Case Study: Chesterfield Royal Hospital NHS Foundation Trust The Importance of Good Governance

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1 Case Study: Chesterfield Royal Hospital NHS Foundation Trust The Importance of Good Governance Summary In March 2008, Chesterfield Royal Hospital NHS Foundation Trust experienced increased numbers of new Clostridium difficile infections (C. difficile) and commenced a large scale change programme, aimed at improving the trust s healthcare associated infection (HCAI) prevention and control practices at all levels. As part of this programme they reviewed their infection prevention and control governance processes. The trust found that there were five key aspects that, in hindsight, were crucial to the success of their change programme. They were: 1. Good leadership 2. Good communication 3. Appropriate training and embedding best practice 4. Collective responsibility and accountability 5. Good assurance processes. Chesterfield s change programme was highly successful and strong governance arrangements such as improved leadership arrangements, improved assurance processes and clearer reporting lines, have now been embedded throughout the trust. These have improved infection prevention and control knowledge, skill, practices and processes are now evident across the trust. Introduction Serving North Derbyshire's population and beyond, Chesterfield Royal Hospital NHS Foundation Trust has 550 beds and provides a full range of acute services and 24-hour accident and emergency care. In March 2008, the trust experienced increased numbers of new Clostridium difficile (C. difficile) cases and it was acknowledged that strong leadership and a culture change from the board right down to ward level was needed to address this. In response to this the board requested the development of and subsequently approved a substantial business case to secure and devote resources to a change programme aimed at putting in place new initiatives to improve the trust s infection prevention and control practices. As part of this the board agreed an overarching vision for the programme that of making infection prevention and control and improved quality of care and patient safety the priorities. Once the resources had been identified and the vision was agreed, the focus shifted to: Improving the leadership arrangements, including associated decision-making and reporting Communicating with and to staff about the effort required Ensuring everyone had the skills and capability to make the required changes and embedding new practices Ensuring everyone knew what was expected of them and took responsibility for this Ensuring the appropriate assurance processes were in place to ensure the changes made and successes achieved are sustained

2 Activity Good leadership Once the resourcing and vision for the programme was confirmed the investment in raising the profile of the trust s issues with HCAIs and the effort required to address this began. The change process was led by the board, who encouraged a culture of openness and honesty and, as a first activity, ensured that all board members understood HCAI prevention and control issues and best practice approaches and were, therefore, able to lead and challenge from an informed base. The Director of Nursing, who was also the Director of Infection Prevention and Control retired in December The board took the opportunity to change the focus and approach for this post and made a strategic decision to change this to being a Chief Nurse role, again combining this with the role of Director of Infection Prevention and Control. In April 2009 the new Chief Nurse commenced in post. The strategy adopted by the new Chief Nurse was to provide a visible and accessible style of leadership and, by doing so, provide a board level role model, together with the newly created role of local Infection Control Champion. Seventy six Infection Control Champions were created. The champions were staff from all areas of the trust and their primary function was to provide local leadership, monitor quality and the use of appropriate infection prevention and control processes and practices. They also acted as a local infection prevention and control resource that could be approached by other staff for assistance and guidance. The Infection Control Champion role is still in place in the trust today. As part of this approach, the Chief Nurse has adopted the practice of unannounced spot checks looking at compliance, cleanliness and operational issues effecting compliance with various team members, including the Director of Facilities, the Infection Control Senior Matron and Non Executive Directors. He also works clinically up to one day per week to ensure working practices are optimal and obtains feedback from staff about any issues and patients about their experiences during this time. The trust s governors (locally elected members of the public acting in a critical friend capacity) also undertake ward visits and observe cleanliness and obtain feedback from patients. The results of these informal patient feedback sessions are provided to the matrons and the Chief Nurse. An essential part of establishing improved leadership in this area was developing the appropriate audit and reporting processes and systems so that leaders at every level, from the ward to the board, were assured that changes and progress were being made. One of the key aspects of Chesterfield s reporting system involves the Infection Control Nursing Team, who report to the Chief Nurse via a data sheet, which was updated in real time whenever a new case of either C. difficile or meticillin-resistant Staphylococcus aureus (MRSA). The Chief Nurse shares this with General Managers, the Executive Team and the Strategic Infection Control Committee members. Good communication Another crucial aspect of the change programme was the communication strategy, which reinforced the importance of the work and spread the message of collective responsibility. The trust believes that it was their communication of the vision and associated goals, activity and progress being made towards the goals that led to the change in culture within the trust that meant that preventing and controlling HCAI became a priority for all staff. The communication efforts meant that staff were made aware of the seriousness of the situation, how this had a negative impact on the quality of care and patient safety, and the fact that as part of the programme aimed at changing this, they were now responsible for improvements in this area. The communication approach established via the change programme is ongoing. The communication strategy involved a multi-pronged approach. It included the use of a screensaver (which popped up on screens after only 30 seconds of inactivity) that reinforced the clean you hands message. The intranet homepage included a clock that counts the number of days, hours, minutes and seconds since the last MRSA bacteraemia (this clock is still in place and as of 1.20pm on 10 June 2010 the count since the last MRSA was 126 days, 20 hours, 5 minutes - 2 -

3 and 28 seconds). The trust believes that the MRSA clock is a particularly useful tool for focussing the minds of staff. Other HCAI prevention and control information communication activity involves information being shared with staff via the staff bulletin, on the intranet, via , on staff payslips and posters in staff areas, on ward notice boards and in corridors. Another activity was the sharing of results, which had the desired effects of raising awareness and making staff competitive. Whenever there was an HCAI incident this is shared trust wide along with information about the particular ward s efforts to understand why it occurred and make changes to address any issues. Patient and public involvement and communication was built into the change programme and the results of this is used to inform activity. Patients are asked to complete exit forms that ask questions about the care they received, the cleanliness of the hospital and other metrics. The information is fed back to each ward and is illustrated in the trusts quality report. Training and embedding best practice and ensuring collective responsibility and accountability Significant to the improvement was the recognition by the Executive team that sustainable success would only come from ensuring collective responsibility and that this would only occur if staff were trained and competent to deliver what was expected of them. The Chief Nurse feels strongly that these two areas must have equal attention and that staff will only get on board with the changes and effort required when they do. If changes are expected, but staff do not have the training or competencies then the change will be limited. Also, if the requirement to make changes is accompanied by training, staff will feel that they are being supported to make change. All staff are now required to attend training in key areas of hand hygiene and infection prevention and control best practice. Across the trust, a considerable amount of attention was focussed on improvements in cleanliness and the role of Housekeeper was developed. Housekeepers ensure a focus on efficient and effective cleaning as a matter of course, i.e. on a daily basis and not just in times of deep cleaning, and provide support and advice to other staff as required. They also fill a monitoring and assurance function. Ensuring that all staff take responsibility has been achieved by ensuring staff are competent, making responsibilities clear, devolving monitoring and decision-making aspects to the appropriate team members at the appropriate level and via the development of a reporting structure and data/ information analysis sharing arrangement. Information aimed at supporting decision-making is provided at all levels. More recent efforts aimed at ensuring staff have the ability to undertake what is expected of them has resulted in the appointment of additional pharmacy staff to support more effective use of antibiotics and implement antibiotic pathways. Good assurance processes While the strategy and investment to address the HCAI issues were developed and rolled out in 2008, the trust has ensured that attention and assurance measures have remained at the high levels established during the programme s most intense period. Continued assurance that the leadership and culture of the trust is still focused on addressing HCAI issues is essential to sustaining the improvements made. The in-programme and now post programme assurance efforts consist of: Chief Nurse Quarterly Reports Chief Nurse Quarterly Quality reports to the Board include infection control reports and commentary by the Infection Control Committee who review the results of regular infection control audits, including hand washing. This committee also receives reports from the now - 3 -

4 robust root cause analysis (RCA) process where all HCAI incidents are considered by the admitting consultant, the Matron, ward sister and microbiologist. Weekly infection control meetings Weekly infection control meetings are held to consider retrospective data and advise on the forward look. These meetings chaired and led by the chief nurse include the director of facilities, facilities matron, pharmacy, microbiologists and infection control nurses, plus the principal matron. Patient Surveys In order to provide triangulation, and determine the effectiveness of communication, regular patient surveys are conducted to inform with regard to patient confidence. Every patient who is discharged from an inpatient bed is given a questionnaire to complete and return. This information, coupled with the wards nursing metrics are fed back to each ward team monthly. Monthly nursing forums Monthly nursing forums are held by the principal matron with all the senior nurses to review the results and share good practice. Regular audits of cleanliness, hand hygiene and staff appearance are undertaken and fed back to each Matron, Sister. Outcomes The benefits that Chesterfield have experienced as a result of the successful implementation of the change programme are: Strong HCAI governance has been embedded and there are now clearer systems, clearer reporting lines and improved assurance to the board, management, staff, patients and the public. Increased awareness of the importance and implementation of processes and activity aimed at preventing and controlling HCAI across the trust Improved infection prevention and control knowledge and skills across the trust Improved infection prevention and control practices and processes across the trust Improved patient and public understanding and perceptions of the quality of care provided by the trust. Continued assurance that the leadership and culture of the trust is still focused on addressing HCAI issues beyond the end of the life of the change programme, is essential to sustaining the improvements made. Therefore, Chesterfield is committed to ensuring that these remain a priority. Conclusion The trust found that there were five key aspects that, in hindsight, were crucial to the success of their change programme: 1. Good leadership having good leadership was crucial for the success of the programme. They achieved this in multiple ways, for example, the Chief Executive (CE) stepped into the role of chair of the trust s Strategic Infection Control Committee and the trust board took the decision to change the Director of Nursing role to a Chief Nurse role, with an associated change in scope/ job description. Unlike the Director of Nursing role, which was largely managerial and office based, the Chief Nurse is much more visible throughout the trust and spends time on the wards providing care, leading by example and observing practice. 2. Good communication having a clear vision is one thing, but having the governance structures in place to ensure that it and other relevant aspects of the project are communicated is essential. 3. Training and embedding best practice Chesterfield ensured that staff had the skills and capabilities to undertake the changes in practice and process expected of them, which resulted in staff feeling supported to make the changes required. 4. Ensuring collective responsibility and accountability good governance in this respect is about ensuring that everyone knows what is expected of them and that they will be held - 4 -

5 accountable for this. Chesterfield ensured that they devolved responsibility down and expected everyone to share the responsibility and work towards the goal that had been set. 5. Assurance having appropriate assurance systems in place was crucial to the success of the programme and continue to be essential in ensuring that the improvements made have been sustained. Contact information Case study lead: Alfonzo Tramontano, Chief Nurse and Director of Infection Prevention and Control address: Telephone no: