1. MRSA/HCAI Improvement Programme 1 Author: Improvement Programme Review Team Version: Final version Date: 30 th March 2007 MRSA/HCAI Improvement Programme Shrewsbury & Telford NHS Trust Final Report

2. MRSA/HCAI Improvement Programme 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 Section 1 Section 2 Section 3 Links: Acknowledgements

3. MRSA/HCAI Improvement Programme 3 Content Page Links: Acknowledgements Section 3 Section 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

4. MRSA/HCAI Improvement Programme 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.

5. MRSA/HCAI Improvement Programme 5 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 everyone’s responsibility 1.2 Your key message and immediate priorities

6. MRSA/HCAI Improvement Programme 6 1.3 Data analysis data in the following slides are from your submitted MESS data December 2005 to November 2006

7. MRSA/HCAI Improvement Programme 7 1.3.1 What is the direction of travel? The challenge is significant to be where you need to be in March 2008

8. MRSA/HCAI Improvement Programme 8 Areas to target are: General Medicine & General Surgery. 1.3.2 Number of MRSA cases split by Specialty - A look at your problem areas

9. MRSA/HCAI Improvement Programme 9 1.3.3 Number of MRSA cases split by Pre- and Post-48 Hours 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 The table shows that in the last 12 months, 23% of your bacteraemias were pre-48hr cases. N.B. The national average is 28%.

10. MRSA/HCAI Improvement Programme 10 The breakdown of your MRSA cases by age band 1.3.4 Number of 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.

11. MRSA/HCAI Improvement Programme 11 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)

12. MRSA/HCAI Improvement Programme 12 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.

13. MRSA/HCAI Improvement Programme 13 ActionsMilestones 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 1.4 Suggested target milestones

14. MRSA/HCAI Improvement Programme 14 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

15. MRSA/HCAI Improvement Programme 15 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/…

16. MRSA/HCAI Improvement Programme 16 1.6 Encouraging signs  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 …/continued

17. MRSA/HCAI Improvement Programme 17 Acknowledgements Section 1 Section 3 Links: Content Page 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

18. MRSA/HCAI Improvement Programme 18 People Performance Processes Practices 2.1 Key themes MRSA bacteraemia reduction Leadership Training Directorate responsibilities and ICT Roles & responsibilities Bed management and transfers Storage space Performance frameworks Performance framework ownership Use of data Performance data Audit Pre-48 hour cases Hand hygiene High impact interventions Screening & decolonisation Antibiotics Root cause analysis

19. MRSA/HCAI Improvement Programme 19  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 Leadership 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 everyone’s 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 2.2.1 People Findings

20. MRSA/HCAI Improvement Programme 20  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 Training 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 2.2.2 People Recommendations Findings

21. MRSA/HCAI Improvement Programme 21 Directorate responsibilities and infection control team 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 everyone’s 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 2.2.3 People 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

22. MRSA/HCAI Improvement Programme 22  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 Roles & responsibilities 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 1:1s Ensure the Medical Director has the detailed data he needs to be effective in his role 2.2.4 People Recommendations Findings

23. MRSA/HCAI Improvement Programme 23 Performance frameworks  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 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 2.3.1 Performance Recommendations Findings

24. MRSA/HCAI Improvement Programme 24 Performance framework ownership  whilst progress has been made to focus activity within some specialties, the infection control team appear to be undertaking the majority of the work 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 2.3.2 Performance Recommendations Findings

25. MRSA/HCAI Improvement Programme 25 Use of data  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 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 2.3.3 Performance Recommendations Findings

26. MRSA/HCAI Improvement Programme 26 Performance data  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%) 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 2.3.4 Performance Recommendations Findings

27. MRSA/HCAI Improvement Programme 27 Pre-48 hour cases  23% of bacteraemias were diagnosed as being present within 48 hours of admission, this is below the national average (28%) 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 2.3.5 Performance Recommendations Findings

28. MRSA/HCAI Improvement Programme 28 Audit  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 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 2.3.6 Performance Recommendations Findings

29. MRSA/HCAI Improvement Programme 29 Bed management and transfers  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 2.4.1 Process 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 Recommendations Findings

30. MRSA/HCAI Improvement Programme 30 Storage space  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. 2.4.2 Process Ensure sinks are accessible for all to use Find alternative storage space for unused equipment Recommendations Findings

31. MRSA/HCAI Improvement Programme 31 Hand hygiene  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 2.5.1 Practice 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 Recommendations Findings

32. MRSA/HCAI Improvement Programme 32 2.5.2 Practice 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  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 High impact interventions Recommendations Findings

33. MRSA/HCAI Improvement Programme 33 2.5.3 Practice 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  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 Screening & decolonisation Recommendations Findings

34. MRSA/HCAI Improvement Programme 34 2.5.4 Practice 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  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 Antibiotics Recommendations Findings

35. MRSA/HCAI Improvement Programme 35 2.5.5 Practice 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  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 Root cause analysis Recommendations Findings

36. MRSA/HCAI Improvement Programme 36 Acknowledgements Section 1 Section 2 Links: Content Page 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

37. MRSA/HCAI Improvement Programme 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 week’s 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. MRSA/HCAI Improvement Programme 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@dh.gsi.gov.uk and Sally Batley, Deputy Head, MRSA Improvement Programme, sally.batley@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. MRSA/HCAI Improvement Programme 39 Acknowledgements Section 1 Section 2 Section 3 Links: Content Page 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

40. MRSA/HCAI Improvement Programme 40  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 everyone’s responsibility Your key message and immediate priorities