Quality improvement statement 4: Workforce capacity and capability
Trusts prioritise the need for a skilled, knowledgable and healthy workforce that delivers continuous quality improvement to minimise the risk from infections. This includes support staff, volunteers, agency/locum staff and those employed by contractors.
Patients can expect staff to have the necessary skills and knowledge to undertake infection prevention and control procedures in their area of work.
Boards ensure staff have the skills and training required for infection prevention and control.
1. Evidence of local arrangements to ensure all staff working in clinical areas have an appraisal and development plan that includes discussion of infection prevention and control. This includes evidence that staff working in both clinical and non-clinical areas have clear objectives in relation to infection prevention and control which are linked to the trust's objectives.
2. Evidence that all staff working in clinical areas, including specialist 'link practitioners', have sufficient time to fulfil their responsibilities on (and objectives for) infection prevention and control.
3. Evidence that staff are provided with feedback on their performance in relation to infection prevention and control (for example, on hand hygiene or when prescribing antimicrobial drugs). This includes evidence that they are given support to fulfil this role.
4. Evidence of local arrangements to ensure all staff working in clinical areas complete infection prevention and control training within 1 week of commencing work.
5. Evidence of local arrangements to ensure infection prevention and control training and competencies are updated and checked at appropriate intervals.
6. Evidence that local workforce planning and workforce reviews explicitly consider, and are informed by, the trust's infection prevention and control strategy and local HCAI outcomes.
7. Evidence of local arrangements for an annual review of training resources to ensure consistency with the national evidence base and professional and occupational standards.
8. Evidence of local arrangements to ensure consultant medical staff from a range of specialities champion infection prevention control. This includes evidence that they are given protected time to achieve defined objectives in this role.
9. Evidence that all staff working in clinical areas are familiar with, and competent in applying, the trust's infection prevention and control policies and procedures.
10. Evidence of local arrangements to train all staff in the communication skills needed to discuss HCAIs with patients and the public.
11. Evidence that the trust has a proactive, accessible and user-sensitive occupational health service. This includes evidence of a high level of competence in all areas of healthcare infection prevention and control to ensure the welfare of healthcare workers (including short-term and agency workers). In addition, evidence is needed that the service puts an emphasis on preventing blood-borne viruses, tuberculosis, vaccine-preventable diseases and acute respiratory and gastrointestinal infections.
An agreed performance indicator for the proportion of staff appraisals that include infection prevention and control. Performance against this indicator is checked on a regular basis.
Monitoring of proportion of new staff who undergo pre-employment occupational health screening or assessment within a given timeframe.
Trust programme in place to review the immunisation status of staff and to ensure vaccines are offered, when necessary.
Trust programme in place to review the skills, competence and capacity of the multi-disciplinary infection prevention and control team to ensure it is fit-for-purpose.
A mechanism is in place to ensure the need to reduce HCAIs across the organisation is explicitly considered during workforce planning.
Presence of an infection prevention and control 'link practitioner' or member of staff in every clinical and support unit (with protected time).
Training needs-analysis is informed by the trust's infection prevention and control strategy and local HCAI outcomes and is reviewed annually.
Staff education on the occupational health aspects of how to prevent and control healthcare infections is provided by occupational health service. (For example, this may include advice on the number of days staff should not work following an episode of sickness and diarrhoea.)
Monitoring of the proportion of new staff undertaking mandatory infection prevention and control training within 1 week of commencing work.
Presence of escalation procedures and processes for individuals who repeatedly do not fulfill their specified infection prevention and control responsibilities.
Patient surveys of their experience of staff skills and knowledge in relation to infection prevention and control.
Monitoring of the proportion of staff whose post-exposure prophylaxis (PEP) management to HIV is delayed.
Criterion 1: Guidance for compliance 1.1
Criterion 6: Guidance for compliance 6.2
Criterion 10: Guidance for compliance 10.1