Quality improvement statement 1: Board-level leadership to prevent HCAIs
Trust boards demonstrate leadership in infection prevention and control to ensure a culture of continuous quality improvement and to minimise risk to patients.
People visiting, or receiving treatment in, hospitals can expect all trust staff – from board to ward level – to take responsibility, and be accountable for, continuous quality improvement in relation to infection prevention and control.
Boards are proactive in ensuring continuous quality improvement by leading on, and regularly monitoring compliance with, all relevant infection prevention and control objectives, policies and procedures.
1. Evidence that the board is up-to-date with, and has a working knowledge and understanding of, infection prevention and control.
2. Evidence that the board has an agreed set of key performance indicators for infection prevention and control which includes compliance with antibiotic prescribing policy.
3. Evidence that the agreed key performance indicators are used by the board to monitor the trust's infection prevention and control performance.
4. Evidence that the trust's aims and objectives for infection prevention and control are included in the board's 'Balanced score card'.
5. Evidence that a board member has been assigned to lead on infection prevention and control.
6. Evidence of a board-approved infection prevention and control accountability framework. This includes evidence of specific responsibilities allocated to staff working in, or coming into contact with, clinical areas (reflected in their job descriptions and appraisals).
7. Evidence that a mechanism is in place to report regularly to board meetings on important infection risks and the control measures that have been implemented.
8. Evidence that the board has agreed an annual improvement programme on infection prevention and control which is linked to the business planning cycle and has identified actions and resources.
9. Evidence that the trust promotes a 'self-governance' culture for infection prevention and control. This includes evidence that all staff, from board to ward, are accountable and take ownership and responsibility for continuous quality improvement.
10. Evidence that the board is assured that monitoring mechanisms are in place in each clinical area, and that each area is accountable for compliance with relevant aspects of the code of practice.
11. Evidence of regular communication from the chief executive on the trust's expectation of patients, visitors and staff in relation to infection prevention and control.
12. Evidence that the director of infection prevention and control is involved in contract negotiations with commissioners on the key performance indicators for infection prevention and control.
13. Evidence that the board demonstrates to patients, the public, staff and itself that it is making continuous progress towards meeting all relevant statements in this guide.
Annual improvement plans include comparative data on progress towards relevant quality improvement statement goals, as well as in areas covered by other relevant guidance. (An example is NICE's clinical guideline on prevention and treatment of surgical site infection)
Regular audit of board infection prevention and control accountability framework.
Infection prevention and control features in the planned board development programme.
Audit of infection prevention and control objectives within annual work programme.
Criterion 1: Guidance for compliance 1.1, 1.5
Criterion 6: Guidance for compliance 6.2