Quality statement 3: Responsibilities of hospital staff

Quality statement

Hospital staff have individual objectives and appraisals on infection prevention and control linked to board‑level objectives and strategies.

Rationale

Trust boards provide leadership in infection prevention and control, but all hospital staff have responsibility for, and are accountable for, infection prevention and control. Boards can help minimise the risk to patients and ensure continuous quality improvement by leading on and regularly reviewing all relevant infection prevention and control objectives, policies and procedures. A clear governance structure and accountability framework will allocate specific responsibilities to all staff. All staff having these responsibilities as clear objectives that are reviewed in appraisals and reflected in development plans will help ensure that board‑level objectives are achieved and that the risk of healthcare‑associated infection is minimised.

Quality measures

Structure

a) Evidence of local arrangements to ensure all staff have clear objectives in relation to infection prevention and control that are linked to board‑level objectives.

Data source: Local data collection.

b) Evidence of local arrangements to ensure all staff have an appraisal and development plan that cover infection prevention and control.

Data source: Local data collection.

Process

a) Proportion of hospital staff who have individual infection prevention and control objectives that are linked to board‑level objectives.

Numerator – the number in the denominator who have individual infection prevention and control objectives that are linked to board‑level objectives.

Denominator – the number of hospital staff.

Data source: Local data collection.

b) Proportion of hospital staff who have an appraisal of their infection prevention and control objectives.

Numerator – the number in the denominator who have an appraisal of their infection prevention and control objectives.

Denominator – the number of hospital staff.

Data source: Local data collection.

c) Proportion of hospital staff who have a development plan that includes infection prevention and control.

Numerator – the number in the denominator who have a development plan that addresses individual needs for knowledge, abilities and skills in infection prevention and control.

Denominator – the number of hospital staff.

Data source: Local data collection.

What the quality statement means for service providers, hospital staff, and commissioners

Service providers (hospitals) in secondary care settings ensure that all staff have objectives in relation to infection prevention and control that are linked to the board's objectives and strategies, that these objectives are appraised and included in development plans, and that staff are supported to carry out these objectives.

Hospital staff (including hospital clinicians, nursing staff, allied healthcare professionals, administrative staff and catering staff) in secondary care settings follow working practices and tasks on infection prevention and control described in their personal objectives; have feedback on their performance against these objectives through an appraisal; and are supported to ensure that learning, training and other development needs on infection prevention and control set out in a development plan are met.

Commissioners (such as clinical commissioning groups) ensure that they commission services from secondary care providers that appraise and support their staff to achieve their objectives on infection prevention and control.

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

People receiving treatment in, or visiting, hospitals can expect that all hospital staff have the skills and knowledge needed to carry out infection prevention and control procedures in their area of work.

Source guidance

Definitions

Hospital staff

All clinical and non‑clinical staff, including support staff, volunteers, agency or locum staff and those employed by contractors.

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