Queen Elizabeth University Hospital Independent Review - report recommendations: Scottish Government response

Response to Recommendations from Chapter 9 – Themes

Part A - IP&C, Technical Expertise, Standards of Professional Work

Recommendation 45

45) Regardless of their professional background, those with Infection Control as part of their job role should undergo regular performance appraisal. This should include enquiry about challenges and problems encountered in the role, including team effectiveness. (9.4.1)

Scottish Government's Response

The Scottish Government will include this recommendation in the Oversight Board report. This recommendation applies to all territorial boards with IPC functions.

Recommendation 46

46) Enhanced professional appraisal must, similarly, encompass critical appraisal and reflection. Critical incidents where Incident Management Teams (IMTs) present dilemmas and challenges should provide candid and confidential material for discussion with a view to continuous improvement. (9.4.2)

Scottish Government's Response

The Scottish Government will include this recommendation in the Oversight Board report. This recommendation applies to all territorial boards with IPC functions.

Recommendation 47

47) The selection of Infection Control professionals in management positions such as the leadership team should be by competitive recruitment with the possibility of extension or reappointment. Appointees should be given every opportunity to address areas where assessment shows room for growth and learning. Effective team work must be an element. (9.5.1)

Scottish Government's Response

Responsibility for recruitment rests with the Boards and we will invite them to advise the Scottish Government on which forum to use to take it forward.

Recommendation 48

48) Incident management and problem assessment inevitably involves hypothesis development and testing; governance must ensure that hypotheses are sound, contestable and the debate that strengthens or removes hypotheses is respectful and transparent. (9.5.2)

Scottish Government's Response

The Scottish Government will include this recommendation in the Oversight Board report. This recommendation applies to all territorial boards with IPC functions.

Part C - Governance and Assurance

Recommendation 49

49 - We endorse the recommendations of the Review of Edinburgh Schools as applied to hospital and other healthcare buildings and public sector capital investment. We recommend that they are implemented in full. (9.9.2)

Scottish Government's Response

NHS Scotland's Building Design & Construction Group are considering the Review of Edinburgh Schools and a number of other reviews into building failures. A response to these reviews is scheduled to be finalised by January 2021 and this inform the Scottish Government's response to this recommendation on the applicability of the Review of Edinburgh Schools to hospital and other healthcare buildings.

Recommendation 50

50) The data on which those with responsibility offer assurance must be sharable to ensure transparency, complete with information on context and, where available and appropriate, valid comparison and external peer challenge. (9.9.3)

Scottish Government's Response

The Scottish Government will write to Chief Executives and ask the National Centre to take this recommendation forward, or advise on an alternative platform to deliver it.

Recommendation 51

51) Stakeholders advising on critical systems such as IP&C should be:

• Properly trained, experienced, capable of management and organisation of resource, capable of effective influence and have scoped the highly specialist functions of a healthcare building;
• Capable of escalating problem solving, and networking with evidence providers nationally and internationally when the situation demands it;
• Capable of understanding the implications of derogations, guidance and compliance;
• Diligent in documenting decision-making that is transparent and accountable. (9.9.4)

Scottish Government's Response

The National Centre will provide a progressive, cohesive and integrated approach to specialist workforce education development for this multi-agency and multi-professional staff group (both internal and external to the National Centre) in agreed partnership with NES and Boards. It will also ensure Boards have access to staff with appropriate skills for projects, and assigned staff have the time, training and support to undertake their role.

Recommendation 52

52) Board and Area Infection Control Committees should:

• Have programme management responsibilities;
• Where they have clear governance responsibilities, have well defined scope and remit in respect of other governance bodies;
• Have the remit and scope of their governance responsibilities clearly defined;
• Be competently supported by the Infection Control Manager, so that secretariat and professional leads pursue matters arising diligently, reporting progress and resolution at subsequent meetings;
• Have clear and well understood interfaces between the CCGC, other sub-Committees of the Board and other governance groups. (9.9.4)

Scottish Government's Response

The Scottish Government will look to the QEUH Oversight Board report for appropriate recommendations before considering how to take forward action nationally.

Recommendation 53

53) The Health Board should:

• Retain as formal consultants experienced construction professionals in non-executive positions at times when the organisation is making major investment in estates and facilities. They should scrutinise the project team's performance, critical external relationships with the contractor and assurance systems that include independent verification. They should also provide comment on main developments and changes;
• Expect fuller briefings with problem-orientated records and risk management plans for key adverse events, such as those that are the subject of unplanned capital investment, or sustained and adverse public attention;
• Expect the documentation of more significant critical incidents to address the wider effects on patient care and lessons learned in regular, routine reporting of the Infection Prevention and Control function. This should be in addition to Healthcare Infection Incident Assessment Tool (HIIAT) reports;
• View the Estates and Facilities management function of the NHS Board as central to the Board's work, as NHS GG&C does now, to ensure that stewardship of the built environment and the Board's capital assets receive proportionate management focus. (9.9.4)

Scottish Government's Response

The Scottish Government will look to the Health Boards to apply these principles to all capital investment projects, which will be overseen by the National Centre.

Recommendation 54

54) The documentation and audit trails of key decisions during the time of important projects should be better preserved in order to ensure accountability and clarity of past decision-taking. There should be a review of reasonable timescales for records retention, and this may involve law or regulation to ensure the necessary changes. (9.11.1)

Scottish Government's Response

The National Centre, working in conjunction with NHS Boards, will implement this recommendation.

Part D - Behaviour and Relationships

Recommendation 55

55) We therefore report examples of team and individual behaviour that were inappropriate. We ask the teams we have identified to reflect on these remarks, and the extent to which the IP&C function has left behind the tendency to focus on the dispute rather than the problem needing to be solved for the benefit of the patients at the centre of the incident. We commend initiatives already underway to address this matter. We direct readers to the recent (2019) reports from John Sturrock QC and Coia and West on inappropriate behaviour care and compassion for staff, and urge stakeholders to examine and apply the recommendations of these reports in their own context. (9.12.9)

Scottish Government's Response

The Scottish Government will look to the QEUH Oversight Board report for appropriate recommendations before considering how to take forward action nationally.

This work will build on the existing work across the Scottish Government and NHS Scotland on workplace culture and whistleblowing, and any internal actions being taken forward by NHS GGC.

Part E - Communication

Recommendation 56

56) We welcome NHS GG&C's recent investment in its strategic communications capability. NHS GG&C's Board needs to ensure political and public messaging that is accurate and sensitive:

• To manage adverse events and atypical public disclosures effectively within an overall plan underpinned by values of accountability and transparency;
• To recognize that modern communications need to acknowledge perceptions as well as facts as the NHS Board sees them;
• To adapt to a changing picture including defensive approaches that could include rebuttal of inaccurate reporting and disclosure that is false or threatens confidentiality;
• To recognise tactically within its internal and external communications that declining public trust may necessitate greater disclosure in justifying its actions rather than tighter control on the flow of information (9.14.1)

Scottish Government's Response

The Scottish Government will look to the QEUH Oversight Board report for appropriate recommendations before considering how to take forward action nationally.

Part G - Research, Evaluation and Learning

Recommendations 57 and 58

57) Construction related research and evaluation should be grouped under the following headings:

• Air quality;
• Water quality;
• Sanitary ware;
• Healthcare & BREEAM;
• Microbiology, Environment Health & Public Health;
• Communicating health and risk. (9.16.4)

58) There are three key areas where evidence review and research is urgently needed, so that future technical guidance can be clearer, and project and incident managers can make better decisions:

i. The evidence base for air changes and air quality that protects against infection in a range of hospital settings; we understand that air ventilation systems, the resulting air quality characteristics and their influence on clinical outcomes is an under-researched area.

ii. The need for additional water disinfection for large buildings and little used water outlets, especially where vulnerable people are concerned; several rapid developments are occurring in the realm of modern hospital design, complexity of water systems, microbiological testing relating to water, unusual organisms and vulnerable patients, and the influence of these developments on patient safety and clinical outcomes.

iii. The significance of findings of unusual micro-organisms in patient and environmental sampling. (9.17.1)

Scottish Government's Response

The National Centre will research and share best practice and changes in standards/models for the built environment across the world to inform guidance and capital projects. It will develop a research strategy and define detailed research priorities.

Recommendation 59

59) We ask the Academy of Medical Royal Colleges and Faculties in Scotland and the UK, the Royal College of Nursing, together with the Royal Academy of Engineering, The Royal Incorporation of Architects in Scotland, Architecture and Design Scotland and those with interests in the environmental sciences to examine ways to engender a community of practice and scholarship that enhances collaborative work in improving the healthcare built environment. The National Centre for Reducing Risk in the Healthcare Built Environment should facilitate this initiative with its UK counterparts. (9.20.1)

Scottish Government's Response

The National Centre will lead this exercise.

Recommendation 60

60 - The National Centre for Reducing Risk in the Healthcare Built Environment and local NHS Boards should encourage linkages, facilitate robust networks that are cross-disciplinary, build on experience and form part of career and professional development, anticipate the need for expertise in areas where construction projects and novel interventions are in the planning stages. (9.20.2)

Scottish Government's Response

The National Centre will provide a progressive, cohesive and integrated approach to specialist workforce education development for this multi-agency and multi-professional staff group (both internal and external to the National Centre) in agreed partnership with NES and boards. It will also ensure Boards have access to staff with appropriate skills for projects, and assigned staff have the time, training and support to undertake their role.

Recommendation 61

61 - The National Centre and participants should recognise that lessons are often held in organisations at a distance from host institutions by the very nature of unusual occurrences and occasional projects, and that they should create a 'safe space' where experience that is reputationally sensitive can flow more freely. (9.20.3)

Scottish Government's Response

The National Centre will support the routine and effective collation, and appropriate dissemination of lessons learned across NHS Scotland.

Part I - Duty of Candour

Recommendation 62

62) Infection Control specialists should reflect as a group on the development of their role in Duty of Candour relating to HAIs. They should share examples in confidence as a learning process, with a view to sharing experience. As these events are unusual, such learning should be on a Scotland-wide basis, in a confidential setting. It may subsequently form a critical event for reporting and discussion in enhanced professional appraisal. (9.28.1)

Scottish Government's Response

The Scottish Government will look to the QEUH Oversight Board report for appropriate recommendations before considering how to take forward action nationally.

Recommendation 63

63) Those responsible for Duty of Candour Policy in NHS Boards and Government may wish to review their operational processes to allow for this eventuality. They should consider how to apply the Duty consistently relating to HAI, encompassing governance to acknowledge events that have triggered a Duty action, along with a review of any learning that might arise from the Duty investigation. (9.28.2)

Scottish Government's Response

The Scottish Government will look to the QEUH Oversight Board report for appropriate recommendations before considering how to take forward action nationally.