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A learning from practice podcast to support the NICE/HPA Quality improvement guide: prevention and control of healthcare-associated infections (HCAIs) in secondary care

Julian Hartley, Chief Executive and Mandy Bailey, Chief Nurse, from University Hospital South Manchester discuss their experiences of tackling HCAIs locally. The podcast may be of interest to chief executives, board members and senior managers; it is 17 minutes long and was recorded on location so has occasional background noise.

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This podcast was added on 23 Nov 2011

Podcast transcript

NICE Shared learning podcast to support the Quality improvement guide on the prevention and control of healthcare associated infections in secondary care

Recorded with Julian Hartley, Chief Executive of University Hospital South Manchester and Mandy Bailey, Chief Nurse. [file length: 17 minutes]

Hello and welcome to this NICE shared learning podcast to support the quality improvement guide on the prevention and control of healthcare associated infections in secondary care.
Key audiences for the NICE and Health Protection Agency guide include trust board members and senior managers from secondary care.  
I am Mandy Harling (MH), Implementation Adviser at NICE and I am on site at University Hospital South Manchester to meet with the hospital’s Chief Executive Julian Hartley (JH), and Chief Nurse, Mandy Bailey (MB). We will be discussing some of the challenges that they have faced in tackling HCAIs locally and some of the approaches that they have found effective in delivering on this work.

Please note, because the recording was made on site at the hospital, there may be occasional background noise.

MH: Hello Julian and Mandy

JH &MB: Hi (from both)

MH: Firstly, could you give us an idea of the population that your hospital serves and the types of services that you provide?

JH: Certainly, here at the University Hospital of South Manchester we serve a large local population of around 300,000, but we also serve a much wider population for specialist services across the whole of the northwest for some services, particularly lung and heart transplant, also burns and plastics and other specialist cardiac surgery. So we have a significant specialist service population also.    

MH: What was the starting point for your infection prevention and control work here at University Hospital South Manchester and how were the priorities identified for this work?
JH: Well the starting point was very much that in April 2009 we found ourselves in a position where our MRSA trajectory was well above the target. That presented risks of significant breach of our terms of our authorisation with our regulator. But more importantly it was a key patient safety issue. So we had a very very clear objective as an organisation that we needed to really look differently at how we dealt with this issue. And Mandy and her team started a huge and very rigorous process of looking at redeveloping our strategy for infection prevention. And I’ll let Mandy pick up the story from there.

MB: I think that’s fair and the strategy that we focussed on was the patient safety element of preventing any infection and by ensuring that the approach was that it was actually everybody in the hospital had a role to play in preventing infections. So our campaign came up with a title of ‘infection prevention is everyone’s responsibility’. And so we focussed on what you as an individual could do - whether you were a board member like myself or our finance director or our operations director, to whether you were a nurse on the ward, a doctor, or a physio or even all of our administrative staff as well as our cleaning and portering staff. So in terms of working together, it was how we could engender the approach with every colleague so that we worked with every day had a role to play.
 
MH: The NICE and Health Protection Guide highlights the pivotal role that senior leadership has in the delivery of infection prevention and control programmes. Could you explain how your senior team have been involved in this work at University Hospital South Manchester?
JH: Yes, we felt that it was absolutely vital that this issue had the ownership of all members of the senior leadership team. So, as well as the board discussing our approach and being clear about the need to really bear down on infections, as an executive team we all took responsibility for ensuring that this was an objective in all of our personal objectives. Which meant that the finance director as well as Mandy as Chief Nurse and indeed as Brendan as Medical Director - in fact that all of us - all executive directors had a role to play in one of the elements that Mandy talked about, which was raising awareness. So, we ran a series of infection prevention road shows which every executive director participated in, common set of slides developed by Mandy and the infection prevention team. Mandy and her colleagues then took us through each of those, gave us a mini tutorial on all of the issues. We were then able to take those messages out to the organisation. And we took it in turns, but what we did was that we ensured that we had 100% coverage of the whole organisation, so every single member of staff heard from an executive director why this mattered, why it was a key patient safety issue, and what their role in helping reduce infections was.
That was a very very important first step in ensuring senior management and senior leadership input.

MB: I think the other aspects that’s really important around senior leadership is that in terms of some of the lessons that we learned if an infection occurred - particularly around focussing on MRSA at the start – the clinical team, which would be the consultant and the ward nursing colleagues, would come and talk through what had happened to the patient to Julian as the Chief Executive, Brendan as our Medical Director and myself as the Chief Nurse and Director of infection prevention that raised the awareness of the importance that we wanted to understand how an infection could occur and if there were things we could learn. And we were able to demonstrate that and so we changed a number of our policies and practices around how we inserted our cannulas, how we looked at cleaning our wound infections because we picked up a number of patterns that were happening in that way.  The other part I think fundamentally was being a role model and a clear and supporting people, challenging when people were not following policy. So the fact that all the board directors whenever they are in a clinical area whether you are a non executive or an executive are always bare below the elbows.

MH: Were there any particular challenges that had to be overcome to enable the delivery of this work?
JH: Yes there were many challenges. The first challenge was making sure that the whole organisation understood that this was a very important issue, for patient safety, for the reputation of the organisation, but most fundamentally for the experience of every single patient that comes into our care. And we needed to make it absolutely clear that we had the answers in our own hands to improve the situation. That through all of the measures that Mandy will say more about, that we were able to make a difference, but that required a big culture change in terms of how we engaged with our staff. So we very much adopted the principles of deep employee engagement in terms of good communication, recognition, continuous improvement, and an enlightened management style to ensure that this agenda was very much part of our approach to reset the relationship between senior leaders and people at the front line

MB: It builds upon the challenges that were around the culture really, which I think is fundamentally the challenge. But also the customer practice, people had got to the point where they thought there was not a lot that we could do about this, they thought they were already delivering good care, which they were. But actually, could we be more consistent with our practice, and more focussed on our practice and more aware of our practice and that would bring us a far better result in outcome. And I think the scepticism when we started the journey was quite palpable and you could see that in terms of how people talk about “why should I be bare below the elbows, what is the evidence?” But actually now you hear “I can’t believe we’ve done it”, “we’ve delivered a massive change”, “we’ve reduced our infection rates significantly, by over 50% in two years”. And so people now feel actually we can do this, and that everyone has a role to play.  
Also making it not only as an exec team our objective, it is one of our objectives for every employee in the trust. And we also asked them to sign a pledge that they would do everything that they could to actually prevent infection.    

MH: From your experience, what has been required to foster a culture of continuous improvement across your trust?
JH: Well, I think that Mandy’s points earlier, about the different elements of our strategy really helped us in this respect. Because as well as the cultural change and the communication message which were absolutely widespread: so you couldn’t walk through this hospital without seeing a poster or a pop up on a computer or some reference to infection prevention. And not just a bland statement, but we used our own staff, pictures of our own staff with key messages. So people recognised one another, and it reinforced the sense of community and collective endeavour on this agenda. But also, in terms of continuous improvement the performance management of this was important. So the structure that we adopted, which went from ward to board enabled us to see very clearly where good performance was happening and where poor performance was happening, and that was against a range of indicators. And we were able to set up a frequent infection prevention performance steering group, which I chaired and that enabled us to bring all of the data together and see immediately where we had the challenges. But what was really important was recognising good, positive results. So for example, wards that had gone for a whole period without not only any issues, but that had scored 100% on all key measures we recognised those in a letter from myself and Mandy to the relevant ward sister. What that started to do was generate some healthy competition between different wards and different parts of the organisation to ensure that everyone was really on top of this and delivering. And supported by things like patient safety walkabouts that we’d do, or first Friday which is when we go and talk to patients. We were able to get those messages across and talk to frontline staff about their challenges, their initiatives, their improvement methods that they were using to change practice. And all of that was continuously reinforced positively by myself and my colleagues.

MH: What has helped to sustain this drive for quality improvement across the trust?
JH: Well, I think that it is very much about consistency and constancy of purpose. Mandy already alluded to the fact that at the heart of the south Manchester way is that patient care is at our heart. So infection prevention continues to be very important to us, and the fact that we’ve only had one MRSA bacteraemia this year, one more than we’d like, but that’s down from around 25 in previous years, shows that this is being sustained year on year. And also the constant reinforcement and refreshment of the message is important. So we have, I hesitate to say this, but we have put things on You Tube that have been light hearted, but have conveyed a serious message. We have also done the great hospital hand wash where we got all members of staff out into the car park and everyone together washed their hands. Our communications team are always coming up with innovative, inspiring ideas to keep this fresh and to ensure that we do sustain the message, and that it doesn’t get stale and that people don’t get complacent. 
 
MB: I think that’s fundamental. You can’t just do it and then stop. If you are going to have continuous improvement then you’ve got to continually look at new ways of getting the message across and reinforcing the messages you want until it becomes second nature.
So, I think that’s a whole message in terms of how we operate, and it’s the continual refreshing of it with our pop ups on a computer, so when you turn on your computer you have a message now. It’s usually either infection prevention, another safety message, a patient experience message but it does get across the messages and certainly if unfortunately we have an infection the picture changes on the pop ups, the whole organisation knows that we’ve had one.

How are your board kept informed regarding staff compliance with good infection prevention and control practices? 
JH: The board are kept informed every month in some detail through the quality account, which includes a whole section on infection prevention, which we developed as part of our overall strategy. And that gives the board assurance for every single ward and department in the organisation against half a dozen key indicators which includes audit, hand hygiene compliance and insertion of lines, a range of things which Mandy can elaborate on. And that enables us at a glance to see how those areas are performing against a traffic light system of red, amber and green. And because we have a zero tolerance approach you only get green if you are 100%. And therefore that means that those areas that do achieve that, and achieve that consistently, are singled out for special praise and attention and the board are part of that process.

MB: I think that the key component for keeping the board informed is the process we have around ward to board feedback. So the indicators that Julian mentioned are around the high impact interventions that are utilised and our performance monthly against audits against those. Alongside our environment, our hand hygiene compliance, the number of colleagues trained in ANTT training[1]. All those indicators are performance managed by service and by ward. I have now taken on the leadership of the infection prevention performance review meeting where we will pick up key themes that we may need to address.  We thank the people who have achieved 100% and we work on some of the issues where I can support the clinical team if there is a particular area where they might have a problem that they want some executive and senior leadership and support with. And I think that connectivity is really important and it shows that it is taken seriously as a board and as the leadership, but also it’s taken equally seriously on each ward.

MH: So thank you Julian and Mandy for your time today.
MB: Thank you.
JH: Thanks very much. 

Thank you for listening, we hope that you found the information in this NICE podcast useful. Further detail on the NICE and Health Protection Agency Guide and supporting tools can be found on the NICE website at  www.nice.org.uk  

[1] The ANTT framework is one of several methods available for training in aseptic techniques.

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.