Healthcare Environment Inspectorate Framework: Update to NHS QIS Board NHS Quality Improvement Scotland April 2009

Context for the Healthcare Environment Inspectorate Scotland (HEIS) *Annual epidemiological report on communicable diseases in Europe 2008 SOURCE: Team analysis ▪ Hospital acquired infections are a serious issue in Scotland with high HAI prevalence in comparison to EU countries* ▪ The Vale of Leven incident prompted a review of HAI in Scotland that identified a number of shortcomings in governance and leadership ▪ The Cabinet Secretary announced the creation of the Healthcare Environment Inspectorate (HEIS) to – Carry out site visits of every Scottish acute hospital – Ensure highest standards of infection prevention, control and cleanliness ▪ NHS QIS has been : – Defining the scope and purpose of the inspectorate – Developing an inspection framework – Testing and refine the inspection framework with key stakeholders – Outlining the implications of HEIS for relationships with stakeholders in NHSScotland – Outlining the organisational implications of the inspectorate for NHS QIS Healthcare Associated Infection Focus of Last Six Weeks

Purpose of HEIS SOURCE: Team analysis Improvement ▪ Catalyse improvement in infection prevention measures across Scotland through an inspection framework leading to a decrease in HAIs and their consequences over time, ▪ Build on and contribute to the existing improvement agenda ▪ Provide assurance to the public, NHS Boards, and the Scottish Government that healthcare associated infection (HAI) standards in acute hospitals are high and that any HAI issues are being tackled Assurance

HEIS will primarily support the assessment element of the improvement cycle, though it will inform the whole integrated cycle Guidance Implementation support Assessment QIS Integrated cycle for improvement

Six principles of the inspectorate philosophy SOURCE: Team analysis ▪ The frequency and intensity of monitoring and inspection proportionate ▪ and risk based Risk based Impact focused ▪ Resources will be focused on areas that will yield the greatest improvement in performance and provide the most assurance to the public, NHS Boards and the Scottish Government Maintaining board accountability ▪ Boards will remain accountable for HAI performance and for fulfilling any statutory requirements Transparent and open ▪ The inspectorate will use a transparent method for inspecting hospitals, involving the public in inspections and publishing the results of inspections shortly after they are completed ▪ The inspectorate will not disclose confidential information without prior agreement (unless it has a statutory obligation to do so) Minimising duplication ▪ The inspectorate will use data already collected to the greatest extent possible in its operations and will not request information that a Board should not already be reviewing as part of its operations ▪ The inspectorate will collaborate with a range of organisations (inc scrutiny and regulatory bodies) to minimise duplication of activity and will evolve over time to ensure it remains efficient and effective Supporting improvement ▪ The Inspectorate will actively contribute to, and enhance, the broader quality improvement agenda

HEIS inspection framework has five components SOURCE: Team analysis Site visits Monitoring Follow-up development and intervention Reporting Escalation ▪ Monitors quantitative and qualitative data to support risk assessment and overall inspection cycle, using analysis of self assessment ▪ Visit hospital sites to validate self assessment and gather first hand feedback on HAI performance (visits hospitals at least once every three years) ▪ Inspections may be announced or unannounced and may be focused on specific themes ▪ Following visits, requires Boards to update improvement plan to address any identified deficiencies ▪ Monitors progress against updated improvement plan ▪ Publishes reports on: – Monitoring – Hospital inspections – Board performance – National performance ▪ Escalates to SGHD performance managers or regulators where necessary The inspectorate will also inform the setting of HAI standards /policy HEIS Role

Proposed monitoring metrics (1/2) Weekly ▪ Number of MRSA positive patients/% of patients MRSA positive ▪ Number of MRSA bacteraemias/% of patients with MRSA bacteraemias ▪ Number of C. diff positive patients/% of patients C. diff positive ▪ Bed occupancy Quarterly ▪ Deaths per infection ▪ Time to treatment for infected patients ▪ Antibiotic prescribing compliance ▪ % MRSA positive patients isolated ▪ % C. diff positive patients isolated ▪ Cleanliness compliance ▪ Handwashing compliance ▪ Patient complaints ▪ Staff complaints/staff survey results Source:Team analysis Primary metrics – reviewed by HEIS

Proposed monitoring metrics (2/2) Annually ▪ Time from outbreak triggers to management starting emergency procedures (e.g., declaring outbreak to HPS, ward closures) ▪ % patients receiving HAI risk assessment on admission ▪ Age of infrastructure ▪ Capital investment per bed per year ▪ Maintenance spend per bed per year ▪ Number of beds per 1000 sq ft ward floorspace ▪ Patient age and case mix by specialty ▪ % nurses completed HAI training in last 3 years ▪ % staff screened for MRSA in last year Primary metrics – reviewed by HEIS Source:Team analysis

1HEIS will draw from a permanent pool of associate inspectors. Permanent pool will allow HEIS to train inspectors in inspection methodology 2 Experts will be invited as required (e.g., will join this team from 3-4pm on day 2 because of recent concerns about airborne spread of infections in ITU) 3Inspection team may take photos, record video, inspect documents, or speak to patients and staff at any stage of the site inspection Inspection team HEIS employees ▪ Lead inspector ▪ Inspector ▪ Project manager Other inspectors ▪ Associate inspector: Public representative 1 ▪ Expert inspector: Ventilation expert 2 Observer ▪ Chief Executive from Board X Team ATeam B Walk round and general review Inspect ward 15Inspect ward 16 Inspect operating theatres Lunch (inspection team only) Inspect ward 26Inspect ward 12 Staff/patient open session Inspection team meeting Give informal feedback to Chief Executive Day 1 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm Team ATeam B Staff interviewsPatient interviews Patient interviewsStaff interviews Staff interviewsPatient interviews Lunch (inspection team only) Inspect ward 2Inspect ward 5 Inspect ward 4Inspect ward 8 Inspect maternityInspect ITU Inspection team meeting Informal close and feedback with Chief Executive and senior team Day 2 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm … Example topics to cover What could an announced initial site visit look like? Source:Team analysis Introduct- ions and objectives Antibiotic prescribing Ccleanlines s Staff attitudes Initial findings/ immediate concerns Evidence of good practice Bed spacing Ventilation Findings and next steps Ongoing concerns

Site visit complete 1 week2 weeks3 hr meeting Within 16 weeks Depends on severity of issues Proposal for post site visit process Serious issue identified Immediate escalation to relevant body Immediate2 hr meeting HEIS/Board Meeting Inspection report published Within 4 weeks of inspection Updated improvement plan published Feedback to hospital following visit Board updates improve- ment plan in response to Report Follow-up by HEIS Draft report presented to Board for review Formal mediation session with Board to review accuracy Board circulates draft internally and prepares responses if needed Formal meeting between HEIS and Board to test improvement plan “fit for purpose” Internal HEIS review of draft report 1 week 12453

Report Source:Team analysis Proposed reporting and frequency ▪ HEIS monitoring metrics with Board commentary (including self-assessment) Monitoring Site visit cycleBoardNational ▪ Electronic/internet ▪ Quarterly ▪ Summary of inspection findings ▪ Recommendations for action ▪ Grading ▪ Inspectees ▪ Electronic/internet ▪ Local healthcare providers ▪ Boards ▪ Scottish Government ▪ Final report published within 6 weeks of site inspection ▪ Every hospital will be inspected at least twice every 3 years ▪ Summary of inspection findings by board ▪ Recommendations for action ▪ Boards ▪ Electronic/internet ▪ Scottish Government ▪ Annual ▪ Summary of inspection findings ▪ Recommendations for national HAI framework ▪ Scottish Government ▪ Electronic/internet ▪ Annual Still to be finalised ContentDistributionFrequency

▪ Scottish Government ▪ HSE ▪ Procurator Fiscal ▪ Governance and support organisations (e.g. QIS) ▪ Scottish Government ▪ Governance and support organisations (e.g. QIS) ▪ Scottish Government Trigger rationale Site inspection complete Feedback to hospital following visit Board prepares improve- ment plan in response to Report Follow-up by HEIS Draft report presented to Board for review Board circulates draft internally and prepares responses if needed Formal meeting between HEIS and Board to test improvement plan “fit for purpose” Internal HEIS review of draft report Trigger points throughout post-inspection process will ensure issues are resolved within a reasonable time-frame When will escalation be triggered? Escalation to: Formal mediation session with Board to review accuracy ▪ Scottish Government ▪ HSE ▪ Procurator Fiscal Source:Team analysis Serious issue identified during inspection Board improvement plan inadequate or not produced within required time-frame Implementation of improvement inadequate or not within required time-frame Inadequate implementation of action plan poses threat to public health

There are a number of important HEIS design decisions that the board should consider ▪ Should the inspectorate focus on understanding current compliance with HAI standards or make a judgment of ability to maintain compliance in the future? ▪ How should the inspectorate approach its monitoring role? ▪ What role should the inspectorate seek to play in the broader Scottish quality improvement agenda? ▪ Should the inspectorate explicitly grade hospitals? ▪ How could the promise of public involvement in HEIS be best delivered? 1234 Open design issues 5

Next steps in relation to HEIS 1234 Current Activity 5 ▪ Test framework with key stakeholders ▪ Test and finalise details of inspection framework through scenario testing – Monitoring – Site visits – Follow-up – Reporting ▪ Draft Concordat proposal and test with HAI related bodies ▪ Prepare for and run prototype inspection regime in two pioneer sites in June ▪ Full implementation by September