4
5
1
4 & 20
Total No of
medication errors
that did harm
Compliance with
Track and Trigger /
EWS
Pressure Ulcers
Grade 2/3/4/ Skin
Integrity
Compliance with
Nutritional
Assessments
Single Sex
Breaches
SIRIs Not Incl
Pressure Ulcers
% shifts 'at risk
staffing'
% shifts 'minimum
staffing'
% shifts 'agreed
staffing'
4
Total No of Falls
that did harm
% End date
included
% Correct
prescription
8
ANTT Injectables
Ward
8
Hand Hygiene
Combined
CQC Outcomes
13
0
0
93%
6%
1%
60%
0
0
73%
27%
0%
0
100%
0
0
55%
45%
0%
100%
1
90%
0
0
87%
4%
9%
100%
0
100%
0
0
87%
13%
0%
0%
100%
97%
96%
100%
85%
0
0
100%
93%
100%
95%
98%
94%
0
0
100%
Sobell *
100%
N/A
91%
91%
100%
0
0
100%
SEU D & Triage*
90%
95%
92%
100%
100%
1
0
SEU E
98%
77%
86%
100%
100%
0
0
Hand Hygiene
Compliance
with Track and
Trigger / EWS
100%
Total No of
medication
errors that did
harm
1
Oncology Ward **
% End date
included
13
% shifts 'at risk
staffing'
4 & 20
% shifts
'minimum
staffing'
1
% shifts
'agreed
staffing'
5
SIRIs Not Incl
Pressure Ulcers
4
Single Sex
Breaches
4
Compliance
with Nutritional
Assessments
4&9
Pressure Ulcers
Grade 2/3/4/
Skin Integrity
4
Total No of
Falls that did
harm
8
Antimicrobial
National
Cleaning
Overall Score
In Patient Wards
8
Haematology **
Division
Clinical Areas
8
% Correct
presciption
Ward
Surgery & Oncology (6)
8
ANTT
Injectables
S & O Quality Scorecard Board
July Data
CQC Outcomes
SEU F *
87%
95%
91%
100%
100%
0
0
100%
0
100%
0
0
87%
13%
5F *
100%
95%
90%
100%
100%
0
0
100%
0
95%
0
0
69%
27%
4%
HGH E Ward *
96%
95%
91%
100%
70%
0
0
100%
0
100%
0
0
90%
8%
2%
1%
UGI *
92%
80%
92%
100%
100%
n/a
0
100%
0
80%
0
0
77%
22%
Colorectal *
100%
75%
92%
73%
100%
0
0
100%
0
80%
0
0
99%
0%
1%
Jane Ashley *
100%
100%
92%
100%
100%
0
0
100%
0
100%
0
0
85%
13%
2%
Urology *
90%
100%
94%
90%
90%
0
0
80%
0
100%
0
0
90%
7%
3%
Transplant **
Renal Ward **
88%
89%
97%
80%
93%
91%
100%
100%
96%
90%
0
0
0
0
100%
90%
0
0
90%
89%
0
0
0
0
93%
58%
4%
37%
3%
5%
Oxford Man Unit*
100%
100%
94%
0
0
0
0
Oxford Tarver Dialysis*
100%
100%
90%
0
0
0
Stoke Mandeville *
89%
100%
0
0
0
0
90%
10%
0%
Milton Keynes *
98%
90%
0
0
0
0
50%
45%
5%
0%
95%
5%
0%
100%
0%
0%
Swindon *
100%
100%
0
0
0
0
95%
5%
Wycombe *
85%
100%
0
0
0
0
100%
0%
0%
Th Churchill **
Th TDA / DCU *
85%
92%
87%
0
0
0
0
0
0
1
0
85%
95%
13%
5%
2%
0%
99%
83%
1%
14%
0%
3%
91%
94%
Oncology Treatment
90%
100%
91%
0
0
0
0
Brody Centre HGH
90%
100%
93%
0
0
0
0
0
Triage
90%
100%
92%
0
0
N/A
Research
100%
100%
92%
0
0
0
0
JR Endoscopy **
HGH Endoscopy **
96%
100%
93%
100%
89%
95%
0
0
0
0
0
0
0
0
Action Plan
Nutritional Assessments: An improvement on last month however the Matrons continue to work closely with ward sisters and nursing teams by auditing results
weekly and feeding back results and actions via team meetings.
Ward cleaning scores: An improvement this month. Action: Matrons continue to attend each ward audit and feeds back immediately to staff all issues raised.
Cleaning on wards being monitored weekly.
Hand hygiene results have improved however matrons recognise need to monitor ANTT results which are variable again this month. Focus now on challenging
unacceptable practice to educate staff.
There were two pressure ulcers that developed whilst patients were in-patients last month. RCA has been undertaken in both cases and the need to document
inspection of skin on admission has been highlighted in both cases. This learning has been shared throughout the Division.
Key
Poor
Fair
Good
New Structure Metrics V.1Final August 2011 SY
National Cleaning Specification (%)
**
>95
V. High Risk
*
>92
High Risk
Significant Risk
>85
90-95
87-92
80-85
<90
<87
<80
Green
Amber
Red
Antimicrobial Prescribing
80% or more
70 - 79%
69% and below
5
1
4 & 20
Pressure Ulcers
Grade 2/ 3/4 / Skin
Integrity
13
% shifts 'minimum
staffing'
4
75%
96%
100%
100%
0
0
1
100%
10
0
100%
0%
0%
81%
75%
97%
100%
100%
0
0
2
100%
2
0
100%
0%
0%
HGH CICU **
86%
100%
94%
0
0
0
100%
13
0
100%
0%
0%
HGH DCU *
N/A
N/A
0
0
0
100%
0
0
100%
0%
0%
Th West Wing **
78%
N/A
96%
0
0
0
0
0
100%
0%
0%
Th JR **
Th HGH **
77%
N/A
74%
N/A
95%
N/A
0
0
0
0
0
0
0
0
0
0
100%
100%
0%
0%
0%
0%
% Correct % End date
presciption included
Action Plan
Deputy Matron attending new medical staff induction to highlight importance of hand hygiene in critical care.
ANTT low due to agency staff not being aware of the equired best practice. ANTT demonstrated and taught to all new agency staff on unit.
Pressure ulcers : two in AICU/CICU from patients admitted with grade 2 sores.
One in CICU grade 2 sore in corner of mouth due to Endo Tracheal Tube (ETT). Staff reminded of importance in changing sides of ETT during
change of tapes.
Clinically Justified single sex breaches are reported internally and to the PCT- due to short delays in transferring from a specialised environment
to a ward environment
Key
Poor
Fair
Good
New Structure Metrics V.2Final November 2011 SY
National Cleaning Specification (%)
V. High Risk
High Risk
Significant Risk
**
*
>95
>92
>85
Antimicrobial Prescribing
90-95
87-92
80-85
<90
<87
<80
Green
Amber
Red
80% or more
70 - 79%
69% and below
% shifts 'at risk
staffing'
84%
Antimicrobial
% shifts 'agreed
staffing'
AICU **
Ward
Hand Hygiene
SIRIs Not Incl
Pressure Ulcers
4
Single Sex
Breaches
4&9
Compliance with
Nutritional
Assessments
4
Total No of
medication errors
that did harm
8
Total No of Falls
that did harm
8
National Cleaning
Overall Score
8
ANTT
Injectables
8
CICU **
Directorate
Anaes / CC / Th
Critical Care,
Theatres,
Diagnostics &
Division
CQC Outcomes
Compliance with
Track and Trigger /
EWS
CCTDP Quality Scorecard Board
July Data
1
4 & 20
SIRI's (Not Pressure Ulcers)
13
% shifts 'at risk staffing'
5
Single Sex Breaches
Acquired Pressure Ulcers grade 4
Acquired Pressure Ulcers grade 3
4
Acquired Pressure Ulcers grade 2
Track and Trigger
4
Major/Extreme Impact
Moderate Impact
Minor Impact
Medication
Incidents
Near miss/ No harm
Falls
Major/Extreme Impact
Antimicrobial
Moderate Impact
4 &9
Minor Impact
4
Near miss/No harm
8
% End date included
8
% Correct presciption
Hand Hygiene
Ward
8
National Cleaning Scores
8
ANTT Injectables
Directorate
Orthopaedics
Re
MARS
Division
CQC Outcomes
Nutritional Assessments
MARS Quality Metrics July 2012
Day Surgery
100%
100%
0
0
0
0
1
0
0
0
0
0
0
100%
0
0
0%
Ward A
Ward B
100%
93%
96%
100%
100%
0
3
0
0
0
0
0
0
0
3
0
0
0
0
0
0
90.00%
0
0
0
0
0
0
100%
88.00%
0
0
0
0
0%
0%
Ward D
Ward E
100%
100%
100%
100%
100%
100%
1
1
0
1
0
0
0
0
1
1
0
0
0
0
0
0
92.00%
93.00%
0
0
0
0
0
0
100.00%
90.00%
0
0
0
0
0%
0%
Ward F
87%
100%
100%
3
0
0
0
0
0
0
0
89.00%
1
0
0
86.00%
0
0
0%
Recovery
100%
98%
100%
0
0
0
0
1
1
0
0
97.00%
0
0
0
0
0
0%
100%
81%
80%
80%
Theatres
93%
100%
0
0
0
0
1
0
0
0
0
0
0
Outpatients/POAC
100%
100%
0
0
0
0
0
1
0
0
0
0
0
92.00%
OCE Ward
80%
100%
0
2
0
0
0
0
0
0
0
0
0
88.00%
Action Plan
Ward/Department
Issue
95.00%
Action
Lead
0
Review Date
0
0%
0
0%
0
0%
Status
Ward F
87% Overall Hand Hygiene compliance; this includes:100% Discuss poor compliance in the medical and
Vicky Wren, Ward F
compliance for nursing staff; 73% compliance for doctors; therapy teams with the Clinical Director and
Sister
83% compliance for AHP.
therapy team leaders; try to obtain names of
individual involved; re-audit weekly until 100
achieved and maintained for 2 consecutive weeks
31-Aug-12
In progress
OCE Ward
80% Overall Hand Hygiene compliance; this includes:80% Raise poor compliance at ward meetings and
compliance for nursing staff; 100% compliance for doctors; NRS Governance; weekly audits until 100%
100% compliance for AHP.
compliance achieved and maintained for 2
consecutive weeks
31-Aug-12
In progress
Sue Hunt, Ward
Sister