Quality improvement statement 3: HCAI surveillance


Trusts have a surveillance system in place to routinely gather data and to carry out mandatory monitoring of HCAIs and other infections of local relevance to inform the local response to HCAIs.

What does this mean for people visiting, or receiving treatment in, hospitals?

People visiting, or receiving treatment in, hospitals can expect the trust to monitor infection levels across all service areas and use this information to adjust practice, where necessary. For example, they can expect the trust to close beds, or a ward to visitors, in response to an outbreak.

What does it mean for trust boards?

Boards ensure there is a fully resourced and flexible surveillance system to monitor infection levels in the trust. Outputs are shared across the organisation and used to drive continuous quality improvement.

Evidence of achievement

1. Evidence of an adequately resourced surveillance system with specific, locally defined objectives and priorities for preventing and managing HCAIs. The system should be able to detect organisms and infections and promptly register any abnormal trends.

2. Evidence of clearly defined responsibilities for the recording, analysis, interpretation and communication of surveillance outputs.

3. Evidence of arrangements for regular review of the surveillance programme to ensure it supports the trust's quality improvement targets for infection prevention.

4. Evidence of fit-for-purpose IT systems to support surveillance activity. This includes evidence of validation processes that ensure data accuracy and resources that can analyse and interpret surveillance data in meaningful ways.

5. Evidence of surveillance systems that allow data from multiple sources to be combined in real time (epidemiological, clinical, microbiological, surgical and pharmacy).

6. Evidence that surveillance systems capture surgical-site and post-discharge infections.

7. Evidence that trusts share relevant surveillance outputs and data with other local health and social care organisations to improve their infection prevention and control.

8. Evidence that systems are in place for timely recognition of incidents in different spaces (for example, wards, clinical teams, clinical areas, the whole trust). This includes evidence of regular time-series analyses of data.

9. Evidence that the trust reports all outbreaks, serious untoward incidents (SUIs) and any other significant HCAI-related risk and incident to the local health protection unit.

10. Evidence that surveillance data in key areas is regularly compared with other local and national data and, where appropriate, is available at clinical unit level.

11. Evidence of a process for surveillance outputs to feed into accountability frameworks, inform audit priorities and be used to set objectives for quality improvement programmes in relation to HCAI prevention.

12. Evidence of surveillance outputs being analysed alongside comparative data to ensure continual improvement.

13. Evidence of surveillance outputs being fed back to relevant staff and stakeholders, including patients, in an appropriate format to support preventive action.

14. Evidence that the trust has developed, and regularly reviews, a hospital-wide incident plan to investigate and manage major infection outbreaks and HCAI incidents. This includes evidence that high-level managerial and clinical mechanisms are in place for coordinating, communication (including with other agencies) and deploying adequate resources.

Practical examples

  • Surveillance data (for example, on antimicrobial resistance) is routinely communicated to the board and to individual clinical units. This includes comparative data on performance within the trust over time and compared with other local or national data.

  • Regular publication of outputs from the surveillance system, for example, on post-surgical infection rates and rates of compliance with recommendations on surgical prophylaxis.

  • Analysis of trends from local and national surveillance data informs practice across the trust or setting. For example, it could be used to initiate a review of how prepared the trust is for an infection outbreak.

  • Surveillance outputs are used to monitor progress against local quality improvement objectives.

Health and Social Care Act code of practice

Criterion 9: Guidance for compliance 9.3m, 9.3u

  • National Institute for Health and Care Excellence (NICE)