The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report

Chapter 3 Preventing and controlling infection

The report identifies a wide range of system and individual failures that had a profound influence on the infection prevention and control services offered to patients at the Vale of Leven Hospital (VOLH). We accept in full all the report's recommendations on how infection prevention and control structures, policies, procedures and practices can be strengthened at NHS board and individual unit level.

The measures put in place since 2008 by the national HAI Taskforce (see Chapter 2) have achieved notable success in raising staff and public awareness of the risks of infection, reducing HAI and improving healthcare outcomes. Our aim now is to ensure that the momentum created by the Taskforce's work at national level continues to drive improvement in practice in NHS boards.

In this chapter, we focus on key elements of preventing and controlling infection in hospitals highlighted by the report, specifically in relation to:

• patient safety, environmental integrity and cleanliness
• NHS board-level policies and procedures
• auditing, quality assurance and improvement.

3.1 Patient safety, environmental integrity and cleanliness

This section focuses on actions at ward and NHS board level that will serve to protect patient safety and ensure that the environments in which they are cared for are clean and fit for purpose. It relates to report recommendations: 29, 63, 64, 65 and 66.

What the report tells us

A ward patient who contracts C. diff is clearly at risk of serious health problems and requires immediate and skilled care and treatment, but the report warns that staff must also remain ever-vigilant to the threat the infection poses to others. It urges NHS boards to ensure effective isolation of patients who are suspected of contracting C. diff infection, with procedures in place to ensure that any failure to isolate is reported to senior management (recommendation 63).

The main way to prevent cross-infection is to isolate the patient in a single room, but as the report recognises, it may be necessary as a last resort in exceptional circumstances and under strict conditions of dedicated nursing to cohort^[11] patients because of a lack of single rooms. Cohorting should not be used as a substitute for single-room isolation, it states (recommendation 64), and appropriate steps should always be taken to isolate patients with potentially infectious diarrhoea (recommendation 65).

The healthcare environment should not compromise effective infection prevention and control. Poor maintenance practices, such as the acceptance of non-intact surfaces, should not be tolerated, the report states (recommendation 66).

Nurses who gave oral evidence to the Inquiry accepted that patients were not always weighed on admission and that some were not weighed regularly thereafter. They offered various explanations for this, one of which was a lack of appropriate weighing equipment. The report recommends that NHS boards should ensure appropriate weighing equipment in each ward, with patients being weighed on admission and at least weekly thereafter (with weights recorded). Faulty equipment should be repaired or replaced and a contingency plan should be in place in the event of delays (recommendation 29).

The report acknowledges that good and appropriate hand hygiene is essential to prevent or reduce contamination, as is maintenance of the healthcare environment, with thorough cleaning of all areas to prevent contamination of surfaces.

Our current position

Promoting patient safety

The scope and scale of ambition for patient safety in Scotland is far-reaching. The Scottish Patient Safety Programme (SPSP), Healthcare Improvement Scotland and NHS Education for Scotland are among those we are working with to build a safety-aware improvement culture throughout the service.

Scottish Patient Safety Programme

The SPSP helps us to achieve the ambition set out in the Healthcare Quality Strategy for NHSScotland that "there will be no avoidable injury or harm to people from healthcare".

The SPSP has sought to engage frontline staff in improvement work by promoting the application of a set of tested, evidence-based interventions and a common improvement model. Changes are led by staff directly involved in caring for patients, who can monitor improvements through the collection of real-time data in their units.

Scottish Patient Safety Indicator
The new Scottish Patient Safety Indicator focuses on reducing key preventable harms in acute hospitals and supporting progress towards the aim of achieving 95% harm-free care. It promotes a person-centred approach to reducing harm experienced by patients in acute healthcare settings and brings together existing improvement work across hospital teams.

The next steps for the SPSP are to spread and sustain the initial improvements that have been made. This will be achieved by Healthcare Improvement Scotland supporting NHS boards to fully implement the 10 Patient Safety Essentials.

The 10 Patient Safety Essentials

The 10 Patient Safety Essentials, which have been part of the SPSP since it was launched in 2008, are evidence-based, time-tested and internationally recognised as being fundamentally important to safe care. They include leadership walk-rounds (allowing leaders, including executive and non-executive directors, and frontline staff to discuss and reduce barriers to reliably delivering safe care), ward safety briefs (to improve communication and awareness for teams in hospital wards), hand hygiene and infection prevention and control care bundles (see Chapter 2), a standardised early warning scoring system (which alerts health staff quickly to how ill patients are) and a surgical checklist (using a model developed by the World Health Organization (WHO) that has contributed to a 18.7% reduction in surgical mortality in Scotland between 2008 and 2014). Healthcare Improvement Scotland has been working with boards to ensure that staff are supported to deliver the measures reliably and consistently. They have also been considering the effectiveness of board monitoring of the 10 Patient Safety Essentials and ensuring that arrangements are in place to provide support for implementation as required.

Due to the success of the SPSP, the programmes were continued and expanded in January 2013, building on the established practices and progress made in the first five years to include work in maternal and children's health services and mental health and primary care settings.

Leadership and infrastructure for safety

The different parts of the SPSP share common requirements for leadership and infrastructure. Healthcare Improvement Scotland is visiting all NHS boards to evaluate and promote safety work, with an emphasis on supporting local leadership and infrastructure and encouraging integration across and between programmes.

Healthcare Improvement Scotland developed a strategic delivery plan for the SPSP in 2014, identifying seven challenges common to all elements of the SPSP:

1. promoting improvement capacity and capability in NHS boards

2. using data to drive improvements

3. evaluating safety interventions and the SPSP

4. assessing NHS boards' capacity to spread and sustain improvement

5. reviewing and improving the SPSP delivery model

6. reviewing and improving the national SPSP infrastructure

7. improving the integration of safety work with other national improvement programmes.

Work is now ongoing to promote improvement across all seven areas.

Actions at NHS board level

The events at the VOLH led to an unprecedented review of infection prevention and control processes, structures and practices across NHSScotland. Key areas scrutinised included the structures and resources to deliver an effective infection prevention and control service, NHS board performance against the Healthcare Associated Infection (HAI) Standards and the National Infection Prevention and Control Manual, and compliance with HAI Taskforce guidelines.

Measures driven by the HAI Taskforce Delivery Plan

The national HAI Taskforce Delivery Plan April 2008 to March 2011, published in March 2008 following the outbreak of C. diff and associated deaths at the VOLH, brought patient safety and environmental cleanliness to the fore. NHS boards received support, guidance and expert advice in implementing the plan and all of its elements are now being applied in every board, with the Healthcare Environment Inspectorate (HEI) providing detailed scrutiny through announced and unannounced inspections (see Chapter 2).

Promoting hand hygiene compliance in NHS boards

As Chapter 2 explains, hand hygiene compliance monitoring is no longer carried out nationally. NHS boards are responsible for monitoring and recording their own performance, using Scottish Government minimum requirements for hand hygiene monitoring.

To support hand hygiene in NHS boards, we have funded Health Protection Scotland to develop a way of identifying the level of use of hand hygiene products and disposable gloves. This initiative, which is recommended by WHO, promotes hand hygiene compliance by providing feedback that encourages discussion of practice at board level.

NHS board HAI reporting templates enable each acute hospital and key community hospital to monitor hand hygiene and cleaning compliance. Hospitals carry out regular audits, producing "report cards" that present information on hand hygiene compliance broken down by staff group and technique used.

Cleaning and estates

NHSScotland National Cleaning Services Specification monitoring framework

The patient care environment was highlighted as a concern in the report and has also featured in HEI inspections. Health Facilities Scotland revised the NHSScotland National Cleaning Services Specification in 2009 and developed a monitoring framework to enable NHS boards to assess the physical healthcare environment and identify areas for repairs and improvements.

How does the monitoring framework operate?

The monitoring framework enables ongoing assessment of the outcomes of cleaning processes. This means NHS boards can assess the extent to which cleaning procedures are being carried out correctly and identify any necessary action. The fundamental principle of "continuous improvement" forms an essential component of the monitoring framework. It therefore not only provides a reporting mechanism, but also a rectification process that can be used locally to identify, prioritise and address issues of non-compliance.

Health Facilities Scotland publishes national cleaning services specification quarterly compliance reports. These show that since the first report in June 2006, NHS Greater Glasgow & Clyde's performance improved from 94.2% compliance to 95% by 2007, and has remained at around 95%: this equates to a "green" compliance rating.^[12]

We announced in April 2009 that over £5 million was to be made available in 2009/10 to support recruitment of additional cleaners to ensure the highest standards of cleaning in NHSScotland. Funding has been sustained at this level since then, and there will be no further privatisation of cleaning contracts in NHS boards.

Investment in NHS estates, assets, facilities and equipment

Having the right facilities in the right place is important to the people who use NHSScotland services. We are constantly looking to improve the NHSScotland asset base (things like property, medical equipment, vehicles and information technology) and capital allocations. We have committed over £400 million to improve NHS infrastructure between 2014 and 2016, and an additional estimated £500 million through the Non-Profit Distributing Model (which was developed to replace the discredited Private Finance Initiative) and hub programmes.

Investment in backlog maintenance and improvement in the physical condition of NHS buildings contributes to the provision of a clean and safe environment. The 2014 report on the state of NHSScotland assets and facilities, based on a standard method developed to categorise backlog maintenance consistently across Scotland, detailed overall backlog maintenance in NHSScotland of £797 million. This represents a £213 million reduction since 2011, with high-risk backlog reduced by 60%.^[13] We expect all the significant and high-risk backlog maintenance identified by 2012 (£424 million) to be eliminated over the next five years. The backlog at the VOLH is currently £4.8 million, with £494,000 identified as high-risk.

We recognise that investment continues to be required for planned preventative maintenance to avoid the creation of new backlog pressures. Actions and measures to track NHS boards' progress in tackling backlog maintenance year-on-year are already in place. Local prioritisation of available resources is necessary, but the timing of planned asset disposals can change subject to planning processes and local market conditions. We are investing £5 million over three years to support enabling works and planning to support the disposals process. This will generate disposal income that can be reinvested in the estate and remove backlog and other costs, such as security and rates, from surplus sites.

NHS boards determine how they prioritise spend on their hospital estate. Boards receive a formula-based funding allocation to cover routine maintenance and equipment replacement, with project-specific funding also being allocated. While the overall capital budget across NHSScotland will decline in 2015/16, formula allocations to NHS boards will rise to £157.2 million, an increase of 8% on 2014/15. This will allow boards to continue to focus on maintenance and equipment replacement.

Single-room accommodation and bed spacing

All planned new-build hospitals in Scotland are now required to provide 100% single-room accommodation for patients, and refurbished hospital builds have to ensure at least 50% single-room accommodation. This will make a significant contribution to reducing patients' risk of contracting and passing on infection.

Bed spacing is often thought of as the space between adjoining beds in a multi-bedded ward. Virtually all of the research work in relation to positioning of hospital beds, however, has looked at ergonomics rather than infection risk, so the published standard refers to required access space around the bed, rather than distance between beds.

The current bed-spacing requirement set by the Scottish Government is for a space of 3.6m (11.10 feet) wide by 3.7m (12.1 feet) deep. NHS boards should seek to achieve this when carrying out refurbishment work to existing multi-bedded ward accommodation, meaning that consideration may have to be given to reducing the number of beds in rooms. They should strive to achieve this standard in all accommodation, taking into account factors such as their inpatient population, the impact of any ongoing refurbishment work and the opinions of the local infection prevention and control team.

The standard is not legally enforceable, but we are working with NHS boards and Health Facilities Scotland to ensure that it is met over time. If any NHS board is unable to achieve the standard in a particular facility because of physical constraints, the board should ensure that protocols are in place to protect patients and others.

3.2 NHS board-level policy and procedures

This section describes policies and procedures at NHS board level that are designed to promote patient safety and protect people from infection. It relates to report recommendations: 3, 16, 32, 33, 34, 35, 40, 41, 53, 55, 56, 57, 58, 59, 61 and 72.

What the report tells us

The report underscores the importance of NHS board policies reflecting up-to-date evidence and guidance, and of appropriate procedures being in place to enable rapid reporting of suspected outbreaks of C. diff infection to infection prevention and control teams (recommendations 3 and 16). Specific measures to ensure policies on prudent antimicrobial prescribing are followed are set out in recommendations 34, 35 and 40.

The need for timely and appropriate transfer of information is highlighted throughout the report, with NHS board responsibility for ensuring escalation of concerns about nurse staffing issues and investigation of complaints specified in recommendations 32 and 33. Elimination of delays in processing laboratory specimens and managing patients with infections are addressed in recommendation 41.

Issues in NHS boards relating to surveillance (recommendation 53), reporting (55), the constitution, activities and recording of key groups responsible for monitoring infection prevention and control (56-59), unannounced inspections of clinical areas (61) and internal investigations (72) are comprehensively addressed.

Our current position

HAI structures in NHS boards

HAI committees and reporting structures

NHS boards are required to have infection-control committee structures in place to support board-to-ward and ward-to-board communication. Each board has HAI executive leads and infection control managers within their committee structures.

Antimicrobial management teams in NHS boards

National initiatives to improve antimicrobial prescribing practices are supported at board level by NHS board antimicrobial management teams (AMTs). AMTs have been established in all boards to maintain antimicrobial stewardship activities at local level (the effectiveness of which is scrutinised in HEI inspections), promote application of antimicrobial policies in hospitals and other settings, and support audit and feedback activities.

AMTs have been driving comprehensive approaches to education on antimicrobial stewardship for clinical staff. A national AMT network has been established to enable AMTs in different boards to share experience and good practice.

Surveillance

As Chapter 2 notes, national and local surveillance data are collected across a range of areas to support and monitor HAI policy. Guidance on local HAI surveillance programmes has been developed by Health Protection Scotland, supporting NHS boards to develop effective local data-driven infection prevention and control systems.

Feedback and complaints

The Patient Rights (Scotland) Act 2011 (see Chapter 2) includes a new right for people to complain, raise concerns, make comments and give feedback about the services they have received from the NHS. It also places a duty on NHS boards to actively encourage feedback as a tool for continuous improvement, monitor, take action and share learning from views received, and publicise their feedback and complaints processes. Boards produce an annual report on the feedback, comments, concerns and complaints they have received, explaining how they are using the information to improve services.

The Scottish Health Council reported in April 2014 that all NHS boards have made some progress in responding to the aspirations of the Act, with many being able to demonstrate innovative thinking and techniques in their handling of complaints and feedback. The Council's Listening and Learning report nevertheless identifies three significant learning points to focus improvement activity moving forward:

• remove the fear factor - effort should be made to transform the culture to support staff and the public to be open and confident in giving and receiving feedback
• welcome feedback - NHS boards must widely publicise the information people need to give feedback and make complaints and support them to do so
• show the improvement - there must be a focus on learning from feedback, implementing changes and informing people what improvements have been made as a result.

Listening and Learning was positively received by NHS chief executives in May 2014. We are now working with NHS boards, the Scottish Public Services Ombudsman, the Scottish Health Council and other partners to take forward its recommendations.

These include a recommendation that the Scottish Public Services Ombudsman's Complaints Standards Authority should lead on the development of a revised NHS model complaints procedure. The changes proposed as part of this revised procedure - including the introduction of a distinct five working‑day stage for early local resolution of complaints - will bring the NHS system more closely into line with that operating in other public service sectors.

We updated our Can I Help You? guidance on handling and learning from feedback, comments, concerns and complaints about NHS services in April 2012. We also provided funding to enable NHS Education for Scotland and the Scottish Public Services Ombudsman to develop and deliver training for NHS staff and other NHS service providers on responding to feedback, comments, concerns and complaints in accordance with the aspirations of the Patient Rights (Scotland) Act 2011.

We have supported the national roll‑out of the independent Patient Opinion website since April 2013. This provides an anonymous online route for people to share their experiences of care - good or bad - directly with boards and engage in constructive dialogue with them about how services can be improved.

Under integration of health and social care, NHS boards and local authorities remain the responsible bodies for delivering health and social care services. Complaints about service delivery will be dealt with through existing statutory health and social work complaints procedures. Work is underway to align social work complaints with health complaints in line with the Scottish Public Services Ombudsman's model complaints handling procedures, so that the stages of complaint handling are aligned. Referral to the Scottish Public Services Ombudsman is the final stage in the complaint handling process, whether the complaint relates to a health or social work matter.

Duty of candour

Healthcare Improvement Scotland published the second edition of its Learning from Adverse Events through Reporting and Review national framework in 2013. Since then, we have seen significant improvements across the country in NHS boards identifying episodes of harm, informing and supporting the people affected, providing staff training and focusing on learning and improvements. We now want to further support boards to act in an open and transparent way with people when something has gone wrong with their care and treatment by introducing a statutory duty of candour. The introduction of a statutory duty of candour will support the move towards a planned, coordinated and consistent approach that supports respectful disclosure of episodes of harm. It will ensure services are open and honest with people and that staff involved in disclosing harm and supporting people affected by it undergo appropriate training. Public reporting of the application of a duty of candour procedure that includes an emphasis on learning and improvement actions will be an essential aspect. The duty of candour will emphasise the importance of ensuring that: people are told about the harmful event(s) and are involved in the process of review all people affected have access to support staff have the right training and support when it is necessary to disclose harm the public is informed about the arrangements, providing assurance about accountability and promoting confidence in a culture that emphasises learning when there has been an unintended or unexpected incident resulting in harm. Introducing legislation is a powerful signal of our recognition of the importance of transparency, candour, engagement and support, all of which will further enhance work to establish a learning culture that puts people at the centre of the health and care delivery system.

Data systems for acute hospitals

We are working to streamline and make more accessible the wealth of information and data available on the quality of hospital care in NHSScotland. Much of this work is rightly being taken forward at NHS board level.

Recent information technology developments have allowed NHS board teams to improve services by linking data from various local systems to create information "dashboards". These dashboards provide a visual display, usually on a single computer screen, of the most important information currently available on a selected topic. NHS boards' ability to access national datasets on, for instance, acute care, cancer and mental illness, enables them to monitor their own performance against the national picture.^[14]

The Hospital Scorecard

The Hospital Scorecard was developed to provide assurance about hospital performance following the Public Inquiry into systems failures at the Mid-Staffordshire NHS Foundation Trust in England.14 It consists of the following indicators: hospital mortality rates readmissions to medical and surgical units length of stay in medical and surgical units waiting times in accident & emergency departments C. diff infection rates Staphylococcus aureus bloodstream infection rates the patient experience survey. The scorecard is produced quarterly and allows comparison of each hospital's performance against the national average. It also identifies "outliers" - hospitals whose performance is significantly different from the norm - that may warrant further investigation or scrutiny and on which the Scottish Government will engage with NHS boards. For more information, go to: http://www.isdscotland.org/Health-Topics/Quality-Indicators/Hospital-Scorecard/

3.3 Auditing, quality assurance and improvement

This section describes how auditing, quality assurance and improvement methods are being advanced across Scotland. It relates to report recommendations: 14, 26, 38, 52, 61 and 62.

What the report tells us

Deficiencies in record-keeping and documentation of patient progress by nurses and doctors are highlighted in the report, which points out that good record-keeping is integral to good patient care (for more on record-keeping, see Chapter 4). Insufficient involvement of nurse managers and senior medical staff is identified as making a significant contribution to the lack of auditing of records that was evident to the Inquiry Team (recommendations 14, 26 and 38).

NHS boards are called to account for auditing adherence to infection and prevention control policies at least annually (recommendation 52), backed by unannounced inspections of clinical areas by senior infection prevention and control staff and lay representatives to ensure quality in relation to infection prevention and control practice (recommendation 61). Senior managers and infection prevention and control staff should visit clinical areas at least weekly to verify quality in infection prevention and control practices (recommendation 62).

Our current position

Quality improvement

Quality improvement uses a range of methods, such as audit, to deliver change that improves outcomes for people receiving services. It is not just about methods and science, however: it is also about culture.

We speak about a "culture of improvement" in which staff want to learn, to develop their services to meet patients' needs better, to receive criticism positively and see it as a means to improve practice, and to introduce change objectively and without fear.

It is also about a way of thinking and seeing the world. People who have been trained in, and understand the concept and practicalities of, quality improvement tend to adopt a "default position" of viewing services and outcomes through a "quality lens". This is the kind of approach, culture and mindset we are aiming to embed in the service through our Healthcare Quality Strategy for NHSScotland and other measures.

Quality improvement is being taken forward in partnership with performance management techniques to improve services and ensure delivery to an agreed standard.

Quality improvement and performance management approach for NHS boards

Performance management processes help clarify policy objectives, measure and report performance, and target support.

Local delivery plans describe how NHS boards will respond to the Scottish Government's priorities, which are set out in the Local Delivery Plan Standards (formerly HEAT targets - see Chapter 2) and improvement priorities. They are underpinned by financial and workforce plans and reflect the ambitions and aspirations of the Healthcare Quality Strategy for NHSScotland and the 2020 Vision.

We introduced 10 Performance Management Principles for NHS boards to ensure local delivery plan targets are delivered in the spirit of improvement. A key principle encapsulates this by stating: "Clinical decision making in the interest of the patient is always more important than unequivocal delivery of performance measures".

The Quality Measurement Framework

The Quality Measurement Framework brings a structure to the many different measurements in use across NHSScotland. It allows the Government and NHS boards to set priorities and demonstrate improvements locally and nationally.

The framework has three levels:

• national reporting towards achievement of the Quality Ambitions (person-centred, safe and effective care)
• national performance management targets for NHS boards (the Local Delivery Plan Standards/HEAT targets)
• all other measures required for quality improvement nationally and locally.

As we mentioned in Chapter 2, we are now designing an integrated health and social care measurement framework.

Annual NHS board reviews and performance reports

NHS boards hold either ministerial or non-ministerial reviews annually. Ministerial reviews are prioritised on the basis of local circumstances, with each NHS board receiving at least one per parliamentary session. The reviews continue to provide a key mechanism for holding boards to account for their performance, focusing particularly on the impact they are having on delivering outcomes related to the Quality Ambitions, 2020 Vision and Local Delivery Plan Standards/HEAT targets.

We monitor each NHS board's performance on an ongoing basis, including performance against Local Delivery Plan Standards/HEAT targets, published scrutiny reports and other audits and statistics. If we find that an NHS board is facing significant challenges in delivering quality services for patients, we invoke our performance support arrangements. These include a range of supportive measures, such as developing enhanced management information, performing diagnostic visits and providing expert advice.

Scotland Performs

In addition to reporting on progress against national indicators, the Scotland Performs website provides a one-stop shop for information on NHS board performance against Local Delivery Plan Standards/HEAT targets. It includes information on why the standards are important, latest performance data and links to further information. This complements the information reported in the NHSScotland Chief Executive's annual report. We are developing a new web tool, NHS Performs, to provide easy access to information on hospital-level performance and the pressures they face.

The Scottish Health and Care Experience Survey Programme

Now in its fifth year, the Scottish Health and Care Experience Survey Programme provides valuable information on people's experiences of acute and community health and care services.

Nationally, surveys conducted as part of the programme help us understand variation across Scotland and identify progress against key policy objectives. Locally, they allow NHS boards to identify variation within their own area, benchmark with the rest of Scotland and track changes over time. The results are used by boards alongside other feedback mechanisms (such as complaints) to help them recognise progress and identify areas for improvement.

The 2014 hospital inpatient survey indicates that the vast majority - 89% - of inpatients in Scotland reported that their overall care and treatment was either "good" or "excellent".

The 2014 Scottish Health and Care Experience Survey Programme hospital inpatient survey: Vale of Leven Hospital results

Taken as a whole, the VOLH's results are positive. Patient experience has improved since the previous survey (2012) and the hospital scored very positively on questions relating specifically to cleanliness of the hospital environment and hand washing. The overall rating for care and treatment was 94% "good" or "excellent", which was 5% higher than the Scotland average, and 4% higher than the 2012 survey. Specific findings from the survey include: hand-wash gels being available for visitors and patients to use (98%, 3% higher than the Scotland average) doctors washing their hands at appropriate times (95%, a 6% improvement on 2012 and 4% higher than the Scotland average) the main ward or room patients stayed in being considered clean (99%, 4% higher than the Scotland average) and bathrooms and toilets being considered clean (98%, 7% higher) staff taking account of the things that matter to patients (75%, 11% higher than the Scotland average), providing emotional support (76%, 9% higher) and treating patients with compassion and understanding (82%, 8% higher).