Board Assurance a guide to building assurance frameworks for by suchenfz

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									Board Assurance: a guide to building assurance frameworks
       for reducing healthcare associated infections




                            -1-
Contents

Foreword                                                                                  3


About Assurance                                                                           4


Board assurance – A quick reference guide                                                 6


The Department of Health Assurance Framework – an overview                                8


Practical guide 1 – Principal objectives                                                  10
      What are they and where do they come from?                                          10


Practical guide 2 – Principal risks                                                       11
      Understanding risks – Code of practice                                              12


Practical guide 3 – Key controls and gaps                                                 13


Practical guide 4 – Assurances and gaps                                                   15
      Criteria for assessing assurance and gaps                                           15
      Audit and compliance data                                                           15


Practical guide 5 - Putting it all together                                               17
      Assurance Framework Self Assessment Tool                                            18
      Effective delivery planning                                                         18


References, further reading and related links                                             20


Appendix 1 – Example of practical application at Princess Alexandra Hospital              21
Appendix 2 – Example of good practice at County Durham and Darlington NHS Foundation Trust 23
Appendix 3 – Example of good practice at Guys and St Thomas NHS Foundation Trust          24
Appendix 4 – Example of practical application at Torbay Care Trust                        26


Annex 1 – Assurance matrix                                                                29
Annex 2 – Example of HCAI Action Plan                                                     30




                                                   -2-
Foreword

Healthcare associated infections (HCAI), such as Meticillin-resistant Staphylococcus aureus
(MRSA) and Clostridium difficile infection (CDI), can cause our service users anxiety and suffering
and have considerable cost implications for the NHS. One of the keys to achieving significant
reductions in avoidable infections across the whole health economy has been for organisations to
have an effective assurance framework in place. This helps to ensure effective processes are
implemented to drive and sustain a culture of zero tolerance to avoidable HCAIs.


This guide illustrates how the five-stage process endorsed by the Department of Health (DH) for the
development of assurance frameworks can be used to assure organisations’ boards, management,
clinical and medical staff, patients and the wider public that the safety agenda is of high priority and
is being well managed. In addition, the enclosed assurance self-assessment tool will allow you to
gauge the level of assurance within your organisation.


This guide is intended for use by every member of the organisation. Although the models are
aimed at board-level assurance, the principles are relevant and can be replicated across all levels
of the organisation and across the whole health economy in order to ensure sustainable reductions
in infections.


In order to aid your understanding of the practical application of assurance frameworks to reduce
infections, included within this document are examples of practice from a range of organisations.


Acknowledgements
We would like to acknowledge the following organisations for their contributions towards the
examples of best practice:
                 •   Princess Alexandra Hospital NHS Trust
                 •   County Durham and Darlington Hospitals NHS Foundation Trust
                 •   Guy’s and St Thomas’ NHS Foundation Trust
                 •   Torbay Care Trust




                                                  -3-
About assurance

The Department of Health’s Integrated Governance Handbook1 notes the importance of
implementing an assurance framework to enable organisations’ boards irrespective of size or care
setting:
•   to be in control of their agenda
•   to be confident that their systems, policies and people are operating in a way that is effective in
    driving the delivery of objectives by focusing on identifying, prioritising and minimising risk.


Further, the requirement for all NHS chief executive officers to sign a Statement on Internal Control
(SIC), as part of the statutory accounts and annual report, heightens the need for boards to be able
to demonstrate that they have been properly informed about the totality of their risks, both clinical
and non-clinical.


As the Integrated Governance Handbook makes clear, an effective assurance framework provides
a clear and concise structure for reporting key information to boards. It identifies which of the
organisation’s objectives are at risk because of inadequacies in the operation of controls, or where
the organisation has insufficient assurance about them. It should also provide structured assurance
about how risks are managed, reduced, and eliminated effectively, to deliver agreed objectives.
This will ensure the spread of good practice throughout the organisation and allow the board to
determine where to make the most efficient and effective use of their resources.


The 2010/11 Foundation Trust Regulator, Monitor, states in its effective governance briefing
(February 2008):2


‘It is important that boards of NHS foundation trusts have processes in place to ensure they
understand the risks of non-compliance, and thereby accurately self-certify – this stretches beyond
the [Monitor’s] Compliance Framework. As performance expectations are reflected in contracts
between providers and commissioners, with the potential for significant financial and regulatory
penalties where contracts are not delivered, a failure on the part of boards to understand actual and
potential performance, and take mitigating actions accordingly, may impact on patient care, and be
expensive and reputationally damaging. Boards must therefore ensure that they understand the risk
of entering into contracts for service delivery and the likely consequences of a failure to deliver.
Boards are likely to have objectives relating to the quality and safety of services provided to service
users, and may well have specific objectives relating to HCAIs. HCAIs clearly present a potential
risk to the quality of services provided to service users and to the reputation of the organisation to
provide clean, safe care with privacy and dignity. Boards will therefore need to have assurance that
the policies in place for managing HCAI are robust, can stand up to scrutiny, and are adhered to by



                                                   -4-
both clinical and non-clinical staff all day, every day. To do this they need to be able to provide
evidence that they have systematically identified their objectives and managed the principal risks. A
robust assurance framework fulfils this purpose.


Such a framework will also help boards ensure they are meeting their statutory duties under the
The Health and Social Care Act 2008: Code of Practice on the prevention and control of
infections and related guidance3. These are the subject of external assurance by the current
health and social care regulator (in 2010/11 the Care Quality Commission), that they have the
systems, policies and people in place to deliver at least the “must-dos” of cleanliness and HCAI set
out in the Operating Framework. The regulator only reviews a small slice of what is needed to
ensure the safety of patients in an organisation in relation to HCAI avoidance. It is therefore
imperative that boards ensure their assurance systems and processes are sufficiently robust to
encompass all aspects of care.


This document is illustrated with examples from organisations of their experience of working
through this process, the full story for each is outlined in Appendices 1 to 4.




                                                   -5-
Board assurance – A quick reference guide

This summary enables you to quickly assess which parts of the assurance framework you have in
place and which you might need to focus on in order to reduce HCAI. See corresponding section
later in this guide for a more in-depth discussion.


1. Are your principal objectives defined?                                    Yes           No
Principal objectives are the strategic goals within an
organisation. These will drive the response to HCAI within your trust.


2. Are your principal risks identified?                                      Yes           No
Principal risks will highlight any obstacles to achieving the
principal objectives as well as the associated consequences. They may include, for instance, gaps
in staff training or skill mix.


3. Do you have key controls in place to manage risks?                        Yes           No
Key controls are those mechanisms in place to manage the
principal risks. Controls should relate directly to the principal risks (though each risk may need more
than one control, and the same control may address more than one risk) and should be practical.


4. Are High impact interventions (HII) implemented?
                                                                             Yes           No
Adopting the “care bundle” approach will tackle those key clinical
procedures that can increase the risk of infection if not performed.


5. Is current good practice in antimicrobial prescribing, isolation and screening in place?
Further information can be obtained in the document
“Antimicrobial prescribing – a summary of best practice”                     Yes           No



6. Is assurance provided on the effectiveness of controls?
This element is about gathering the evidence about the
                                                                             Yes           No
effectiveness of the key controls.


7. Is compliance with controls measured and reported, eg. HII tools?
Observation and recording of clinical procedures can show where
                                                                             Yes           No
improvement action is required ultimately to achieve 100%
compliance every time, without which the control is not as effective as it could be.




                                                  -6-
Putting it all together
All of the stages of the assurance framework should work together as a continuous process of
identifying objectives, assessing risks, introducing controls and assessing whether these controls
have been effective.


8. Do organisational board papers include all the above elements?
Organisations should ensure all the above elements are
                                                                            Yes          No
incorporated into their routine board reports.


9. Is there an assurance framework assessment tool?
                                                                            Yes          No
A tool to help assess where a trust currently is in terms of
compliance against the assurance framework and to help identify areas to target HCAI
improvement.


10. Are effective delivery plans are in place?
                                                                            Yes          No
Having assessed the current position, boards should have a
delivery plan which is outcome focused, owned and measurable. This will improve key controls to
manage principal risks and gain assurances where required.




                                                  -7-
The Department of Health assurance framework – An overview

Putting the assurance framework into practice should make it a live, dynamic and iterative process
within each organisation. It needs to be reviewed, revised and updated regularly. Figure 1 can be
used as a basis for this work.


There are a number of assurance framework models in existence. In 2006, the Department of
Health published guidance for trusts in developing robust assurance frameworks. That document
addressed the need for such assurance frameworks as well as providing a tool, which can be used
practically by individual organisations.


The current view of the existing framework, illustrated in Figure 1, outlines the overall model of the
assurance framework, and is described in further detail throughout this document.


An example showing how the assurance framework can be completed for HCAI can be found in
Annex 1.




                                                  -8-
Figure 1: Extract from Building an Assurance Framework: A Practical Guide for NHS
Boards (Department of Health, March 2003)
 

                                                    Core/ developmental standards,
    Principal objectives
                                                    local targets and priorities


    Principal risks                                 Potential risks to meeting
                                                    objectives

    Key Controls                                    Reasonable management of
                                                    risks

                                                    External audit, internal audit, other
    Assurances on
                                                    reviews and inspections, management
    controls
                                                    checks, assurance makers, prompts



    Board reports:
       • Positive assurances                        SHA assessments, statement on internal
       • Gaps in controls                           control, Regulator statement, other board
       • Gaps in assurance                          declarations



                                                    To improve control, ensure delivery of
    Board action
                                                    principal objectives, gain assurance,
                                                    ensure good governance/ integrated
                                                    governance                                   

Principal objectives – Core/developmental standards, local targets and priorities


Principal risks – Potential risks to meeting objectives


Key controls – Reasonable management of risks


Assurances on controls – External audit, internal audit, other reviews and inspections,
management checks, assurance markers, prompts


Board reports – Positive assurances • gaps in controls • gaps in assurance
SHA assessments, Statement on Internal Control, Regulator Statement, other Board declarations


Board action – To improve control, ensure delivery of principal objectives, gain assurance,
ensure good governance/integrated governance


                                                 -9-
Practical guide 1 – Principal objectives


What are they and where do they come from?
Principal objectives are the strategic goals within an organisation. They will drive the response to
HCAI.


The basic principal strategic objectives in the area of HCAI are likely to be based on the “must-dos”
in the operating framework1 – for example, local implementation of the national Objective for MRSA
and Clostridium difficile infection (CDI) – though some trusts may have other broader objectives, for
example to have no avoidable infections.


Example of practical application – Defining principal objectives


Princess Alexandra Hospital NHS Trust
‘Princess Alexandra NHS Trust have a principal objective of being a zero tolerance trust in relation
to HCAI.’


These strategic objectives may well be supported by more detailed and specific objectives. These
are likely to be stated in the Infection Control Annual Report and its monthly revisions within a trust.
A number of factors, including Department of Health documentation, code of practice or local
intelligence, can also drive, define and prioritise these objectives.


Examples of practical applications – Defining principal specific objectives


County Durham and Darlington NHS Foundation Trust
Guy’s and St Thomas’ NHS Foundation Trust
Both County Durham and Darlington NHS Foundation Trust and Guy’s and St Thomas’ NHS
Foundation Trust have an objective of achieving 100% compliance with the Saving Lives high
impact interventions. The range or relationship between principle specific objectives and identified
risks can be very different in different organisations, as will be discussed later


Torbay Care Trust
Torbay Care Trust have a principle objective of having a zero tolerance approach to any MRSA
bacteraemia originating in the community. Their specific objective is related to urinary
catheterisation practice.


1
    http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_110107



                                                         - 10 -
Practical guide 2 – Principal risks

Principal risks are those which threaten the achievement of the principal objectives. These can be
derived from both hard and soft intelligence available within an organisation and will highlight any
obstacles or barriers to achieving the objectives, as well as the associated consequences.


Precisely what the risks are will depend on the objectives, but examples of risks to strategic
objectives might include (see Annex 1 for further discussion):
•   lack of reliable intelligence on numbers and potential causes of infection
•   absence of, or lack of compliance with, policies on, for example, antibiotic prescribing
•   gaps in staff training or skill mix
•   inadequate screening of patients
•   data collection difficulties.
 
Examples of practical application – Identifying principal risks


Princess Alexandra Hospital NHS Trust
Having set the objective of being a zero tolerance trust, the Trust identified a risk that staff would
not be motivated to achieve the objective as no information was made available to them about the
objective and progress towards achieving it.


County Durham and Darlington NHS Foundation Trust
Having set the objective of achieving 100% compliance with the Saving Lives high impact
interventions, the Trust identified that among the principal risks were: (a) not understanding why
HCAI are happening, and, (b) poor compliance with current best practice.


Guy’s and St Thomas’ NHS Foundation Trust
Having set their objective of achieving 100% compliance with the Saving Lives high impact
interventions, the Trust realised that a major risk to them achieving their objective was that their
current system for capturing data did not allow for a trust-wide view of compliance.


Torbay Care Trust
Having set their objective of having a zero tolerance approach to any MRSA bacteraemia
originating in the community due to urinary catheterising, the Trust realised that a major risk to them
achieving their objective was that the absence of HCAI information for community staff might not
support them to deliver the required reduction in urinary catheterisations.




                                                  - 11 -
Understanding risks – Code of practice


Organisations should self-assess their compliance with the Health and Social Care Act 2008: Code
of Practice for health and adult social care on the prevention and control of infections and related
guidance. This sets out the 10 criteria against which a registered provider will be judged on how it
complies with the registration requirement for cleanliness and infection control. Not all criteria will
apply to every regulated activity.


Compliance: What the registered provider will need to demonstrate criterion


1. Systems to manage and monitor the prevention and control of infection. These systems use risk
   assessments and consider how susceptible service users are and any risks that their
   environment and other users may pose to them.
2. Provide and maintain a clean and appropriate environment in managed premises that facilitates
   the prevention and control of infections.
3. Provide suitable accurate information on infections to service users and their visitors.
4. Provide suitable accurate information on infections to any person concerned with providing
   further support or nursing/medical care in a timely fashion.
5. Ensure that people who have or develop an infection are identified promptly and receive the
   appropriate treatment and care to reduce the risk of passing on the infection to other people.
6. Ensure that all staff and those employed to provide care in all settings are fully involved in the
   process of preventing and controlling infection.
7. Provide or secure adequate isolation facilities.
8. Secure adequate access to laboratory support as appropriate.
9. Have and adhere to policies, designed for the individual’s care and provider organisations that
   will help to prevent and control infections.
10. Ensure, so far as is reasonably practicable, that care workers are free of and are protected from
   exposure to infections that can be caught at work and that all staff are suitably educated in the
   prevention and control of infection associated with the provision of health and social care.


Poor compliance with any of these criteria could be considered as key risks to the achievement of
the principal objectives.




                                                   - 12 -
Practical guide 3 – Key controls and gaps

Key controls need to be in place to manage the principal risks. The controls should be clearly and
concisely stated and open to scrutiny both internally and externally. These controls should relate
directly to the principal risks and should be practical. The relationship between risk and control is
not always one-to-one as a number of controls may be needed to mitigate or negate one specific
risk, and the same control may address a number of risks.


The available documentation includes practical advice on a range of policies and practices which
can help control the risks arising from HCAI. Some of the current best practice guidance is included
in the High Impact Interventions (HIIs), which use the “care bundle” approach to break down clinical
processes into elements that must all be performed every time and for every patient if the best
possible control is to be achieved.


High Impact Interventions:

   •   HII Central venous catheter
   •   HII Peripheral intravenous cannula
   •   HII Renal haemodialysis catheter
   •   HII Surgical site infection
   •   HII Ventilated patients (or tracheostomy where appropriate)
   •   HII Urinary catheter
   •   HII Reduce the risk from Clostridium difficile
   •   HII Improve the cleaning and decontamination of clinical equipment
   •   HII Enteral Feeding
   •   HII Chronic wounds
   •   HII Antimicrobial prescribing
   •   Taking blood cultures – a summary of best practice




                                                  - 13 -
Examples of practical application – Key controls


Princess Alexandra Hospital NHS Trust
Having identified a risk that staff would not be motivated to achieve the objective of being a zero
tolerance trust, because no information was made available to them about the objective and
progress towards achieving it, the trust started several initiatives:
•   a standard report across all wards
•   infection control notice board (ICNB) was developed
•   wards were decluttered so that very few posters were displayed except for the ICNB and the
    cleanYourhands campaign
•   HCAI prompt cards were carried by all nurses and doctors and displayed on the ICNB
•   hand hygiene audit results for each ward were displayed.


County Durham and Darlington NHS Foundation Trust
Having identified a risk that poor compliance with current best practice could threaten the objective
of reducing HCAI, the Trust decided that staff should comply with the Saving Lives high impact
interventions.


Guy’s and St Thomas’ NHS Foundation Trust
In order to tackle the risk arising from their current system for capturing data, Guy’s and St Thomas’
NHS Foundation Trust decided they needed to develop an electronic system that would support
their clinical implementation of the Saving Lives programme.


The system covers many different indicators, staff throughout the Trust are now able to enter data
on HII compliance either at the point of care on the hand-held tablets or on the computer in each
ward. Results are available to the Executive Team so they can monitor compliance across the Trust
and can see not only the compliance against each HII, but also see the number of bacteraemia
cases by ward, to enable real-time reporting.


Torbay Care Trust
Having identified that a lack of relevant supporting information being available was a risk and could
threaten the objective of reducing community originating HCAIs, the Trust introduced clear
expectations on what documentation reflecting the HII elements needed to be completed, by when,
and where it needed to be returned to from the community staff. This provided evidence and
assessment of practice.




                                                   - 14 -
Practical guide 4 – Assurances and gaps

This element seeks to provide structured assurances about the effectiveness of the key controls
that have been put in place to manage the principal risks to the achievement of the principal
objectives. It allows boards to determine where to make efficient use of their resources and address
the issues identified for improvement in relation to HCAI and the quality and safety of care for their
patients. Assurance can be both external (for example through the current regulator inspections), or
internal, (for example through auditing compliance with good practice).


Criteria for assessing assurance and gaps
To help achieve this, an organisation will need to assess whether it identifies assurance gaps
effectively. The following criteria help identify the level of assurance/gap, and help inform what
degree of action is required. Annex 1 is a working example of how this can look in practice.


                                                           Gaps in control: There is a clear conclusion,
                                                           based on sufficient and relevant work, that
                                                           one or more of the key controls on which the
                                                           organisation is relying are not effective.


                                                           Gaps in assurance: There is a lack of
                                                           assurance, either positive or negative, about
                                                           the effectiveness of one or more of the key
                                                           controls. This may be due to a lack of relevant
                                                           reviews, or concerns about the scope or
                                                           depth of reviews that have taken place.
                                                            
                                                           Audit and compliance data
                                                           Audit and compliance information is central to
                                                           the board assurance framework. Trust
                                                           boards need to be satisfied that HCAI policies
                                                           and procedures are being upheld, and that
                                                           continuous and sustainable compliance is in
Full assurance: There are sufficient relevant,
                                                           place to reduce infections. The High Impact
positive assurances to confirm the
                                                           Interventions care bundles are one example
effectiveness of key controls and that
                                                           of a robust system for capturing this type of
objectives can be met.
                                                           information.

 


                                                  - 15 -
Examples of practical application – Assurances and gaps


Princess Alexandra Hospital NHS Trust
Assurance that the controls are operating are provided in a number of ways. The Executive Team
go on walkabouts on wards so they can see that MRSA and CDI information is being displayed and
that the standard has been met. They also check compliance levels while on wards to ensure
standards are being maintained. They look at what is going on in the environment and ask
assurance questions of staff to ensure policy is embedding in practice.


County Durham and Darlington NHS Foundation Trust
Having decided that staff should comply with the Saving Lives High Impact Interventions, the Trust
recognised that action was needed to strengthen the assurances relating to immediate and
continuous compliance across the Trust.
A standard assurance tool was developed for the organisation to use across all sites and wards to
ensure that any non-compliance with the HIIs was recorded, and immediate action could be taken
and re-audited for two further occasions, to ensure sustainability of compliance.


Torbay Care Trust
The trust introduced a variety of methods for providing assurance including self assessment and
observational audit by peers and patients. Regular checks on quality and completeness of
documentation along with use of a board assurance dashboard for reporting to the Board was
utilised




                                                 - 16 -
Practical guide 5 - Putting it all together


The five stages of this guide illustrate the full process to assist an organisation to identify where it is
assured and where further attention is required


By including all of the assurance framework stages it forms a continuous process of defining
objectives, assessing risks, introducing controls, assessing whether these controls have been
effective and introducing additional controls as necessary.


Some of the principle objectives, risks and controls may change with time as the organisation
changes. Additionally, principle risks may change or be eliminated negating the need for previously
identified controls.


The purpose of any self-assessment is to allow organisations to assess which stage their
organisation is currently at in order to give them guidance on what to focus on next. Organisations
might find they have a series of objectives defined alongside identified risks to achieving these, but
may not have put controls in place to mitigate these risks. The assessment process will enable an
organisation to be clear about where action needs to be taken.


In support of the assurance process, key questions need to be asked around what information is
needed at meetings to enable the organisation to make well informed decisions about its objectives,
the risks it is carrying and how these are being managed. KPIs will need to be reviewed over time to
ensure they are providing the relevant information for the organisation to make robust decisions.
 
Examples of practical application – Using the process to set specific objectives


Guy’s and St Thomas’ NHS Foundation Trust
The Trust’s strategic objective is to reduce HCAI. A principal risk is failure to follow current good
practice. A key control would be to achieve 100% compliance with the Saving Lives High Impact
Interventions and this was set as a board expectation. This was recognised as a gap, so, as we
have seen, a specific objective was set to achieve it.




                                                   - 17 -
Assurance Framework Self Assessment Tool
A self assessment tool can be used within an organisation to assess the effectiveness of its
assurance framework.


Figure 2 shows how points can be awarded
depending on levels of assurance provided at
each stage. Using five major headings of the
framework, organisations can self-score as
meeting both the objective and the ability to
demonstrate it, meeting the objective but not
being fully able to demonstrate it, or not
meeting the objective. This tool can be
adapted to meet an organisation’s own
particular need.
 
This tool can be used to help assess where your organisation is currently in terms of a compliance
snapshot with the assurance framework, and also to help you identify areas to target improvement.
This activity should lead to the development of a delivery plan to improve key controls to manage
the principal risks and gain assurances where required.


This activity should lead to the development of a delivery plan to improve key controls to manage
the principal risks and gain assurances where required.


Effective delivery planning
In order to provide additional assurance, trusts need to ensure they have effective delivery plans in
place. These should be directly linked to the principal objectives, which will have been previously
identified. Key actions should be developed, which will help to mitigate the risks to these objectives
being achieved.


Key headings, which can be included in all action plans are:
         •   Risk to be mitigated                                •   Date of review
         •   Actions required                                    •   Completion date
         •   Owner                                               •   Costs/resource requirements
         •   Success measures                                    •   Progress to date.
 
This is not an exhaustive list and will vary depending on the needs of the organisation.




                                                 - 18 -
Annex 3 includes an extract from a delivery plan, which has been developed specifically to reduce
HCAI within an organisation. The detail of what is included will largely depend on the issues
identified within the assurance matrix (Annex 1).


It is recommended that delivery plans should adhere to SMART principles:


                   Specific
                   Measurable
                   Achievable
                   Realistic
                   Time specific


In order to ensure delivery plans are effective, regular monitoring is required. They should be used
as dynamic tools, which are regularly changed and updated by organisations in order to reflect
existing and new principal objectives and as additional principal risks are identified. These should
be discussed at senior operational meetings to demonstrate how improvements have been
obtained, and in situations where such improvements are not being demonstrated, used with clear
escalation and support networks to deliver the required outcomes.




                                                 - 19 -
References, further reading and related links

Building the Assurance Framework: A Practical Guide for NHS Boards, Department of Health,
March 2006
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4128739



Regulator as of 2010/11: Care Quality Commission
www.cqc.org.uk



The Health and Social Care Act 2008: Code of Practice on the prevention and control of
infections and related guidance (published 14 Dec 2010)
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122604



Integrated Governance Handbook 2006, Department of Health, February 2006
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4128739



Operating Framework
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_110107



Monitor: Effective governance in NHS foundation trusts briefing, 18 February 2008
http://www.monitor-nhsft.gov.uk/home/our-publications/browse-category/guidance-foundation-trusts/mandatory-
guidance/effective-govern




                                                        - 20 -
Appendix 1 – Example of practical application at Princess Alexandra
Hospital

Putting assurance into practice
After a Department of Health Improvement Team visit in September 2007, the Princess Alexandra
Hospital NHS Trust decided they needed to ensure that staff, patients and visitors throughout the
Trust were aware of what was going on at ward level to combat MRSA and CDI.


1. Principal objective: To be a zero tolerance trust.
The Board had decided that they would be a zero tolerance trust. This required some big changes
to take place at the Trust, but they knew that by working together they could achieve great results.


2. Principal risks: In the absence of HCAI information, ward staff will not be motivated to achieve
the trusts objective.


The Trust recognised that if people did not know and understand what effect being a zero tolerance
trust was having on HCAI, it was unlikely that the necessary changes would be achieved. They
noted that they had very little in place. They did not have any performance information regarding
HCAI displayed in public areas and limited information was available to ward staff. This made
assessing performance and compliance at a local level challenging.


3. Key controls: The Trust have implemented a number of controls to help manage the risk,
including introducing infection control notice boards, to display performance and compliance data to
staff, patients and visitors.


The Trust identified that they needed to be transparent so that staff, visitors and patients could see
the number of infections the Trust was reporting and what they were doing as an organisation to
prevent patients contracting infections while in hospital. Several initiatives that originated within the
Trust are being continuously developed to suit their needs.


•   Adopting a lean approach, the Trust decided they needed to have a standard report across all
    wards
•   Infection control notice board (ICNB) developed and rolled out to six wards (these were chosen
    because they had had a bacteraemia recently).
•   Very few posters are displayed on walls, except for the ICNB and cleanYourhands campaign
    posters.




                                                   - 21 -
•   All nurses and doctors carry HCAI prompt cards around with them, but they also appear on one
    side of paper on the ICNB.
•   Hand hygiene audit results for each ward are also on display.
•   A matrix was developed for MRSA and CDI so that any cases are instantly identified on the
    ward by colouring in a box. This means everyone is immediately made aware and action plans
    can be put into place.


4. Providing assurance
The Trust are now more assured that the risk is being managed and their objective is being met, as
regular checks are made that information is displayed on wards and that compliance rates can be
easily checked on a regular basis.


Assurances that objectives are being met are provided in a number of ways. The Executive Team
go on walkabouts on wards so they can see that MRSA and CDI information is being displayed and
that the standard has been met. They also check compliance levels while on wards to ensure
standards are being maintained.




                                                - 22 -
Appendix 2 – Example of good practice at County Durham and
Darlington NHS Foundation Trust

Attaining assurance through compliance
Following a Department of Health National MRSA Improvement Programme Assurance meeting,
the following question was posed:


“How does the Trust know that recommended actions from root cause analysis and compliance
audits have been taken forward and sustained across the whole organisation?”


The Trust recognised work was required to seek this assurance and began a project, which
concentrated on the Saving Lives High Impact interventions (HIIs).


1. Principal objective
The Trust’s principal objective is to reduce HCAI.


2. Principal risks
Among the principal risks are:
(a) not understanding why HCAI are happening; and
(b) poor compliance with best practice


3. Key controls
To address the second of these risks, the Trust decided that staff should comply with the Saving
Lives HIIs


4. Providing assurance
A standard assurance tool was developed for the organisation to use across all sites and wards to
ensure that any non-compliance with the HIIs is recorded, and immediate action is taken and re-
audited for two further occasions, to ensure sustainability of compliance. In order to measure
whether using the new tool has been effective in terms of continuous compliance/improvement, the
Trust would use the monthly monitoring to measure increasing and maintained compliance.




                                                 - 23 -
Appendix 3 – Example of good practice at Guys and St Thomas NHS
Foundation Trust

Using the assurance process


1. Defining principal objectives
In October 2003, Guy’s and St Thomas’ NHS Foundation Trust launched an in-house improvement
programme to address concerns in relation to HCAI, and to provide assurance of adoption of best
practices in meeting the needs of patient safety. The improvement programme brought about
significant improvements in staff attitude and reductions in infection rates in the monitored
organisms.


In 2007, the Trust decided that to continue the improvements they had achieved they
needed to develop a system that would support their clinical implementation of the Saving Lives
programme. This was considered fundamental to the success of Phase II of their improvement
programme. They established a relationship with a software company that focuses solely on the
healthcare industry.


The Trust had several objectives with this system. They wanted to achieve 100% compliance with
the Saving Lives High Impact Interventions (HIIs) by having a consistent process and uniformity for
the reporting of compliance against the HIIs.


2. Identifying principal risks
The Trust realised that a major risk to them achieving their objective to reduce HCAI was that their
current system for capturing data did not allow for a trust-wide view of compliance.


3. Introducing key controls
The Trust decided to explore the development of a new system for monitoring
compliance against the HIIs. It would be web-based and available for everyone in the
Trust to use. The tools worked in the following ways:
•   a web-based online system that doesn’t need to be installed on each PC by IT
•   an executive dashboard would be available on the web-based system that would:
       -     allow users to access the dashboard or data capture at any time
       -     be fully integrated with other IT systems
       -     have a facility to allow the user to focus and see compliance with each intervention, by
             ward, audit etc
       -     allow users to add attachments, e.g. photos.




                                                   - 24 -
The new system would also ensure that data capture was effective in three ways:
•   an intuitive data capture tool was made available on all wards across all Trust hospitals
•   it was easy to use, minimising time taken to log data
•   a mobile device ensured data capture is enabled at the point of care using a tablet PC.


With all these in place the Trust were able to start rolling out their new system.


This picture shows an example of the executive dashboards. There are a number of different
indicators, including total number of MRSA acquisitions and the number of confirmed bacteraemias.


Providing assurance
The new system covers many different indicators; staff are now able to enter data on HII
compliance either at the point of care on the hand-held tablets or on the computer in each ward.
They simply go to the web page, enter their password and they are logged onto the system. The
member of staff entering the data then selects the HII they want to enter data against and their
ward.




                                                  - 25 -
Appendix 4 – Example of practical application at Torbay Care Trust

Background
The testing of the new Community High Impact Interventions in February 2009 was initiated from
Torbay’s Catheter Project steering group that identified a need for assurance around clinical
practice in patients’ homes. This included conducting baseline measures from which improvement
could be measured.


1. Principal objective:
•   To have a zero tolerance approach to MRSA bacteraemia in the community.


•   To provide evidence of good clinical practice in order to provide assurance. This required
    measurement through independent observations of clinical practice in patients’ homes. The
    following was considered:


    -   What should be considered when conducting observations in the community?
    -   What is the best way to review clinical practice in patients’ homes
    -   How can the evidenced-based Saving Lives tool be better adapted and used to the
        community setting as a method of providing assurance around good practice in patient’s
        homes?
    -   How could we measure a baseline around urinary catheter care?


2. Principal risks:
•   In the absence of HCAI information, community staff may not be motivated to achieve the PCT’s
    objective.
•   At the time of the study there was some variation between the localities on clinical practice,
    equipment and policies.
•   Some remote workers were not use to close scrutiny, therefore potential for some resistance.
•   Obtaining consent from patients.
•   Planning observations around pre-planned catheter visits may reduce the impact of a third party
    observing.


3. Key controls :
The Trust has implemented a number of controls to help manage the risk. This included:


•   Ensuring the safety of lone workers when accompanied by external observers by providing
    District Nurses with a background summary of unknown visitors




                                                 - 26 -
•   Giving prior warning to patients and getting their consent in advance for observers to come into
    their home.


Controls around practically measuring a baseline for urinary catheter care in the community were
taken:


•   Adapt wording in High Impact Interventions so it can be used for self-assessment.
•   Reviewing the existing guidelines on what to prescribe for recurring catheter related UTIs and
    making recommendations for improvement and standardisation.
•   Equipment issues were raised e.g. sterile wound and catheter packs, paper towels in patients’
    homes and in care homes, availability of saline products, standardisation around which
    catheters should be used, drapes, availability of eye/face protection.
•   Looking at issues around the disposal of clinical waste in community setting and the frequency
    of collections affected by contracts with local council.
•   Using opportunities for the safe storage in patients’ homes of Personal Protective Equipment
    and other equipment.
•   A review of standardised information for patients was conducted.
•   Expectations were clarified around documentation, e.g. consent date, flagging system for
    catheter review, recording of VIPS scores, information for health care assistants on the catheter
    status and what they should be doing regarding the management of the catheter. The catheter
    history chart and District Nurses’ care plan have been adapted to reflect prompts around the HII
    elements. Documentation on discharge is not always clear on who is responsible for checking a
    patient’s catheter, particularly if re-catheterisation is required at the hospital.
•   Training. Building a framework of assurance within existing capacity may require mandatory
    training around key IPC practices to establish required standards. Healthcare assistants need to
    receive update training on how to manage catheters.


4. Providing assurance
Various methods for providing assurance were considered, for example, self-assessment,
observations from peers, line manager and external staff, using patient observations.


As a result, Torbay Care Trust is now more assured around the clinical practice in their patients’
homes from the improved quality of evidence being regularly provided through the various methods.
Assurance is being provided in a number of ways:


•   Regular checks on the quality of documentation across the localities and on discharge with
    feedback directly to the staff giving care.




                                                    - 27 -
•   A layered structure for regular self-assessment and observational peer reviewing provides
    evidence for assurance of compliance around the HIIs.
•   Quality of training and updates for District Nurses, Healthcare assistants and staff in care
    homes by employing a community based infection control clinical skills facilitator
•   Audits on the improvements being made on standardising policy, equipment, clinical pathways
    and prescribing across the localities
•   Introduction of single use catheter packs ensuring a larger sterile field and all the appropriate
    equipment for the procedure
•   A standardised patient / carer information leaflet which provides consistency of supplied
    information to both the patient and carer
•   Board assurance – dashboard shows reduction and re-assessment in the use of urinary
    catheters by locality




                                                  - 28 -
Annex 1 – Assurance matrix




                             - 29 -
Annex 2 – Example of HCAI Action Plan




                                - 30 -

								
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