Health Department
Directorate of Planning & Performance Management

Dear Colleague

MANAGING THE RISK OF HEALTHCARE
ASSOCIATED INFECTION IN NHSSCOTLAND

Summary

This letter requires all NHS Trusts and the Clinical Standards Board for Scotland (CSBS) to implement the relevant recommendations of the joint Health Department/NHSScotland working group on managing the risk of healthcare associated infection (HAI). The full text is available at the SHOW website and a bound copy of the Report will be sent to you when available. The Department intends to implement the recommendations which apply to it. The report also contains recommendations for Willis Ltd/ CNORIS which will be discussed with them. Recommendations specifically for Trusts and CSBS are set out below.

There will be an opportunity to discuss the Report at the meeting of senior managers with responsibility for infection control, decontamination and related matters (HDL(2001)10) at the Royal College of Physicians, Edinburgh on the afternoon of Thursday 28th June.

Related HDLs setting out new arrangements for surveillance of HAI, and on decontamination of medical devices, will issue shortly.

Action

The Report sets out an integrated approach to addressing the risks of HAI. Recommendations specifically for NHS Trusts are:

1. Trust training and development programmes should contain the following elements:

- personal development plans which specify risk management training needs;

- an organisational training plan which ensures the development of skills related to risk management of HAI;

- provision of a wide repertoire of training activities;

27th June 2001

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- documented evidence of training and development related to HAI within clinical governance reporting processes.

2. Trusts should ensure that the risk management of HAI is integrated with CNORIS and clinical risk management structures and processes.

3. Trusts should ensure that the recommendations of the Scottish Infection Manual, HDL(2001)10 and CNORIS are in place.

4. Each Trust should designate a senior manager, as detailed in HDL(2001)10, to be responsible for monitoring the risk management of HAI and ensuring self-assessment of performance against standards takes place.

5. Infection Control Committees should have overall responsibility for HAI (i.e., infection control, decontamination of re-usable medical devices and cleaning services).

6. Trusts should review their Infection Control Team and ensure that it is sufficiently robust both in personnel and other resources to accommodate the wider remit with increased responsibilities and workload associated with HAI risk management processes.

7. Trust annual infection control programmes should be based on the risk management model contained within the AS/NZS 4360: 1999.

8. Trust Boards should produce an annual assurance statement based on an internal audit of HAI risk management.

9. Trusts should use the HAI related standards to self-assess performance in the risk management of HAI.

10. Trusts should submit an annual report to CSBS of the results of self-assessment against the HAI risk management standards.

The report also makes recommendations on national arrangements for further development of HAI related standards, checking compliance with these standards (including external review), and the development of measures of performance. The Scottish Health Plan gives the CSBS primary responsibility for developing HAI related standards and the Board has a programme for acting on the relevant recommendations. CSBS has already set up a HAI Reference Group, drawn from a range of expertise across NHSScotland, to advise on and progress work in this area. It held its first meeting on 13 th June.

The Working Group’s specific recommendations for CSBS are:

1. CSBS should ensure integration of the HAI related standards with the CSBS Generic Standards.

2. CSBS should develop a risk matrix tool for assessing risks related to HAI.

3. CSBS should develop a methodology, based on the risk matrix and in consultation with NHSScotland, for setting, evaluating and verifying compliance with HAI risk management standards).

4. CSBS should establish a Healthcare Associated Infection Reference Group to ensure that standards are regularly evaluated and revised.

5. CSBS should produce an annual report covering the risk management of HAI.

Additional Information

Last year, a joint Departmental/ NHSScotland Working Group under the chairmanship of Richard Carey, Chief Executive of Highland Acute Hospitals NHS Trust, was established to develop a comprehensive framework for use by NHS bodies in managing the risks of infection and to advise on standards and compliance with them. The Group included a cross-section of clinicians and staff from NHSScotland. The Minister for Health and Community Care has now accepted the Group’s report and has asked that its recommendations be implemented. The Working Group’s report encompasses guidance on an overall approach to risk management, learning about risk, Trusts’ risk management processes, and national risk management processes in relation to HAI.

Annexes to the report set out draft service standards for:

- infection control,
- decontamination of re-usable medical devices, and
- cleaning services.

It is expected that CSBS will consult on the draft infection control and cleaning standards between now and October 2001. Following a period for self-assessment, the Board will arrange external reviews of Trusts’ progress in meeting the infection control standard in the period January-March 2002. For the cleaning services standard, discussions are taking place with CSBS and Audit Scotland about dovetailing efforts to review performance. For the decontamination standard, participation in a UK-wide approval process is being actively considered. CSBS will provide further information about these processes and their timing as soon as possible.

The meeting on 28th June is intended to give an overview of current developments in relation to measures to combat HAI and to provide a basis for moving forward. The meeting will cover the Working Group’s report, the work of the CSBS and the Glennie Group (on sterile services provision) and the new programme for national surveillance of HAI. All senior managers with responsibility for decontamination, infection control and related matters should attend the meeting, which will be addressed by Trevor Jones, Richard Carey, John Glennie and speakers from CSBS and SCIEH. (Existing guidance to the service on these issues includes the Scottish Infection Manual (1998) and Priorities and Planning Guidance for 1999-2002.)

Yours sincerely

GERRY MARR
Director of Planning and Performance Management