Quality statement 2: Organisational responsibility

Quality statement

Organisations that provide healthcare have a strategy for continuous improvement in infection prevention and control, including accountable leadership, multi-agency working and the use of surveillance systems.

Rationale

It is essential that organisations and agencies work together to coordinate strategies for infection prevention and control across a local area. It is equally important to share information across organisations in order to meet responsibilities for establishing the current position on infection control, monitoring the impact of quality improvement initiatives and ongoing surveillance. Leadership underpins all infection prevention and control, and is vital to ensure that this remains a priority for the organisation as a whole and each person working within it.

Quality measures

Structure

a) Evidence that the organisation includes infection prevention and control within its overall strategy.

Data source: Local data collection.

b) Evidence that the organisation's board is up to date with, and has a working knowledge and understanding of, infection prevention and control.

Data source: Local data collection.

c) Evidence that a lead for infection prevention and control has been assigned and is taking an active role.

Data source: Local data collection.

d) Evidence of support for, and participation in, joint working initiatives beyond mandatory or contractual requirements, to reduce healthcare-associated infections locally.

Data source: Local data collection.

e) Evidence of an adequately resourced surveillance system with specific, locally defined objectives and priorities for preventing and managing healthcare-associated infections.

Data source: Local data collection.

Outcome

Incidence of healthcare-associated infection.

Data source: 2014/15 NHS Outcomes Framework indicator 5.2 and 2014/15 CCG Outcome Indicator Set indicators 5.3 and 5.4 measure incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Data are derived from the mandatory reporting of healthcare-associated infections to Public Health England, which are published by Public Health England and also reported by the Health and Social Care Information Centre through their Indicator Portal.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that a strategy is in place for continuous improvement in infection prevention and control that includes accountable leadership, multi-agency working and surveillance systems.

Healthcare professionals ensure that they implement strategies for continuous improvement in infection prevention and control through accountable leadership, multi-agency working and adhering to the requirements of surveillance systems.

Commissioners ensure that they commission services from organisations that have strategies for continuous improvement in infection prevention and control that include accountable leadership, multi-agency working and surveillance systems.

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

People receive healthcare from organisations that aim to continually improve their approach to preventing infection (for example, by sharing information with other organisations and monitoring rates of infection).

Source guidance

  • Prevention and control of healthcare-associated infections: quality improvement guide (NICE public health guidance 36), quality improvement statements 1, 3 and 6.

Definitions of terms used in this quality statement

Board

A board is defined as a group of members with overall responsibility and accountability for the governance, safety and quality of an organisation. [Expert opinion]