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HCAI Prevention & Control Strategy

IntroductionShow [+]Hide [-]

The Newcastle upon Tyne Hospitals NHS Foundation Trust recognises that the effective prevention and control of healthcare acquired infection (HCAI) is essential to patient and staff safety and to the overall performance of the organisation.

The strategic approach to HCAI prevention and control as reflected in this document is fundamental to the delivery of the Trust’s organisational objectives in relation to patient safety, clinical governance and performance. Effective prevention and control systems and the development of a committed approach to learning will ensure that the Newcastle upon Tyne Hospitals NHS Foundation Trust continues to develop and improve the safety and quality of patient care.

The strategy will outline the roles and responsibilities of key individuals in the Trust for delivering the strategy.

The Trust Board, managers and staff are responsible for establishing, maintaining and supporting a co-ordinated approach to infection control in all areas of their responsibility. This includes incorporating HCAI control advice and guidance into local policy development. It is important to emphasise that Infection Control is “everyone’s responsibility”.

AimsShow [+]Hide [-]

The aims of the strategy are to ensure that:

  • robust  HCAI prevention and control has a positive effect on the quality of care, safety and well being of patients, staff, volunteers and visitors, and on the business, performance and reputation of the Trust
  • the organisation recognises HCAI prevention and control, and wider infection control issues, as a key element of clinical and non-clinical  governance
  • HCAI prevention and control systems and processes are embedded across clinical directorates and in corporate services including business planning, service development, financial planning, project and programme management and education
  • the organisation adopts a co-ordinated and multi-disciplinary approach in managing HCAI prevention and control through a systematic process of identification, analysis, learning, and management of risk. This approach extends to partnership working with other providers and Commissioners
  • the organisation strives to be amongst its best performing peers nationally and does not exceed national and local targets in relation to MRSA and Clostridium difficile
  • that the Trust will strive to not exceed the national targets in relation to MRSA bacteraemia and C.difficile.

ObjectivesShow [+]Hide [-]

The principal objective of this strategy is to set out the BOARD LEVEL AGREEMENT in terms of Infection Prevention and Control.

It will also seek to provide the Board of Directors with sufficient assurance that appropriate structures and processes are in place to minimise the risks of HCAI to patients, staff and visitors.

PrinciplesShow [+]Hide [-]

The following principles underpin the strategy:

  • that infection prevention and control will be embedded in the core processes and systems of the Trust, including guidelines and procedures, operational policies, education and training, the business planning cycle, and business case development
  • that infection prevention and control will be integrated and converge with business planning, performance management and corporate governance
  • infection prevention and control will be actively managed and positive assurance sought
  • that infection prevention and control is the responsibility of all staff within their own sphere of work
  • that high-risk infection prevention and control areas and activities will attract greatest focus and attention
  • that there will be learning from root cause analysis, data review, incidents, claims, complaints and national reports and explicit roll-out of identified improvements
  • the strategy will actively promote and underpin the acquisition of relevant accreditations, including the Annual Health Check and Code of Hygiene

Infection Prevention and Control Systems and Processes Show [+]Hide [-]

The Trust relies on a number of policies and systems to facilitate the management of all Infection Prevention and Control throughout the organisation. These include the policies which underpin compliance with the duties of the Health Act 2006 (Code of Practice for the Prevention and Control of HCAI) Department of Health. Trust policies are available to all members of staff via the Trust Intranet.

Accountabilities, Responsibilities and Organisational FrameworkShow [+]Hide [-]

It is recognised that effective HCAI prevention and control requires commitment and active involvement of all employees. It is therefore vital that the infection prevention and control process is communicated and embedded throughout the organisation. In addition to the corporate responsibilities outlined below, Clinical Directors, Matrons, Directorate Managers, and Department Heads are responsible for ensuring effective infection prevention and control within their own specialist areas. These include primary responsibility for identification, investigation and follow up of all infection prevention and control issues. Where initial assessment indicates a high level of risk or need for expert advice and /or where the level of risk warrants reporting to an external body, the Matron, Directorate Manager, Clinical Director or Department Head is responsible for bringing the issue to the attention of the Director of Infection Prevention and Control, the Clinical Governance and Risk Department and where appropriate a Board Director, in order to agree decisions about subsequent management of the issue.  

In addition, there is also a need for robust mechanisms for HCAI prevention and control practice and management performance at every level of the organisation.  The performance management, and audit functions will play an important role in testing the effectiveness and embedding of infection prevention and control throughout the Trust. 

Measuring performance on the Trusts processes will incorporate both proactive and reactive monitoring systems, including performance indicators and aggregated analysis of incident and claims investigations and complaints processes to improve clinical care, and patient and staff safety.

Key Designated Responsibilities Show [+]Hide [-]

Overall decisions on prioritisation of infection prevention and control issues and resource allocation will be made by the Executive Team, with advice from the Director of Infection Prevention and Control, and where necessary referred to the Trust Board.

Key Forums for the Management of Infection Prevention and ControlShow [+]Hide [-]

The Infection Control Committee is a sub committee of the Clinical governance and Quality Committee. The Committee is chaired by the DIPC and oversees all Infection Control issues in the Trust.

The Clinical Governance and Quality Committee manages key risks to clinical quality. As a Standing Committee of the Trust its purpose is to ensure that there are in place proper processes for continuously monitoring and improving clinical quality by building upon existing control systems and self-regulation standards.

The Clinical Policy Group advises the Trust on matters of clinical policy and ratifies both clinical and non-clinical policies. In addition it is a route through which matters can be raised for consideration by the Trust Board and Standing Panels.

The Matrons Forum & Sisters/Charge Nurses Forum provides a structural yet interactive forum where Matrons receive, review and implement national and local policy relating to patient care and nursing practice.  This forum enables the process of communication, debate, sharing of knowledge and opportunity to influence the development of nursing standards.

Serious Infections Review Meeting provides a forum for clinical teams [Clinical Director, Matron, Directorate Manager, Ward Sister, Consultant] to meet with the Medical and Nursing Directors and the Director for Infection Prevention and Control for detailed clinical review of and serious infection issue and MRSA each bacteraemia and c.difficile related death.  This enables discussion and learning to be shared across the Trust. (NB: The classification of an infection issue as “serious” is not the discretion of the DIPC supported by Consultant Microbiologists and the Executive Lead.

Directorate/Department Clinical Governance Committees

All Directorates have local clinical governance committees where HCAI prevention and control systems and local strategies are evaluated and service changes agreed as necessary.

The Council of Governors

The Council of Governors provide external scrutiny to the work of Infection Prevention and Control.  This is via formal review of progress at each Council meeting and the Governors Infection Control Group.

Systems for Managing HCAI Prevention and ControlShow [+]Hide [-]

The Trust is committed to ensuring that the HCAI prevention and control processes become embedded in the management of both clinical and non clinical activities, in terms of strategic and operational issues in the functioning of the organisation. In order to underpin an integrated approach to infection prevention and control activities across the organisation, the Trust will maintain and continue to develop the following key systems:

  • Single Trust-wide accident/incident and risk reporting system and database
  • MESS database (MRSA Enhanced Surveillance System)
  • Microbiology database.

Future systems to improve management of infection control will include:

  • Real time bed management system
  • System integration with Patient Administration System (PAS)

Strategy DisseminationShow [+]Hide [-]

The Trust’s HCAI Strategy will be disseminated and made available:

Internally – Directorate and Department managers will be expected to communicate the Strategy to all relevant staff and it should be integral to local induction procedures.  The Nursing and Patient Services Director is expected to communicate the Strategy to the Members Council and the Community Advisory Panel.

Externally – The Nursing and Patient Services Director is expected to communicate the Strategy to Monitor, Primary Care Trusts, Commissioners, Strategic Health Authority, Auditors, Local Overview and Scrutiny Committee, Patient and Public Involvement Forum, and it will be published on the Trust Intranet.

Amendments to the Strategy will be communicated as and when they occur.

Strategy Implementation, Monitoring and Review Show [+]Hide [-]

An annual infection prevention and control report will be provided to the Clinical Governance and Quality Committee on progress with implementation of the strategy and achievements against the Trust Action Plan supplemented by regular reports on operational priorities and progress.

Trust Annual Reports will contain a formal statement of infection prevention and control activity during the previous year as part of the Assurance Framework.

In order to support further development, the Trust will continue to benchmark performance against national and international best practice. This will include participation in both formal external assessments (including NHSLA and Healthcare Commission Standards) and informal processes, including those facilitated by Monitor and National Patient Safety Agency.  

This strategy document will be reviewed on an annual basis to ensure that it continues to reflect current priorities. The Director of Infection Prevention and Control will be responsible for the review of the Strategy.

Operational Responsibilities for Managing HCAI Prevention and ControlShow [+]Hide [-]

The Chief Executive has overall responsibility for infection prevention and control, on behalf of the Board of Directors of the Trust.  In addition, the Chief Executive is responsible for ensuring that the Trust is in a position to provide an overall assurance that the organisation has in place the necessary controls to manage its infection prevention and control.

In order to make such a statement, the Chief Executive and Board of Directors will need to provide evidence that the Trust’s Infection Prevention and Control Strategy is being implemented with systems and processes being regular reviewed and that, where deficiencies are identified, developments and improvement mechanisms are being put in place with the overall aim of continuous improvement.

A Non-Executive Director with a delegated responsibility for infection prevention and control sits on the Board and provides regular reports to the Trust Board of the organisation’s progress with the infection prevention and control.

Executive Team
Specific responsibilities are delegated to members of the Executive team as follows:

The Nursing and Patient Services Director has delegated responsibility to ensure the implementation and further development of the Infection Prevention and Control Strategy.

The Medical Director has delegated responsibility to support the implementation and further development of the Infection Prevention and Control Strategy. 

The Finance Director, Business Director and Operations and Development Director all share in the overall corporate responsibility to support the implementation and further development of the Infection Prevention and Control Strategy.

The Director of Infection Prevention and Control has specific responsibilities to advise the Board on all issues relating to Infection Control.

The Assistant Director-Quality will support the Directors of the Trust with implementation and development of this Strategy. The Assistant Director-Quality will be responsible for ensuring the integration of infection prevention and control with corporate clinical governance departments and systems, with the aim of developing and improving reporting, analysis and learning on all aspects of clinical governance and risk including health and safety, litigation and claims, and complaints. 

The Nurse Consultant for Infection Control will provide specialist knowledge and advice on all matters pertaining to infection control. The Nurse Consultant is responsible for:

  • All areas of infection control in relation to the production, review and implementation of local policies, protocols and guidelines with input from other appropriate clinical and non clinical staff
  • Leading the Saving Lives Campaign
  • Leading the Infection Prevention and Control Audit Programme
  • Developing and maintaining partnership working with other Infection Control Specialists, partner organisations and patient groups across the region.

Clinical Directors, Matrons and Directorate/Department Managers

Directorate Management Teams will be responsible for ensuring that the Infection Prevention and Control Strategy is implemented effectively across all services, which will include:

  • dissemination of the Strategy details and allocation of responsibilities for implementation to service managers and staff
  • identifying directorate specific infection control issues that might not have been addressed explicitly within the Strategy 
  • ensuring that infection prevention and control is incorporated into the Directorate/Department decision-making, service planning, performance management, project management and other related processes
  • establishing key infection control risk indicators which are monitored, reviewed and reported on a regular basis
  • ensuring that there are effective HCAI Prevention and Control processes in place in accordance with the Action Plan and that the appropriate level of local management action is initiated and completed
  • ensuring that infection prevention and control is included as a core item on all management team briefings/meetings
  • introducing infection prevention and control targets for managers as part of the performance and development appraisal process
  • reporting via performance and clinical practice and standards reviews on the Directorate infection prevention and control management performance in addition to new and emerging risks, major changes of priority on existing risks and key actions
  • ensuring that, where necessary, HCAI prevention and control risks are reported on the Risk Register. 


In addition to contributing to the responsibilities as outlined above, Matrons will have responsibility for:

  • leading and driving a culture of cleanliness in clinical areas
  • identification of HCAI prevention and control training needs to ensure that staff and volunteers are able to work safely and comply with Trust procedures, including mandatory training requirements
  • ensuring implementation of Trust HCAI prevention and control policies and procedures
  • ensuring that there is promotion of HCAI prevention and control awareness responsibilities amongst employees, service users, contractors and partners
  • introducing infection prevention and control targets 
  • leading Root Cause Analysis where required to promote learning and practice improvement
  • ensuring effective ward management by Sisters and Charge Nurses, which includes implementation of infection prevention and control policies, the provision of high standards of essential patient care and the maintenance of a safe clean and patient friendly environment
  • monitoring standards of cleanliness in clinical areas.

Directorate/Department Clinical Governance Leads

The Clinical Governance Lead will support the Directorate/Department Management Team in the delivery of effective HCAI prevention and control practice, education, audit and learning.

Infection Control Link Healthcare Professional

The Link Healthcare Professionals role is to act as a facilitator of good practice in infection control within their area of work. The link professional will:

  • attend infection control link meetings and feedback the information gained to colleagues
  • act as a resource to staff in their area of work
  • participate in standard setting and audit.

Responsibilities of all employees Clinical & Non Clinical (including temporary staff)

All staff have a responsibility to ensure patient safety through the implementation of the best possible infection prevention and control practice.

As an employee of the Trust, everyone has a responsibility for and a role to play in managing infection prevention and control, which includes:

  • Being aware of Trust infection prevention and control policy and procedure
  • Adhering to infection prevention and control as required within their job
  • Alerting managers to any infection control risks or environmental deficits within the service area that requires urgent attention
  • Participation in annual mandatory infection prevention and control training
  • Maintaining a clean and safe environment.

As the ethos of the Trust Risk Management Strategy is to develop an environment where the focus and culture is on reporting and learning from mistakes and near misses, formal disciplinary action will not usually be taken as a result of an infection control incident. However a serious breach of infection control policy or negligence causing loss or injury will be regarded as gross misconduct and will be considered within the Trust Disciplinary Procedure Policy. Disciplinary action may ensue where it is found that a member of staff has acted maliciously or recklessly. 

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