TOPIC | ACTION | LEAD | PROPOSED COMPLETION / TARGET DATE |
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Governance | Chief Executive Letter to Boards regarding roles and responsibilities related to HAI, including infection control policies, procedures and antimicrobial prescribing | Scottish Government Health Directorates | 27 th June 2008 |
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A HAI reporting template will be developed for NHS Boards to use as the framework to report progress against the HAI agenda to all Board meetings and form the basis of the Boards Infection Control Managers HAI annual report that will be part of the Director of Public Health's Report. | Scottish Government Health Directorates / NHS Boards | January 2009 |
Charge Nurse Leadership | All Boards will empower their Charge Nurses to deliver against their responsibilities | NHS Boards | October 2008 |
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Implement the recommendations in the Senior Charge Nurse Review | NHS Boards | December 2010 |
Facilities | HAISCRIBE (Healthcare Associated Infection System for Controlling Risk in the Built Environment) sections 3 &4 to be applied to all existing buildings to ensure fabric of healthcare facilities maintained to minimise risk of infection | NHS Boards | August 2008 |
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HAI guidance and education around the built environment to be developed | Health Facilities Scotland | September 2009 |
Planned preventative maintenance programmes reflect requirements of prevention and control of infection | NHS Boards | October 2008 |
Hand Hygiene | NHS Boards to have 'zero tolerance' to non-compliance with hand hygiene | NHS Boards | January 2009 |
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NHS Scotland hand hygiene policy more clearly indicates what agents to use for hand hygiene and when they are indicated. | Health Protection Scotland | November 2008 |
NHS Boards to report hand hygiene compliance (staff and visitors) and facilities on a hospital basis to 2 monthly Board meetings | NHS Boards | January 2009 |
National; overview hand hygiene report produced 2 monthly on NHS Boards compliance | Health Protection Scotland | January 2009 |
Finance | NHS Boards to ensure HAI budget requirements are reflected in capital, maintenance and operational programmes | NHS Boards | April 2009 |
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NHS Boards to have identified budget for urgent repairs and replacement equipment available to Charge Nurses | NHS Boards | January 2009 |
Public Information | All patients to receive information on HAI | NHS Boards | November 2008 |
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Information leaflets to be available on: - HAI (general information)
- Clostridium difficle (patients, relatives and staff)
- Laudering of patients laundry at home
| Health Protection Scotland | November 2008 |
All information is available in a variety of formats that facilitates public understanding | NHS Boards | November 2008 |
Antimicrobials | NHS Boards to implements requirements of CEL 30(2008): Prudent Antimicrobial Prescribing: The Scottish Action Plan For Managing Antibiotic Resistance And Reducing Antibiotic Related Clostridium difficile Associated Disease, including: | Scottish Government Health Directorates / NHS Boards | August 2008 |
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Scottish Patient Safety Programme | Scottish Patient Safety Programme ( HAI elements) are integrated with HAI agenda at NHS Board level | NHS Boards / Scottish Patient Safety Programme | January 2009 |
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Progress on implementation of Scottish Patient Safety Programme ( HAI elements) to be included in HAI reports to 2 monthly Board Safety Patient care bundles associated with HAI | NHS Boards | January 2009 |
Policies and Procedures | NHS Scotland policy guidance on prevention, control and management of Clostridium difficile to be available to NHS Boards, including: - CDAD care bundle
- C.diff check list
- Framework for local surveillance
- Antimicrobial prescribing
| Health Protection Scotland | September 2008 |
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Clostridium difficile Root Cause Analysis tool to be developed and used by Boards to investigate adverse outcomes including death | Health Protection Scotland / NHS Boards | November 2008 |
NHS Board's infection control policies include primary and community care And | NHS Boards | December 2008 |
National Infection control guidance for primary and community care to be developed | Health Protection Scotland | July 2009 |
Infection Control Service | Structure and resources to provide effective infection control service across NHS Board area (hospital and community) assessed and agreed by NHS Boards, including: - Human resources
- Equipment
- Budget
| NHS Boards | October 2008 |
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Death Certificates | Guidance on completing certificates to be reviewed and revised guidance issued | Scottish Government Health Directorates and Registrar General | April 2009 |
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NHS Boards policy / guidance on completing death certificates reviewed to include documenting death associated with HAI | NHS Boards | December 2008 |
Surveillance | Standard template and guidance for local surveillance to be developed and implemented by NHS Boards | Health Protection Scotland / NHS Boards | September 2008 |
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NHS Boards local surveillance to include setting of control limits and trajectories for reduction of rates / incidence of HAI | NHS Boards | December 2008 |
All Boards will have web based test reporting for Clostridium difficile by end of October 2008. | Health Protection Scotland & Diagnostic Laboratories | October 2008 |
A pilot of web based episode reporting with roll out to all diagnostic laboratories from March 2009 | Health Protection Scotland & Diagnostic Laboratories | March 2009 |
Mandatory surveillance of Clostridium difficile associated disease revised to include surveillance of 15 year old and above and quarterly reports | Scottish Government Health Directorates / Health Protection Scotland | April 2009 |
Clinical Governance & Risk Management | NHS Boards Risk Register details HAI risks | NHS Boards | September 2008 |
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HAI incidents and issues recorded on NHS Boards Risk Register reporting systems and reported to 2 monthly Board meetings | NHS Boards | January 2009 |
Communication | Guidance on communication pathway for reporting and escalating HAI incidents / issues to be reviewed (Watt Matrix) | Scottish Government Health Directorates | December 2008 |
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HAI Standards | NHS Boards to self assess current compliance with QISHAI Standards (March 2008) | NHS Boards | December 2008 |
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Education & Training | All healthcare workers receive appropriate level of HAI education and training in line with position, including antimicrobial prescribing and resistance | NHS Boards | April 2009 |
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Infection Control staff undertake appropriate level of education and training | NHS Boards | April 2009 |
NHS Scotland Dress Code and Uniform Policy | NHS Scotland interim dress code, applicable to staff, hospital and community issued for implementation to NHS Board's | Scottish Government Health Directorates / NHS Boards | July 2008 |
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NHS Scotland uniform policy and substantive dress code issued for implementation | Scottish Government Health Directorates / NHS Boards | December 2008 |
Cleanliness Champions | Cleanliness Champions responsibilities and development programme defined | Scottish Government Health Directorates | December 2008 |
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Environmental Cleanliness | Charge Nurses "sign off" standard of cleanliness in clinical areas | Health Facilities Scotland / NHS Boards | September 2008 |
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Cleaning matrix and schedule including discipline responsible for cleaning is available in all healthcare settings | NHS Boards | September 2008 |
Professional Development | All staff to have HAI objective in annual professional development plans | NHS Boards | April 2009 |
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