Author: Improvement Programme Review Team

1
MRSA/HCAI Improvement Programme Shrewsbury
Telford NHS Trust Final Report
Author Improvement Programme Review
Team Version Final version Date 30th March 2007
2
Contents Section 1 1.1 Executive summary 1.2
Your key message immediate priorities 1.3 Data
analysis 1.4 Suggested target milestones 1.5
Actions for recovery improvement 1.6
Encouraging signs Section 2 2.1 Key
themes Findings and recommendations 2.2
People 2.3 Performance 2.4 Process 2.5
Practice Section 3 3.1 Recommended performance
reporting 3.2 Recovery plan

Links
Acknowledgements
Section 1
Section 2
Section 3
3
Contents Section 1 1.1 Executive summary 1.2
Your key message immediate priorities 1.3 Data
analysis 1.4 Suggested target milestones 1.5
Actions for recovery improvement 1.6
Encouraging signs Section 2 2.1 Key
themes Findings and recommendations 2.2
People 2.3 Performance 2.4 Process 2.5
Practice Section 3 3.1 Recommended performance
reporting 3.2 Recovery plan
Links
Content Page
Acknowledgements
Section 2
Section 3
4
1.1 Executive summary

• You met your target in year one but are
  struggling to meet it this year. There are
  pockets of good practice throughout the trust and
  a general desire to be proactive rather than
  reactive in reducing MRSA bacteraemias but this
  will need a direct focus and an immediate
  recovery plan implemented to reach trajectory and
  deliver your target.
• your 06/07 (April to November) trajectory is 22
  and you experienced 36 MRSA Bacteraemias
• the biggest challenge you have is identifying the
  root cause of your bacteraemias and this requires
  your immediate attention. Immediately carry out
  root cause analysis (RCA) to ascertain source and
  cause of all MRSA bacteraemias and backdate for
  the last three months
• your data shows that 77 of your bacteraemias
  occur after 48 hours, of which 33 are within
  Augmented Care. You need to ensure there are no
  avoidable MRSA bacteraemias in Augmented Care
  with immediate effect and maintain this
• you need to demonstrate a 50 improvement in your
  top 5 specialties in the next 6 months, i.e
  general medicine, general surgery, nephrology and
  general intensive care unit
• your data suggests that 23 of your bacteraemias
  occur pre-48 hour. Carry out immediate bespoke
  analysis of pre-48 hour MRSA bacteraemias for
  patients admitted 3 months prior to having
  acquired MRSA in hospital. Work with partners to
  understand cause, and reduce number of pre-48
  hour cases. Reduce by at least 50 by May 07 and
  by at least a further 50 by August 07
• ensure month on month improvements in all areas
• You achieved your MRSA trajectory target last
  year but breached the MRSA trajectory target this
  year. The organisation, as a whole, needs to
  maintain an attitude of awareness and diligence
  to assist recovery against trajectory. Commitment
  to infection prevention and control is evident
  and the sense of importance and urgency held by
  the Chief Executive needs to be translated to all
  levels of the organisation. Your new Divisional
  structure will give you the opportunity to
  promote joint working and enhance communication
  across the organisation. Nominated clinical leads
  are required for all specialties to own and drive
  this initiative, moving away from a culture
  whereby the Infection Control Team led and owned
  all that was associated with infection prevention
  and control. Ensuring everyone understands their
  role, responsibility and accountability is also
  fundamental. Utilisation of the High Impact
  Interventions (HIIs) in specific and focused
  areas as highlighted by the improved RCA will
  lead you to make progress faster. Finally,
  improvements in screening and the use of
  antibiotics will all play an important part.
  Audit and surveillance are key to measuring your
  progress against infection prevention and control
  and should be formalised and fed back to the
  clinical areas as soon after completion as
  possible.
• We have highlighted a number of areas in this
  report which should improve your performance
  towards reducing the levels of MRSA bacteraemia.
  The review team has included in this report key
  performance improvement statements with
  timescales for specific improvement outcomes. You
  need to embed within the culture that it is an
  insult to give patients infections.

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1.2 Your key message and immediate priorities

• Your key message is
• Accountable and responsible care delivery will
  support a reduction in healthcare-associated
  infection
• Immediate implementation of the following 3
  actions will start you on your journey of
  reducing your MRSA bacteraemias (please see the
  embedded document in section 1.5 for your further
  actions)
• initiate root cause analysis within 24 hours of
  bacteraemia identification and complete and
  feedback to your multi-disciplinary team within 5
  days
• develop and share performance information that is
  understood and owned by all levels of the
  organisation
• instil a culture that reducing MRSA bacteraemias
  is everyones responsibility

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1.3 Data analysis

• data in the following slides are from your
  submitted MESS data December 2005 to November 2006

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1.3.1 What is the direction of travel?
The challenge is significant to be where you need
to be in March 2008
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1.3.2 Number of MRSA cases split by Specialty
- A look at your problem areas
Areas to target are General Medicine General
Surgery.
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1.3.3 Number of MRSA cases split by Pre- and
Post-48 Hours
The table shows that in the last 12 months, 23
of your bacteraemias were pre-48hr cases. N.B.
The national average is 28.
Suggestion look at your pre 48 hour patients
and see if they have been to hospital in the
previous 3 months from when their MRSA
Bacteraemia was identified
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1.3.4 Number of MRSA cases by Age Band
The breakdown of your MRSA cases by age band
It is recommended that you compare this MRSA Age
band profile with your admission data (esp. in
the higher age bands) to ensure that no age band
has a significant disproportionate number of
cases.
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1.3.5 What is the scale of your challenge?
Your MRSA figures have recently been above
trajectory. This situation needs to be reversed.
Actual (A)
Trajectory (T)
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1.3.6 Number of MRSA cases split by Augmented
Care Non-Augmented Care
The table shows that in the last 12 months, 33
of your cases occurred in Augmented Care. N.B.
The national average is 24. The target is to
have zero avoidable infections in Augmented Care.
The table below provides a breakdown of where
your augmented cases are occurring.
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1.4 Suggested target milestones
Actions Milestones
A robust recovery plan is required immediately to deliver agreed monthly trajectory by May 2007 Immediately carry out robust root cause analysis to ascertain the source and cause of your MRSA bacteraemias and identify any trends You can make significant improvement in MRSA bacteraemia by at least 50 in General Medicine, General Surgery and renal dialysis by end of May 2007 Carry out bespoke analysis of pre-48 hour MRSA bacteraemias and determine how many of them have had previous hospital admissions in the previous three months Work closely with partner organisations to reduce number of pre-48 hour MRSA bacteraemias. Instigate joint root cause analysis to uncover source. Avoidable MRSA bacteraemia in Augmented Care should be zero To get on trajectory and then move further faster In the six months between June 06 and Nov 06you had 15 cases in General Medicine. Reduce this by at least 50 to 7 or less by May 07 six in General Surgery. Reduce this by at least 50 to three or less by May 07 You have reported four cases in renal dialysis in the past 3 months. Reduce this by at least 50 to two or less by May 07 Reduce pre-48 hour cases by 50 by May 07 Ensure you have zero avoidable cases in Augmented with immediate effect
Further reduction of MRSA bacteraemias by at least 50 in General Medicine, General Surgery and renal dialysis by end of August 2007 Further work with partner organisations to reduce number of pre-48 hour MRSA bacteraemias by a further 50 by August 2007 Maintain zero avoidable MRSA bacteraemias in Augmented Care Month on month reduction in MRSA bacteraemias beyond trajectory Reduction In Breaches by May 2007 General Medicine from 10 to five or less by August 07 Nephrology from four to two or less by August 07 General Surgery from three to one or less by August 07 Reduce pre-48 hour cases by 50 by August 07 Maintain 0 by August 07

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1.5 Actions for recovery and improvement

• We have worked through some of your actions that
  we suggest need to be undertaken in the short
  term. These are based on our findings during our
  2 day review.
• You may wish to expand on these as you develop
  this action plan locally for the medium to long
  term and consider the wider findings in section 2
  of this report

Double Click to Launch
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1.6 Encouraging signs

• the Chief Executive and the Trust Board now have
  a strong focus on patient safety and improving
  the patient experience
• there is a very dedicated infection control team,
  members of which are valued and respected across
  the trust.
• the Director of Infection Prevention and Control
  is highly regarded throughout the trust by all
  interviewed staff groups
• the organisation has many dedicated clinicians
  and staff, some working in less than ideal
  environments, and all committed to making a
  difference
• the outreach team have a model for early warning
  signs for sepsis that could be adapted for MRSA
• there is evidence of some early root cause
  analysis being undertaken across the trust
  despite the challenges of IT support
• there are some good examples of practice in ITU,
  including the use of gloves and aprons, hand
  hygiene, dedicated CVC management and packs and
  general compliance with EPIC guidelines.

continued/
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1.6 Encouraging signs
/continued

• there are several education streams for awareness
  raising, clinical training and clinical skills
  updating accessible for staff
• standards of cleaning were reported and observed
  to be very high within the trust despite
  benchmarking of domestic staffing level
  demonstrating low numbers compared with other
  trusts

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Contents Section 1 1.1 Executive summary 1.2
Your key message immediate priorities 1.3 Data
analysis 1.4 Suggested target milestones 1.5
Actions for recovery improvement 1.6
Encouraging signs Section 2 2.1 Key
themes Findings and recommendations 2.2
People 2.3 Performance 2.4 Process 2.5
Practice Section 3 3.1 Recommended performance
reporting 3.2 Recovery plan
Links
Content Page
Acknowledgements
Section 1
Section 3
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2.1 Key themes
Performance
People
Performance frameworks Performance framework
ownership Use of data Performance data
Audit Pre-48 hour cases
Leadership Training Directorate
responsibilities and ICT Roles responsibilities
MRSA bacteraemia reduction
Processes
Practices
Hand hygiene High impact interventions Screening
decolonisation Antibiotics Root cause analysis
Bed management and transfers Storage space

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2.2.1 People
Leadership
Findings

• the Chief Executive is clearly committed to
  tackling MRSA and meets with the DIPC for a one
  to one meeting every month, receives monthly
  trajectory data and is informed of every
  bacteraemia as it occurs
• the review team is not convinced that the sense
  of urgency and importance and ownership is
  embedded at all levels of the organisation
• many staff and managers expressed the view that
  the trust had only just taken stock of its
  position with regard to MRSA relying on the fact
  that it achieved its trajectory target last year
• the only clinical champion for infection control
  identified by staff in the trust was the DIPC,
  nominated leads are not in place in all
  specialties

Recommendations
Chief Executive, Trust Board, DIPC and Infection Control Team commitment to be supported by a high profile clear communication strategy of the key messages, consistent action, and role modelling to signal the required change and the importance and urgency of the agenda
Ensure MRSA target delivery is of equal importance to other key targets and translated to directorates, teams and individuals objectives accordingly, to ensure delivery and then performance managed
Reducing infection must be seen to be everyones business with clear responsibly, accountability and performance management
Appoint medical clinical leads within each specialty and performance manage specific objectives
Play a key role in the DH MRSA Programme Performance Improvement Network. Disseminate timely, accurate and appropriate information to all staff to encourage a culture of continuous learning, improvement and sharing of best practice
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2.2.2 People
Training
Findings

• the trust has several arms responsible for
  clinical skills training and updating. However
  there is no collaborative approach to these, nor
  are they standardised or consistent across the
  trust
• infection control team are responsible for the
  delivery of all mandatory training, stretching
  available resources
• there is a need to review the training and
  ongoing compliance with aseptic procedures and
  antibiotic prescribing

Recommendations
Deliver a trust-wide clinical skills training strategy and consider alternatives to training techniques such as videos. Clarify specific objectives for those with responsibility and accountability
Monitor training to observe application into practice and modify accordingly. Consider devolving responsibility for day to day infection control and prevention to clinical level and make better use of link nurse role
Link antimicrobial prescribing to a clear policy. Review the current training in antibiotic/antimicrobial prescribing and ensure availability for all medical staff including juniors
Deliver both multidisciplinary and junior doctor aseptic procedure training and then audit to gain local ownership and harvest maximum gains
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2.2.3 People
Directorate responsibilities and
infection control team
Findings

• the review team was unable to find widespread
  evidence of responsibility and objectives for
  infection prevention and control at Divisional
  level
• there are many dedicated matrons and link nurses
  however the DIPC is attempting to drive this
  largely on his own with limited support
• the infection control team are unclear how they
  will be integrated into the performance
  management framework

Recommendations
The focus of activity must be based around directorates, with the ICT enabling rather than undertaking the bulk of activity. Clinical leads within each directorate or speciality will be key to successful implementation, supported by clear objectives and outcome measures
Ensure that clinical leadership is engaged at Divisional level, with clear responsibilities and accountabilities for engagement, reporting and delivering improvements. Responsibilities need to be explicit in clinical director job descriptions
Achieving the target needs to be everyones business. Broaden engagement of Divisions and management teams by strengthening performance management arrangements, setting specific Divisional and sub-divisional team targets using a balanced score card approach to hold teams to account. Immediately identify a nominated lead for each speciality and ensure that the role is underpinned with measurable objectives and a reporting framework
Clear responsibilities and accountabilities must be underpinned with focused objectives for all members of the directorate including clinical directors, clinical managers,and link nurses
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2.2.4 People
Roles responsibilities
Findings

• whilst there is evidence of infection control
  responsibilities within some job descriptions and
  objectives, individuals and teams did not always
  appear to understand what that meant for them,
  what they had to do differently, and where
  responsibilities were shared or individual
• roles and responsibilities were not always fully
  understood in relation to the MRSA target

Recommendations
Accelerate plans to formalise infection control in staff job descriptions and discuss thoroughly at appraisals and personal performance development meetings, in addition to team or directorate meetings and performance manage this
Ensure that consultants are aware of their accountability and responsibility for the infection control practice of their juniors and are appropriate role models. Escalate their engagement in clinical governance to deliver updates and key messages
Re state the roles and responsibilities and accountabilities of the consultants, infection control and matrons to ensure understanding of individual and shared responsibilities and performance manage through regular 11s
Ensure the Medical Director has the detailed data he needs to be effective in his role
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2.3.1 Performance
Performance frameworks
Findings

• an adequate level of MRSA bacteraemia data is not
  embedded in the Board performance reporting
  arrangements
• targets are not set for each Division to deliver
  against and own and embed within core business
• the current forums run to address MRSA issues do
  not have appropriate remits or representation by
  clinicians or multidisciplinary teams to ensure
  action and delivery

Recommendations
Use the new Divisional structure to develop bottom up plans to combat MRSA especially in identified hotspot areas
Include information on where hotspots are in Board papers and include a monthly update report of actions being taken to address HCAI
Each Division to have a target set for MRSA bacteraemias each month against which its performance should be measured even if it zero. This includes a breakdown by clinical teams and individual clinicians in a timely manner as information becomes available
Divisions to be held accountable through performance frameworks for its performance against the MRSA bacteraemia reduction target
Each MRSA bacteraemia should be treated as a breach and performance managed
Review the current mechanisms of engagement of clinicians and multi-disciplinary teams in the agenda and ensure appropriately established. For clinicians, incorporate in the peer review, service mortality, morbidity review meetings
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2.3.2 Performance
Performance framework ownership
Findings

• whilst progress has been made to focus activity
  within some specialties, the infection control
  team appear to be undertaking the majority of the
  work

Recommendations
Medical Director, Deputy Chief Executive and DIPC should work together to develop a strategic approach to reduce HCAI and to agree their individual roles, responsibility and actions
Responsibilities need to be explicit in clinical director job descriptions and job plans
Increase engagement of Divisions, identify clinical leads within each Division or speciality and implement action plans supported by the ICT
Agree measurable outcomes with objectives that are focused and incorporated within the performance management outcomes for the directorate
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2.3.3 Performance
Use of data
Findings

• data related to MRSA and other targets is
  discussed at every public board meeting
• the trust intend to develop key performance
  indicators for infection prevention and control
  as part of the performance management
  arrangements within the new divisional structures
• feedback from root cause analysis can often be
  slow and of limited value above identification of
  obvious factors.
• follow up action is not always monitored
• poor documentation with relation to intravenous
  line insertion was observed by the review team

Recommendations
Raise awareness of the value of MESS data in better targeting of interventions. Report all MRSA bacteraemias as a critical incident or Serious Untoward Incident. Integrate into governance and risk arrangements. Undertake a more robust root cause analysis on each bacteraemia to understand cause and source
Review the current root cause analysis approach used and consider using the newly developed NPSA RCA tool or components of it to be able to identify trends in individuals, teams, environmental issues, sources, case mix issues, collective training and development needs
Ensure timely reporting of root cause analysis findings and appropriate feedback, across the health economy where appropriate. Performance manage and monitor and ensure interventions are targeted
Develop a standardised method for documentation of peripheral line insertion and daily assessment performance manage completion daily
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2.3.4 Performance
Performance data
Findings

• your data shows that 33 of your MRSA
  bacteraemias are within Augmented Care. This is
  above the national average (24)
• other hotspot areas are General Medicine (51)
  and General Surgery (22)
• 23 of bacteraemias were diagnosed as being
  present within 48 hours of admission. This is
  below the national average (28)

Recommendations
Understand sources of your bacteraemias both pre- and post-48 hours to enable focus on the hot spots. Provide basic information and simple messages to staff on MRSA and mechanism of transfer. Adopt more rigorous and evidence based approaches in using data in order to provide the required focus, create the sense of importance and urgency required. Gain greater engagement across the trust and provide assurances to the Board
Use robust and timely enhanced surveillance data to identify which wards and departments have the greatest numbers of bacteraemias and interrogate own trust data to understand sources. Use clinical leads to overcome any data credibility issues.
Ensure a fit for purpose IT system is in place which supports infection control activities in respect of providing information for surveillance and monitoring. Use rigorous methods to identify which areas in General Medicine, Geriatric Medicine and General Surgery require focus in addition to the attention that renal services should be receiving
Using the HIIs within these areas should enable faster progress to be made. Set local reduction targets, dates for attainment and owners. Focus on your hotspots
Complete, sign off and submit MESS data weekly with situational reports and share across the organisation for early use in learning and performance management
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2.3.5 Performance
Pre-48 hour cases
Findings

• 23 of bacteraemias were diagnosed as being
  present within 48 hours of admission, this is
  below the national average (28)

Recommendations
The pre-48 hour group of patients would suggest that some of this group are readmissions or frequent attenders with chronic conditions. Use the root cause analysis tool to identify the source and any contributing factors and look to see if patients have been in hospital 3 months prior to contracting the bacteraemia
Work with the PCTs on further engagement and management of those cases identified
You should address specific issues in Nephrology that may relate to efficiency or permanent vascular access or other dialysis practices, including screening and preventative decolonisation
Once the the source of the pre-48 hour bacteraemias has been identified, review screening and decolonisation protocols in light of the findings. Your figures are suggestive of re-admissions and may require a health economy approach with support from the SHA and PCT
Escalate the work with the health economy partners to reduce the pre-48 hour cases
Ensure RCA of your pre-48 hour cases are fed back into your organisation in a timely manner
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2.3.6 Performance
Audit
Findings

• whilst the review team was informed of the many
  audits that had been conducted, there were
  numerous ward staff who were unaware of the
  results from these audits
• there did not appear to be a mechanism for
  sharing learning from the audits within or across
  specialties nor with future induction, education
  and training, personal development plans and
  performance monitoring frameworks
• most audits related to HCAI were undertaken by
  the infection control team

Recommendations
Use the root cause analysis tool and hot spot areas to focus work for High Impact Interventions and audit
Structure an audit calendar for the organisation and feed the results into directorate performance management to ensure actions are monitored and owned
Establish a mechanism for sharing and spreading good practice and learning across the trust
Link the results of audit into future induction, education and training, personal development plans and performance monitoring frameworks
Involve link nurses and clinical nurse managers more fully in audit activity, feedback and action
Ensure small frequent audits are undertaken when you are focusing on changing culture and practice. Timely feedback is key to ensuring sustainable improvement
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2.4.1 Process
Bed management and transfers
Findings

• the review team were made aware that there was a
  new devolved structure for bed management within
  the organisation
• the trust has wider issues in terms of flow and
  bed management in relation to whole system demand
  management

Recommendations
Ensure bed management policies minimise patient movement and that these are accessible, applicable and adhered to. Due to the numbers of outliers, consider practice and policies in relation to screening and decolonisation for high risk patients. Review the processes for identifying patients requiring isolation or precautions on wards and spread good practice. Ensure at-risk patients are ring fenced or segregated. Review the input and attendance of the infection control team at bed management meetings.
Ensure all staff are aware of and know how to access the flag system on the computer for current and previously MRSA positive patients
Continue to work on improving flow and efficiency and work with partners on securing a whole system solution which incorporates demand management, real alternatives to admission for relevant patients and proactive seven days a week discharge planning
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2.4.2 Process
Storage space
Findings

• on the whole, clinical areas visited by the
  review team appeared clean and uncluttered
• one clinical area observed to present an issue
  with space and storage was the renal dialysis
  ward at Shrewsbury. Patient areas were very close
  together with little room between one patient and
  the next. It is recognised this is not conducive
  to good infection control management and
  additional stations have been opened at Telford.
  In addition the trust is actively pursuing
  further investment for more stations.

Recommendations
Ensure sinks are accessible for all to use
Find alternative storage space for unused equipment
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2.5.1 Practice
Hand hygiene
Findings

• audits of hand hygiene have shown a variable rate
  of compliance of across staff groups within the
  organisation 88 for nursing staff and 78 for
  medical staff.
• for the most part, the review team found that the
  alcohol hand rub or gel was available at the
  point of care delivery, with the exception of one
  or two observed areas

Recommendations
Continue to state the message to all staff that improved compliance with hand hygiene is a priority for the trust and set a target for compliance of 95 across the trust. Ensure all relevant staff understand the rationale behind the need to use gloves, when to wash hands, and when to use gel or rub. Audit through the High Impact Interventions and performance manage to ensure all staff, whether touching a patient or not, decontaminate their hands on entry and exit to clinical areas and always at the point of care
Increase the frequency of hand hygiene audits to be undertaken by clinical managers, publish the results and take any appropriate action. Promote the use of alcohol hand rub as the gold standard for routine hand hygiene when appropriate
Escalate the education and awareness, training and auditing, particularly in areas identified by the root cause analysis as the main areas of focus
Undertake daily/weekly audits in all wards and staff groups who do not adhere to the 95 hand hygiene compliance
Ensure results are fed back weekly to all staff
Consider using league tables as a feed back measure
32
2.5.2 Practice
High impact interventions
Findings

• Some High Impact Interventions are used in some
  of the critical care areas. However the High
  Impact Interventions are not owned widely across
  the trust and are not always being implemented in
  response to the RCA, and could therefore be more
  focused

Recommendations
Undertake robust root cause analysis and prioritise the implementation of the High Impact Interventions for relevant areas
Ensure the utilisation of the High Impact Interventions are owned by the directorates, with clear responsibility and accountability and linked to governance and performance. Performance manage and audit documentation
Observational audit and challenge at point of insertion of lines to become everyday practice. Review and target the training programmes, link audits to individual development programmes
33
2.5.3 Practice
Screening decolonisation
Findings

• there is confusion in some areas around who and
  when to screen
• there is a lack of consistency in applying
  decolonisation for high risk patients
• it was suggested to the review team that some
  elective patients who were screened at
  pre-assessment were not decolonised prior to
  admission

Recommendations
Use national evidence and the recent DH guidance to review and re-launch the screening and decolonisation policies. Provide consistent clarification to staff in relation to screening of all high risk patients (surgery, critical care, elderly care, regular or repeat admissions and admissions from nursing home or residential care homes) as recommended in national guidance (Guidelines for the Control and Prevention of MRSA in Healthcare Facilities by BSAC, HIS, ICNA working party on MRSA)
Use Patient Group Directives (PGD) for decolonisation of MRSA positive patients
Ensure the policies are interpreted and adhered to appropriately and audit compliance. Performance manage and feed back to Divisions and departments
Consider rapid screening for MRSA following business case review
34
2.5.4 Practice
Antibiotics
Findings

• there is evidence that long courses of
  antibiotics are given
• the trust has an antibiotic pharmacist for two
  sessions only
• two sets of antibiotic guidelines exist across
  the trust
• there is no policy for changing from intravenous
  to oral antibiotics
• many patients were treated with intravenous
  antibiotics for longer than 2-3 days
• large amounts of ciprofloxacin

Recommendations
Decrease use of quinolones Consider only prescribing by referral to the microbiologist
Introduce intravenous to oral switch policy after 2-3 days
Review pharmacy skill mix workforce and ways of working with microbiology to deliver maximum gain
Implement automatic stop policy
Empower nurses to challenge antibiotic prescribing and duration
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2.5.5 Practice
Root cause analysis
Findings

• root cause analysis is currently undertaken by
  the DIPC but is not as robust as future
  requirements dictate. It is not always
  disseminated to the clinical teams in a timely
  manner, therefore it is not always owned by the
  Divisions and clinical teams
• there is a reluctance to take ownership for root
  cause analysis at directorate level
• appropriate and timely action is not always taken
  as a result of the analysis of each MRSA
  bacteraemia

Recommendations
Review the rationale and importance of RCA and roles, responsibilities and accountabilities within the trust and communicate to the trust Board
Review the current RCA approach used and develop a more robust approach. Consider using the NPSA RCA tool or components of it to be able to identify trends in individuals, teams, environmental issues, sources, case mix issues, collective training and development needs, etc. Commence RCA within 24 hours of confirmation of an MRSA bacteraemia and feed back of findings and action to clinical teams within 5 days.
Once a more robust approach has been developed and piloted, assign responsibility for undertaking RCA to an individual within the relevant Division who has the time, skills and status to investigate, action and follow-up all cases supported by infection control, DIPC and the risk management team
Ensure timely reporting of RCA findings and appropriately feed back across the health economy where appropriate. Performance manage and monitor and ensure interventions are targeted
Each relevant consultant to report to their Divisional governance group on the findings of RCA and action taken to support learning. Performance manage through existing governance structures
Complete the risk factors page on MESS to ensure a robust data set for learning is available to your organisation
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Contents Section 1 1.1 Executive summary 1.2
Your key message immediate priorities 1.3 Data
analysis 1.4 Suggested target milestones 1.5
Actions for recovery improvement 1.6
Encouraging signs Section 2 2.1 Key
themes Findings and recommendations 2.2
People 2.3 Performance 2.4 Process 2.5
Practice Section 3 3.1 Recommended performance
reporting 3.2 Recovery plan
Links
Content Page
Acknowledgements
Section 1
Section 2
37
3.1 Recommended performance reporting

• Report on actions for recovery and improvement
  through
• the use of the MRSA improvement programme actions
  for recovery and improvement template to track
  progress and report performance into existing
  governance structures
• population of the non-mandatory enhanced
  facilities on the HPA MESS reporting system to
  track and analyse key problem areas
• undertake robust root cause analysis and share
  widely- where are the sources of your
  bacteraemias?
• body site and cause, eg leg wound, CVC lines etc
• which wards are your hotspot areas?
• are there any trends with specific clinicians?
• where do you need to focus your efforts?
• what clinical practice/culture needs to change
• Monday morning sign off (with a situational
  report) of all your previous weeks bacteraemias
  and upload to MESS every Monday afternoon
• call or meet with the SHA lead, DH MRSA programme
  manager, trust implementation lead and others
  from your organisation as appropriate (weekly to
  begin with)
• three month review with members of the PCT, SHA,
  Department of Health and trust to demonstrate
  grip and delivery
• this report needs to be put on the agenda and
  discussed at your open trust Board meeting

38
3.2 Recovery plan

• your recovery plan is embedded below. Can you
  please populate in light of your recent learning,
  our visit and this report. Please then arrange
  for it to be signed by your Chief Executive and
  your host PCT Chief Executive and send to your
  programme manager, kath.harris_at_dh.gsi.gov.uk and
  Sally Batley, Deputy Head, MRSA Improvement
  Programme, sally.batley_at_dh.gsi.gov.uk
• use the MRSA improvement programme actions for
  recovery and improvement (embedded in section
  1.5) to track progress and report performance
  into existing trust governance structures

39
Acknowledgements

The review team would like to acknowledge all
staff within Shrewsbury Telford NHS trust for
their time, honesty and hospitality during the
preparation and delivery of this intensive two
day review

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Section 1
Section 2
Section 3
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Your key message and immediate priorities

• Your key message is
• Accountable and responsible care delivery will
  support a reduction in healthcare-associated
  infection
• Immediate implementation of the following 3
  actions will start you on your journey of
  reducing your MRSA bacteraemias (please see the
  embedded document in section 1.5 for your further
  actions)
• undertake root cause analysis within 24 hours of
  bacteraemia identification and complete within 5
  days
• develop and share performance information that is
  understood by all levels of the organisation
• instil a culture that reducing MRSA bacteraemias
  is everyones responsibility