Annual Infection Prevention and Control Team Work Programme
Annual work programme for 2015/16
1. Executive summary
The annual programme of the Infection Prevention and Control service for April 2015-March 2016 sets out the proposed activities of the infection prevention and control
service which will ensure that the programme of work continues to focus on two main areas: raising awareness of infection prevention and control through education and
training and reducing the incidence of Health Care Associated Infection (HCAI). It also supports the Trusts continuing registration with the Care Quality Commission (CQC).
This programme is based around The Health and Social Care Act 2008: Code of Practice for the NHS on the prevention and control of healthcare associated infections and
related guidance, Care Quality Commission core standards (2009), Saving Lives programme, the National Cleaning Standards 2007 and the Revised Healthcare Cleaning
Manual 2009. Learning from incidents, complaints, root cause analysis (RCA) and observation of care audits have also contributed to this programme.
2. General Objectives
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To sustain and further develop an enhanced programme to focus on promoting the ownership of infection prevention and control by all Trust employees.
To provide assurance that the organisation is committed to a further reduction in the incidence of HCAIs.
To meet our key performance targets agreed with the commissioners of services and improve services year on year.
To give the public and service users whom the Trust serves confidence in the organisations commitment to preventing HCAI’s.
Infection Prevention and Control Annual Work Programme 2015-16
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Objective
Action
Lead
Outcome
Evidence
Date to be
achieved/up
date
Management and Organisation
It is vital that there are clear lines of ownership and accountability for Infection Prevention and Control within the organisation. Ownership at a more local level will
promote the engagement of clinical teams and therefore increase the commitment to infection prevention and control. However, commitment from senior managers
and existence of a local infrastructure and system is vital to sustain good clinical service delivery.
Maintain Board level
involvement in ensuring
infections are reduced to a
minimum.
Annual infection prevention and
control forthcoming year work
programme to be presented to
Trust Board.
The Board will receive an annual
report from infection prevention and
control team.
DIPC
Approval of plan
at Trust Board
Minutes of Board meeting
July 2015
DIPC
Approval of report
at Trust Board
Minutes of Board meeting
report
Annual DIPC report
July 2015
The Board will receive monthly
infection prevention and control
reports.
DIPC
Executive and nonexecutive awareness of
HCAI performance
Minutes of Board meetings
Quarterly reports to Monitor
Monthly in
place
Surveillance
Many patients acquire infection when their body’s natural defences are breached. The risks from such breaches must be kept to a minimum.
To further reduce
healthcare associated
infections, meeting
mandatory surveillance
requirements, monitor
trends in infection and
identify potential outbreaks
promptly.
Continue common alert organism
surveillance e.g. Clostridium
difficile, influenza, Norovirus and
MRSA and mandatory surveillance
Provide advice and support in the
event of outbreaks or infection
prevention and control incidents
IPCT
Complete and review RCA’s as
required, identify learning and
monitor any identified action to
ensure learning has taken place.
IPCT
Infection Prevention and Control Annual Work Programme 2015-16
Meet mandatory
requirements and support
practice and safe patient
management
Minutes from weekly clinical
governance meetings
Identification and learning
from incidents
Root cause analysis reports
Quarterly reports to Infection
Prevention, Control and
Decontamination Committee
and Safety Committee
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In place
Quarterly reports to Infection
Prevention, Control and
Decontamination Committee
and Safety Committee
In place
To continue to reduce
unavoidable cases of CDI.
To continue to work
collaboratively with
external organisations
across the health economy
to identify shared learning
To participate in the monthly CDI
health economy review meetings
for all Oxfordshire CDI cases to
establish and identify any learning
Attend Oxford University Hospitals
(OUH) infection control committee
(HICC)meetings
Attend Bucks Commissioning
infection prevention and control
(BICC)meetings
Attend regional meetings
IPCT
Independent expert review
of CDI cases, identifying
learning.
IPCT
Shared learning, strong
working relationships and
excellent communication
with other organisations
supporting the patient care
pathway.
Monthly meeting minutes
Quarterly reports to Infection
Prevention, Control and
Decontamination Committee
OUH HICC minutes
Minutes of BICC meetings
Minutes of other relevant
meetings
In place
In place
Audit Programme
High quality information on healthcare associated infection and antimicrobial resistant organisms is vital in reducing the risk of infection. Continual monitoring of
infection prevention and control practices and the clinical environment through audit, ensures minimising the risk of infection spread and patient safety.
To provide specialist
infection prevention and
control input into the
annual PLACE (Patient
assessment of the care
environment) assessment
process and national
standards of cleanliness
audits.
To monitor and review
appropriate antimicrobial
prescribing.
Follow up particular infection
prevention and control risks
identified during such inspections.
Facilities hub
managers
IPCT
PLACE assessments
receive expert infection
control advice
Issues identified are
addressed.
To receive and review antimicrobial
prescribing audits as per pharmacy
audit programme
Pharmacy
To identify good and poor
practice for antimicrobial
prescribing and implement
action plans to address any
issues identified.
There is a heightened
awareness of infection
prevention and control
issues and practice.
Standards are improved.
PLACE reports
Monthly facilities hub
managers meetings minutes
Estates risk management
meetings minutes
Quarterly reports to Infection
Prevention, Control and
Decontamination Committee
Decontamination Committee
Prescribing audit reports to
Infection Prevention, Control
and Decontamination
Committee and safety
committee.
Environmental Audit reports
and Action plans.
Infection Prevention, Control
and Decontamination
Committee minutes
Safety Committee minutes
Summary Audit reports
discussed at IPCDC quarterly
In place
Quarterly
To undertake infection
Undertake audits and complete
IPCT
Per audit
prevention and control
reports.
ICLP’s and ward
programme
audits of all clinical areas
managers
and prisons. This will
include hand hygiene,
equipment
decontamination, laundry
issues, and other clinical
practice areas if relevant.
Training
It is vital that all staff within the organisation will receive appropriate training in infection prevention and control. Staff must have access to up to date knowledge and
skills in minimising the risk of infection and safeguarding patients.
Infection Prevention and Control Annual Work Programme 2015-16
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To ensure that all staff
receive infection
prevention and control,
training as part of essential
mandatory training.
To ensure that specialist
infection prevention and
control advice is provided
to related service providers
where infection prevention
and control input will
minimise risks to patients
or staff.
Infection prevention and control
input is co-ordinated by the
Learning and Development team
and additional training provided on
request
IPCT
Learning and
development
All staff will have an
awareness of basic
infection prevention and
control practice and be
updated in key changes to
practice.
Training records.
Induction training packs.
Appraisal records
Infection Prevention, Control
and Decontamination
Committee minutes
Safety Committee minutes
PDR/Appraisals
Monthly
Additional
training
provided on
request
To continue to support the Infection
prevention and control Link
Practitioner programme via bi
annual study days.
IPCT
Training needs will be met.
Infection prevention and
control standards will be
improved.
A 3-monthly newsletter for staff
highlighting topical or newsworthy
information on infection prevention
and control will continue to be
published and circulated to all Trust
staff.
The infection prevention and control
team will attend regular and
additional meetings as required.
IPCT
Staff will gain evidencebased information on
infection prevention and
control
Newsletters
Intranet
Quarterly
IPCT
IPCT will maintain the high
profile of infection
prevention and control and
support the Trusts’
objectives
Minutes of meetings
In place
IPCT will attend national
conferences/study days to ensure
up to date knowledge
IPCT
IPCT will remain up to date
with national guidance and
practice
PDR/Appraisals
Annually
Annually
Hand hygiene
Healthcare workers and the environment are a major route through which patients can acquire infection. Micro-organisms may be transferred by staff, from one
patient to another,and from the environment to the patient.
To maintain hygiene
awareness and
compliance.
Infection prevention and control
Link practitioners (ICLP) will
monitor hand hygiene compliance
Infection Prevention and Control Annual Work Programme 2015-16
ICLP’s
All staff will have an
increased awareness of the
importance of hand hygiene
and hand hygiene
compliance will improve.
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Hand hygiene monitoring
charts and audit reports
Minutes of division quality
and clinical governance
meetings
Minutes of Infection
Prevention, Control and
Decontamination Committee
Minutes of safety committee
Bi monthly
Policies and Procedures
It is vital that staff can readily access current infection prevention and control policies and procedures across the organisation.
To ensure the provision of
Provide input into other Trust
IPCT
Trust wide policies and
Policies and procedures on
evidence based, up to date policies as required.
Governance lead
procedures available to all
intranet.
and relevant infection
staff.
Audit programme
prevention and control
Audit tracker
policies
Ensure policy and procedures are
IPCT
All relevant Trust policies
Detailed infection prevention
available on the intranet for staff to
reflect current infection
and control guidance on the
access in a timely way and this is
prevention and control
infection prevention and
effectively communicated to them
guidance
control intranet page.
Minutes of Infection
Review procedures as part of
Prevention, Control and
rolling programme to ensure they
Decontamination Committee
remain appropriate and meet the
Minutes of Safety Committee
Trust’s needs
National directives and initiatives
Infection Prevention and Control will work across Trust to ensure new national directives and guidance is appropriately implemented.
To ensure that new
Ongoing review of national
IPCT
Trust procedures and
Minutes of Infection
national guidance is
directives from the Department of
infection prevention and
Prevention, Control and
reviewed and acted on.
Health (DH) Care Quality
control practice will comply
Decontamination
commission etc.
with national guidance
Committee
Minutes of Safety
Committee
Ensure on going compliance with IPCT
Trust will maintain high
Minutes of Infection
CQC registration and to prepare
standards and compliance
Prevention, Control and
prior to CQC inspections.
Decontamination
Committee
Minutes of Safety
Committee
Participate in the Academic Health IPCT
Trust will improve standards Minutes of Catheter
Science Network (AHSN)
and compliance with urinary Associated Urinary Tract
innovation project to reduce urinary
catheter management
infections (CAUTI)
catheter infections
workforce meeting
Minutes of Infection
Prevention, Control and
Decontamination
Committee
Minutes of Safety
Committee
Infection Prevention and Control Annual Work Programme 2015-16
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As required
As required
As required
Quarterly
August 2016
Support staff uptake of
influenza immunisation
To support the Trust influenza lead
with increasing staff influenza
immunisation uptake
Influenza lead
Staff influenza immunisation
will increase in 2015-16
Minutes of Infection
Prevention, Control and
Decontamination
Committee
March 2016
Environmental Cleanliness monitoring
The cleanliness of the environment is key in reducing the spread of healthcare associated infections. Collaborative strategic working ensures the environment is built,
maintained and cleaned in an efficient and effective way
To monitor and improve
All hospital cleanliness to be
Matrons and facilities
Robust monitoring of
Audit reports
Ongoing
the standards of
monitored quarterly including
managers
cleanliness standards and
Minutes of Infection
environmental
Adenosine triphosphate ATP
efficacy of environmental
prevention and control
cleanliness, including
monitoring in community
cleaning
Committee
ward kitchen audits
hospitals and older adult mental
Monitoring of ward kitchen
Safety committee
health wards.
audits
ATP reports
The water quality will be
monitored in the Trust to
ensure it meets national
standards and
requirements
Water quality testing will be
undertaken as per testing
regimes and results
reported/escalated as required.
non-compliant results will be
reported immediately and action
taken to safeguard patients, staff
and visitors
Facilities/ IPCT/
microbiologist
Provide Trust assurance of
water standards
Compliance with national
standards minimising risk of
infection transmission
Minutes of Infection
Prevention and Control
Committee,
Water safety group minutes
Quarterly
Decontamination
Infection prevention and control will work with the nominated Trust decontamination lead to ensure compliance with national requirements and that appropriate
policies and procedures for decontamination are in place.
To ensure Trust is
To continue to work with the
IPCT/ decontamination Trust decontamination
Minutes of Infection
Ongoing
compliant with national
decontamination lead to develop
lead
strategy and policies will
Prevention, Control and
decontamination
and support the decontamination
comply with national
Decontamination
requirements
strategy and work programme for
guidance
Committee
Trust
Minutes of Safety
To review external Service Level
Committee
Agreement (SLA) contracts to
Minutes of Medical devices
ensure compliance and
Committee
assurance with methodologies
Patient involvement
Infection prevention and control will provide suitable and sufficient information on HCAI to the patient, the public and other service providers to promote ownership
and engagement with infection prevention and control.
Patients and visitors will Infection Prevention and Control
Ward managers and
The public will have
Review of comments and
Ongoing
be encouraged to
information to be displayed and
facilities/area
confidence in the efforts of
complaints and lessons
support infection
kept updated on Ward Notice
managers
the Trust in preventing the
learnt acted upon.
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prevention and control
within the organisation
Boards.
Cleaning schedules to be
displayed for public viewing
To revise and update patient
information leaflets as necessary
spread of infection
CQC compliance
To ensure that service
IPCT
Service users will have
Leaflets
Reviewed
users and their carers
accurate easy to understand Website
every 2 years
are updated on risks of
information.
HCAI and given specific
information on
infections.
New Builds and refurbishments
The environment is a major risk to the development of HCAI. Infection prevention and control will work with the estates and facilities teams to ensure compliance with
national requirements and that appropriate policies and protocols for infection prevention and control and building requirements are in place.
The infection control
Continue to work with estates to
IPCT
Compliance with national
Project meeting minutes
Ongoing
team will provide expert
review and examine all new
Estates project
standards minimising risk of
Minutes of Infection
opinion and advice on
proposals for new buildings.
managers
infection transmission
Prevention, Control and
all new developments or
Area/service managers
Decontamination
refurbishments.
Committee
To review and support all
Estates/IPCT
Compliance with national
Project meeting minutes
As requested
refurbishments and building
standards minimising risk of
Minutes of Infection
activity ensuring compliance with
infection transmission
Prevention, Control and
national standards
Decontamination
Committee
Key
DIPC- Director of Infection Prevention and Control
IPCT- Infection Prevention and Control Team
CQC- Care Quality Commission
IPCDC- Infection Prevention, Control and Decontamination Committee
ICLP- Infection Prevention and Control Link Practitioners
PLACE- Patient Led Assessment of Clinical Environments
References
The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance www.dh.gov.uk Department of Health (2008)
updated 2010.
Care Quality Commission (2009) Core Standards .www.cqc.org.uk
Saving Lives: reducing infection, delivering clean, safe care’ www.clean-safe-care.nhs.uk Department of Health (2007)
National Patient Safety Agency (2007) The National Specifications for Cleanliness in the NHS www.npsa.nhs.uk
Helen Bosley
Infection Prevention and Control Matron
Oxford Health NHS Foundation Trust
April 2015
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