A Local Trust Perspective

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A Local Trust Perspective

• A Holmes
• Imperial College

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Harnessing Organisational Changefor Infection
Prevention
Hammersmith Hospitals NHS Trust Embedding
infection prevention across an organisation
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Why Organisational Change?

• Much expertise, not used effectively
• Small IC teams in huge Trusts (fire-fighting,
  without major strategic input)
• Not closely linked to management framework
• Systems based approach needed
• Sustainability
• To be a core part of corporate governance
• Create organisational learning
• Culture and behaviour of whole Trust to change

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• Policies, procedures, systems, protocols,
  education, audit, surveillance, care bundles,
  rapid testing, gel, risk analysis, ICPs, expert
  input etc etc- not enough..
• Need to..
• Put in the forefront of clinical care
• Change the organisations culture and behaviour
• Embed in the fabric of organisation

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Institutional and Cultural Barriers

• Multiple parallel hierarchies
• Complacency and acceptance of HAI
• Not in centre of clinical and managerial arena
• Consultant clinician autonomy, and resistance
  to standardising practice
• No perceived individual responsibility
• Lack of shared vision

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Professional Barriers

• Historically in UK
• -Status of infection control
• -Lack of public health leadership in acute
  trusts
• Clinicians and managers separation from IC
  responsibility (reinforced by separate IC
  service)
• Work on local engagement undermined by national
  directives
• Surveillance schemes outside (and duplicate)
  speciality organisations
• Lack of professional recognition

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Platform for Organisational Change

• Patient care the driver
• High Clinical profile essential
• Multidisciplinary engagement
• Multiple Leaders
• Collaborative
• Addressing local issues
• Chief executive backing
• Hammersmith Organisational Model for Infection
  Prevention (HOMIP)- an evolving, step by step,
  strategic approach

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Three Key Elements

• Directorate accountability
• Performance management
• Clinical incident reporting

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Directorate Accountability

• Follows decision making and funding
• GMs and Clinical Directors accountable
• Clinical leaders identified
• Reinforces ownership
• Embed specialist surveillance
• Facilitates targeted
• activity and rapid
• adoption of best practice

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Performance Management

• 2004-5 Infection Control targets in balanced
  score card for each clinical directorate
• Core outcome measures agreed ( MRSA blood stream
  infections, all MRSA new cases, C. difficile
  diarrhoea, hand hygiene, antibiotic use)
• Supplemental speciality specific measures
• Traffic light system
• Information on risks
• Reviewed 04-05 and
• further targets set 05-06

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Monitoring

• In the balanced score card of each directorate
  with monthly goals, data feedback and reports
• Directorates monthly performance meetings and
  action plans
• Trust Executive- summary data
• Standing agenda item - monthly Trust Clinical
  Governance meetings

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An example.
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Supplemental Specialist Targets

• Cardiothoracic SSI surveillance to be
• embedded in ICP
• Compliance with continuous SSI surveillance in
  orthopaedics
• Surveillance of dialysis
• associated BSI
• Neonatal BSI surveillance
• to be embedded
• Resistant gram negatives
• in ITUs ( MRAB)

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Clinical Incident reporting

• Counters complacency and acceptance
• Incidents investigated within directorates
• Each MRSA BSI generates a clinical incident
  report, investigated further by directorate. All
  BSIs next
• Post op infection in surgery, SSI in cardiotx to
  be introduced
• Reporting encouraged

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Next Steps

• Improved risk monitoring
• -bed moves
• -staffing levels
• -training attendance
• -environmental scores
• Consultant appraisals
• Multidisciplinary skills centre programmes
• Multidisciplinary leadership training

• Performance manage non-clinical directorates
• -Nursing
• -Information and IT
• -Human resources
• -Occupational health
• -Laboratory services
• -Estates and facilities

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Cultural Acceptability

• Use appropriate language
• Relevance and credibility- (and sound statistics)
• Recognise local and speciality specific issues
• Use existing systems and meetings
• Multidisciplinary skills
• training and standards
• Multiple internal
• communications
• and media activities
• A strategy of logical
• incrementalism Quinn 1980

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Impact?

• High profile on management and clinical agenda
• Directorates half days and work shops (Consultant
  attendance part of appraisal)
• Directorate led activity, annual reports, action
  plans
• Trust level presentations
• Use of clinical incident reporting, investigation
  and action
• Development of MSc for pharmacists
• Patient pathways/ICPs embedding best practice
• Much activity re BSIs

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BSI Control Measures

• Line care- standards for insertion and care
• Line related BSI clinical incident
• IV to oral and get lines out policies
• Vascular access leadership post
• Training/audit
• Performance management
• Targeted BSI surveillance
• Developed for high risk
• areas- in neonates and
• in dialysis (with CDC)

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Dialysis associated BSI

• Surveillance in day to day
• unit activity
• Programme of optimising
• vascular access (BSI 32 x
• risk with temporary line vs
• fistula Tokars AJIC 02)
• Enhanced infection control
• and line care
• BSI fallen significantly

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Dialysis associated BSI

• Surveillance in day to day
• unit activity
• Programme of optimising
• vascular access (BSI 32 x
• risk with temporary line vs
• fistula Tokars AJIC 02)
• Enhanced infection control
• and line care
• BSI fallen significantly

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Overall Trends in Dialysis Unit (31-month study
period)
 
p value lt 0.05 p value lt 0.01
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MRSA BSI

• Trust-wide MRSA BSI Episodes
• 2002 - 2003 124
• 2003 - 2004 125
• 2004 - 2005 81
• (Down 35)
• 2005- till Dec 48
• Yr end forecast 64
• (Down 21)
• (DH 05-06 target 87)
• Targeted action shifting from location and
  speciality to time of occurrence and patient
  pathways

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Evolution

• Infection Control
• Infection Prevention
• Health Care Improvement
• Protecting patients and staff,
• promoting a culture of safety,
• quality and value in health care delivery

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