Quality Improvement Plans based on the Unannounced Hygiene Audit Report

By the Health Information and Quality Authority (HIQA) at UL Hospitals, Nenagh Hospital on the 17th September 2015

(existing hospital QIP based on unannounced HIQA visit in October 2014 Amalgamated)

Standard / Findings/ Non Compliance / Action Plans / Action Taken / Lead Responsibility / Target Timeframe / Progress To Date / Review
Standard 3
Environment and Facilities Management / Patient equipement cleaning check list incomplete due to lack of hygiene resources / Clean patient equipment as per timeframe outlined in equipment log
Equipment to be cleaned by staff member who uses it
Equipment not in use to be stored off the ward
Increase Hygiene Hours / Hygiene staff cleaning equipment and signing logs
In progress, equipment cleaned by staff after use i.e. observations machines
Equipment moved to the equipment store room off the ward when not in use
Hygiene WTE deficit
Escalated to Corporate risk register September 2014
5 new MTA’s commenced in Nenagh Hospital since Jan 2016.More positions to be filled. Recruitment on going / Bridget Kelly CNM 2
Bridget Kelly CNM2
Bridget
Kelly CNM2
Cathrina Ryan A/ODON
Josephine Hynes HR
Irene O’Connor Facilities / Ongoing
Ongoing
Completed
Completed
Ongoing process / Equipment being cleaned and signed by hygiene staff
Equipment being cleaned by staff after use
Excess equipment decanted off ward to equipment store room
Completed
Ongoing process / Ongoing review and monitoring in monthly Environmental Hygiene Audit
Daily monitoring by ward CNM
Daily monitoring by ward CNM
Completed
Ongoing process
Standard / Findings/ Non Compliance / Action Plans / Action Taken / Lead Responsibility / Target Timeframe / Progress To Date / Review
Standard 3
Environment and Facilities Management / High levels of dust in 10 bedded Medical 2 / Intermittent deep clean as staffing allows
Implement deep clean rota of rooms where all furniture and beds are pulled out, cleaned, returned to room e.g. Room 1 + 2 every Monday. 3+4 every Tuesday
Monitoring of environmental hygiene / Staff allocated when available to perform a deep clean to supplement daily cleaning
Hygiene Schedule and duties being redesigned in line with recruitment of new staff – same at discussion level with Hospital Management and Union Representation
Monthly Hygiene audits being carried out at ward level.
Ongoing risk on Hospital Risk Register / ADON on duty
Cathrina Ryan A/ODON
Irene O’Connor Facilities
Bridget Kelly CNM2 / Ongoing
April 2016
Ongoing and Monthly / Intermittent deep cleans carried out at ward level.
New Duties, Roles and responsibilities being drafted and discussed by management and Union representation. Meetings ongoing and issues being progressed.
.
Maintained on Risk register. Ongoing and monthly monitoring / Ongoing Review
First quarter 2017
Ongoing and monthly monitoring
Standard / Findings/ Non Compliance / Action Plans / Action Taken / Lead Responsibility / Target Timeframe / Progress To Date / Review
Standard 3
Environment and Facilities Management / Inadequate patient Preparation / waiting area / Patients prepped for procedure in post procedure observation area / Patient waiting area to be included new plans for remodelled Endoscopy Unit for JAG accreditation / Philip Brennan / Second quarter of 2017 / Upgrade of MAU to commence on ground floor. Plan to move MAU by first quarter of 2017 which will release more floor space to Endoscopy. / Second quarter of 2017
Standard 3
Environment and Facilities Management / No Endoscopy patient discharge lounge / Patients being discharged from bed space
Designation of Endoscopy Discharge Lounge with remodelling of Unit for JAG accreditation / Discharge care and advice being provided in observation bed space
New Seating area being set up - / Celia Dwan CNM2
Philip Brennan
Facilities / Ongoing
Second quarter of 2017 / Discharge care and advice being provided in observation bed space
Upgrade of MAU to commence on ground floor. Plan to move MAU by first quarter of 2017 which will release more floor space to Endoscopy / Ongoing
Second quarter of 2017
Standard 3
Environment and Facilities Management / Clutter on work surfaces in Procedure room 1 / Office space adjacent to Endoscopy Procedure Room 1 designated to Endoscopy. / New office space provided to Endoscopy Unit. All possible equipment / paperwork decanted to new office space / Philip Brennan Facilities
Celia Dwan CNM2 / Completed
Ongoing monitoring and audit / Completed
Ongoing monitoring and audit / Completed
Ongoing monitoring and audit
Standard / Findings/ Non Compliance / Action Plans / Action Taken / Lead Responsibility / Target Timeframe / Progress To Date / Review
Standard 3
Environment and Facilities Management / Failure to remove sterile consumables and clean sharps tray after use / Re-education of all staff in Department / Education to be carried out by IP&C ADON Barbara Slevin. Education schedule being finalised / Celia Dwan CNM2
Barbara Slevin ADON / First Quarter 2017 / Staff have been updated on relevant policys and awareness created around availability of same by Dept manager / First quarter 2017
Standard 3
Environment and Facilities Management / Isolation Room Door open / Review practices of keeping door open in isolation cases after appropriate patient safety assessment i.e. for slips trips and falls / Each patient assessed on an individual basis. Reason for leaving door open to be documented and reported / Relevant CNM2 / Ongoing
IPC Education programme / Ongoing, assess on a patient by patient basis / Ongoing, assess on a patient by patient basis
Standard 6
Hand Hygiene / Clinical Hand Wash sinks in Medical 2 do not fully conform with Health Building Note 00-10 Part C / Assessment of hand wash sinks in medical 2. Forward business case to Estates re feasibility of replacing / Awaited / Philip Brennan
Facilities / February 2016 / Awaiting possible ward revamp / Suspended
June 2017
Standard / Findings/ Non Compliance / Action Plans / Action Taken / Lead Responsibility / Target Timeframe / Progress To Date / Review
Standard 8
Invasive Medical Device related infections are prevented or reduced / Improvement in Documentation for Peripheral Vascular Care bundles & Urinary Catheter Care bundles required / Care bundles to be incorporated to NEWS Chart and become part of patients routine observations / Ongoing Audits continued. Local and HIQA Audit results fed back to staff. QIP in place until documentation streamlined / Relevant CNM2
Barbara Slevin ADON
Cathrina Ryan A/ODON / May 2016 / Await Guidance from Project Group Lead
Monthly review via Metrics on Medical Floor. New audit tool introduced to audit care bundles on Medical floor. / First quarter 2017
Standard 3
Environment and Facilities Management / Blood Glucose Device and container being brought to patient’s bedside / All staff reminded for need to make up and clean down individual tray when taking a patients blood glucose / Hospital policy re circulated. CNMS requested to monitor and tutor staff in their work areas / Cathrina Ryan A/ODON
Relevant CNMS / January 2017 / Reaudit March 2017 / Ongoing Monitoring and Audit

Outstanding Items From HIQA QIP 2014

Standard / Findings/ Non Compliance / Action Plans / Action Taken / Lead Responsibility / Target Timeframe / Progress To Date / Review
Standard 3
Environment and Facilities Management / Sanitary Facilities not being checked in the evening – checklists not being signed off in evening / Sanitary Facilities check sheet to be redesigned to reflect National Cleaning standard of 3 cleans and 2 check cleans a day.
Monitoring of patients sanitary facilities / Redesign of shift patterns and rosters to have availability of Hygiene attendants on duty in afternoons / evenings to carry out checks / cleans
commenced
Appropriate schedules designed and to be distributed
Monthly sanitary facility audits / Cathrina Ryan A/ODON
Irene O’Connor Facilities
Bridget Kelly CNM2 / December 2016
Monthly and ongoing / Meetings commenced with Unions and MTAs for review of rosters to facilitate extended day. Final draft of rosters circulated to include evening cleaning
WTE Deficit identified– awaiting appointment of same to achieve and maintain hygiene standard. 5 MTAs recruited and 7 further vacancies identified. Recruitment ongoing.
Ongoing / First quarter 2017
Ongoing
Standard 4
Human Resource Management / Deficits in Hygiene
staff WTE identified on Medical 2 ward / Recruit and replace
deficits in hygiene WTE / Placed on Hospital
risk register in April 2014 and escalated to Facilities Management
Risk submitted to Chief Operations Officer N Spillane January 2015 / Cathrina Ryan
A/ODON
Josephine Hynes HR
Irene O’Connor Facilities
Noreen Spillane COO / First quarter 2017 / Ongoing recruitment and training across ULH Group. Awaiting further allocation to Nenagh
MARCH 2016 –
5 New staff allocated to hospital. Second hygiene MTA allocated to Med 2 / First quarter 2017