Quality improvement statement 2: Be a learning organisation

Statement

Trusts use information from a range of sources to inform and drive continuous quality improvement to minimise risk from infection.

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

People visiting, or receiving treatment in, hospitals can expect the trust to learn from its own and other healthcare providers' experience, and to use this learning to improve the quality of care and practice in infection prevention and control.

What does it mean for trust boards?

Boards ensure mechanisms are in place for the trust to use a range of information, in addition to surveillance data, to minimise risk of infection to patients, staff and visitors. This includes information about both good and bad practice.

Evidence of achievement

1. Evidence that processes have been put in place to learn from experiences outside the organisation in relation to infection prevention and control. This includes evidence that learning is occurring on a continual basis.

2. Evidence of regular, systematic generation and sharing of learning from trust's own experiences of infection prevention and control – including good practice and adverse events. This includes evidence that learning is based on a range of intelligence sources and is used to inform, and feed into, clinical and risk management processes.

3. Evidence that mechanisms are in place to disseminate learning among relevant staff groups

4. Evidence that the trust promotes a culture of learning in relation to infection prevention and control, and ensures staff have time to participate in preventive learning activities.

5. Evidence that recommendations and actions identified as being needed following an incident, surveillance or learning activities have been implemented.

6. Evidence that the continuous quality improvement cycle is informed by conclusions from robust learning methodologies.

7. Evidence that the trust works with local health partners (including health protection units) to capture and learn lessons from the management of major infection outbreaks and other HCAI-related incidents.

8. Evidence that the trust promotes innovation to minimise harm from infection, for example by promoting research opportunities, practice development initiatives and action learning sets for staff.

Practical examples

  • Local gap analyses performed on official reports and action plan developed to address identified gaps in local practice.

  • Surveys of patient and staff experiences on infection prevention and control are fed into learning activities.

  • A range of forums give staff the opportunity to learn from each others' experiences in relation to infection prevention and control.

  • Audit of infection prevention activities undertaken across the trust as a result of learning from others.

  • Audit of antimicrobial drug usage to check it complies with trust policy. Feedback given to relevant staff.

  • Audit of hand-hygiene practices and feedback given to relevant staff.

  • Feedback given to individual surgeons on wound infection rates.

  • Audit of appropriate isolation facility usage.

Health and Social Care Act code of practice

Criterion 1: Guidance for compliance 1.1, 1.3

Relevant national indicators

Quality improvement indicators:

  • NRLS1 – Consistent reporting of patient safety events reported to the reporting and learning system (RLS)[6]

  • NRLS2 – Timely reporting of patient safety events reported to the RLS[7]

  • NRLS3 – Rate of patient safety events occurring in trusts that were submitted to the RLS[8] .



[6] For details of the indicator, visit https://mqi.ic.nhs.uk/IndicatorDefaultView.aspx?ref=3.02.12

[7] For details of the indicator, visit https://mqi.ic.nhs.uk/IndicatorDefaultView.aspx?ref=3.02.15

[8] For details of the indicator, visit https://mqi.ic.nhs.uk/IndicatorDefaultView.aspx?ref=3.02.16

  • National Institute for Health and Care Excellence (NICE)