Quality statement 1: Surveillance

Quality statement

Hospitals monitor healthcare‑associated infections and other infections of local relevance to drive continuous quality improvement.

Rationale

Mandatory national and local surveillance of healthcare‑associated infections (such as Staphylococcus aureus [MRSA] and Clostridium difficile [C difficile]) provides information that can be used to assess the infection risk of people in hospital and inform the response. However, mandatory monitoring only covers a small number of healthcare‑associated infections. Identification and monitoring of other infections of local relevance, including resistant organisms, contributes to a fuller understanding of the risk of infection to people in hospital. The results of monitoring can be used by staff across the organisation to help inform practice, review the effectiveness of responses, and review how well strategies to reduce healthcare‑associated infections are working.

Quality measures

Structure

a) Evidence of local arrangements for hospitals to monitor healthcare‑associated infections and other infections of local relevance.

Data source: Local data collection.

b) Evidence of local arrangements for the results of monitoring healthcare‑associated infections and other infections of local relevance to be used across the organisation to inform and review objectives for quality improvement.

Data source: Local data collection.

Outcome

Incidence of healthcare‑associated infections.

Data source: Local data collection and national data collection including 2015–16 NHS Outcomes Framework indicator 5.2 (MRSA and C difficile); 2015–16 Clinical Commissioning Group [CCG] Outcome Indicator Set indicators 5.3 (MRSA) and 5.4 (C difficile). National data derived from the Mandatory Surveillance of MRSA, MSSA, E coli and C difficile published by Public Health England.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (hospitals) ensure that systems are in place to carry out mandatory monitoring of healthcare‑associated infections and other infections of local relevance, including resistant organisms; and ensure that the results are shared across the organisation and used to drive continuous quality improvement.

Health and social care practitioners in secondary care (including hospital clinicians, nursing staff and allied healthcare professionals) report healthcare‑associated infections, act on information provided to them about local infections to reduce infection risk, and adjust clinical practice for continuous improvement.

Commissioners (such as clinical commissioning groups) ensure that they commission services from hospitals that have systems to carry out mandatory monitoring of healthcare‑associated infections and other infections of local relevance, including resistant organisms; and ensure that they share the results across the organisation to drive continuous quality improvement.

What the quality statement means for patients, service users and carers

People receiving treatment in, or visiting, hospitals can expect the hospital to monitor infection levels across all service areas to help improve services and minimise future infection rates.

Source guidance

Definitions

Monitor healthcare‑associated infections

Monitoring includes mandatory monitoring of healthcare‑associated infections and also other infections that are of local relevance, including resistant organisms, within the hospital setting. Monitoring should be through a surveillance system that detects organisms and infections, and promptly registers any abnormal trends. Data from multiple sources (epidemiological, clinical, microbiological, surgical and pharmacy) need to be combined in real time, and should allow for timely recognition of incidents in different spaces (for example, wards, clinical teams, clinical areas and across the whole trust). Surveillance data in key areas should be regularly compared with other local and national data.

[Adapted from Healthcare-associated infections: prevention and control (NICE guideline PH36)]

Continuous quality improvement

Improving the provision of services and practice by using a range of audit and statistical tools to assess the current situation, identify areas for improvement and measure the results.

[Healthcare-associated infections: prevention and control (NICE guideline PH36)]