infection prevention and control commissioning toolkit

Infection Prevention and Control Commissioning ToolkitGuidance and information for nursing and commissioning staff in England

Supported by

A joint RCN and IPS publication

This publication is being reviewed in 2019

This publication is due for review in January 2018. To provide feedback on its contents or on your experience of using the publication, please email [email protected]

RCN Legal Disclaimer

This publication contains information, advice and guidance to help members of the RCN. It is intended for use within the UK but readers are advised that practices may vary in each country and outside the UK.

The information in this booklet has been compiled from professional sources, but its accuracy is not guaranteed. Whilst every effort has been made to ensure the RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which it may be used. Accordingly, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or alleged to be caused directly or indirectly by what is contained in or left out of this website information and guidance.

Published by the Royal College of Nursing, 20 Cavendish Square, London W1G 0RN

© 2016 Royal College of Nursing. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers. This publication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it is published, without the prior consent of the Publishers.

Third Edition

Acknowledgements

The Royal College of Nursing (RCN) and Infection Prevention Society (IPS) would like to thank the following for leading the revision of the publication:

Rose Gallagher, RCN Professional Lead for Infection Prevention and Control

Sarah Turner, Senior Health Protection Nurse, Stockport Metropolitan Borough Council and IPS representative

Chris Sweeney, Associate Head of Health Protection, Wigan Council and IPS representative

Stuart Abrahams, RCN Policy Adviser

We are very grateful for the support and advice of NHS England and members of the RCN/IPS Commissioning workgroup who contributed to the development of this resource.

This is a joint publication by the RCN and IPS. The RCN supports the vision of the IPS that no person is harmed by a preventable infection.

The IPS and RCN’s Infection prevention and control commissioning toolkit was originally developed at a time when the NHS in England was undergoing considerable reform and transition to a new commissioning structure. The toolkit has been revised twice since being first published in 2012. Further revision of the toolkit reflects a more focused approach to developments in infection prevention and control within health and social care and provides direction for future priorities that impact on health, public health and antimicrobial resistance.

This resource assumes all providers of health and social care are fully compliant with the criteria and elements of the Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance (DH, 2015) and The CQC Fundamental Standards (http://www.cqc.org.uk/content/fundamental-standards) introduced in April 2015.

For further information on the IPS and RCN infection prevention and control activity please visit www.ips.uk.net and www.rcn.org.uk/ipc


http://www.cqc.org.uk/content/fundamental-standards

http://www.ips.uk.net

http://www.rcn.org.uk/ipc

mailto:[email protected]

Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety

3 Return to contents

Foreword 4

1. Introduction 5

Developing a strategic focus for prevention of infection 5

Why focus on these issues? 5

Building an evidence base 6

2. How to use this toolkit 8

Who will find the toolkit useful ? 8

3. Reducing the incidence of HCAI: moving towards a zero-tolerance approach 9

Expectations and the role of commissioning organisations 9

Expectations of provider organisations 10

4. Indicators 11

Using the IPC commissioning indicators 11

Mandatory indicators 11

Basket of suggested indicators 11

Quality requirements: threshold method of measurement and consequences of breach 13

Contents

Infection Prevention and Control Commissioning Toolkit

Guidance and information for nursing and commissioning staff in England

5. Appendices: 14

1: Infection prevention and control basket of suggested indicators – secondary care 15

2: Infection prevention and control basket of suggested indicators – primary and community care 27

3: Infection prevention and control basket of suggested indicators – mental health 37

4: Infection prevention and control basket of suggested indicators – social care 48

5: Leading and developing the health care associated infection (HCAI) system 56

7. References and further reading 59


4

InfectIon PreventIon and control commIssIonIng toolkIt

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In recent years vital work has been undertaken across the

health care system to tackle issues associated with infection prevention and control (IPC). The reduction in the number of some health care acquired infections (HCAIs), particularly C. difficile infection which has fallen by 42% since the beginning of the decade, is evidence of the improvements made.

The prevention of infection is fundamental to the safety and quality of care delivered to patients and remains a key priority for the NHS. As the epidemiology of many HCAI cases becomes more complex and as the threat of antimicrobial resistance increases, it is essential that we build on the progress made to date and work to identify new ways to improve practice.

To help achieve this we will need to develop the assurance processes currently in place; focusing our efforts not only on the measurement of targets and objectives, but also on the identification of learning and the implementation of action to drive improved outcomes for patients.

Fundamental to this approach will be the collaboration between different health care organisations to achieve a shared understanding of pertinent issues and ambition to enable improvement across the whole health economy. The commitment and support from leaders across the healthcare system will be vital for supporting this and for ensuring we can continue to drive improvement around infection prevention and control.

NHS England is pleased to support this resource which will help organisations to develop ways of working that meet the current and future challenges associated with this area of national priority.

Commissioners are encouraged to use this tool in the development of purposeful IPC strategies that are shaped, owned and delivered by local health economies.

Foreword

Putting quality at the centre of everything we do

A statement from Dr Mike Durkin, Director of Patient Safety, NHS England




Developing a strategic focus for prevention of infection

The prevention of infection is a key priority for the NHS, as set out in Five Year Forward View (NHS England, 2014) and is central to reducing the need and demand for antibiotics, the main driver for antimicrobial resistance (AMR). Greater investment in the prevention of infection from a public health and infection prevention and control perspective offers one solution to the challenges faced by the NHS and offers part of a solution to enable best use of NHS budget, through improved productivity and efficiency.

Reducing health care associated infections (HCAIs) remains high on the government’s safety agenda and in the general public’s expectations for quality of care. Since 2008, there has been a legal requirement on the NHS and on all health and social care organisations to implement the Health and Social Care Act 2008, and to meet the standards of the Code of Practice within the Act (DH, 2015). The prevention and management of HCAIs has also evolved to become an integral element of new NHS structures developed since the toolkit was first introduced. The recent NHS England ‘Sign up to safety’ campaign and development of national patient safety expert groups/collaboratives and quality improvement initiatives is a positive step forward and an opportunity to support ongoing improvements and learning in infection prevention and control (IPC).

The previous commissioning toolkits were developed to support both commissioning and provider organisations. They focused on helping to ensure that structures, objective setting, processes, monitoring and assurance arrangements and resources for the prevention of HCAIs are in place and regularly reviewed. The RCN and IPS recognise that moving forward, more needs to be done to provide a strategic focus for improvements in the recognition, management and reduction in HCAIs in order to manage the risks associated with antimicrobial

resistance and protect the health and wellbeing of the public, as well as to reduce health care costs. The RCN and IPS believe that the following improvements can be made.

• Commissionersaligningeffortsacrosspublichealth, primary and secondary health care, and social care on key infections that would benefit from a ‘joined up’ approach to prevention, recognition and management.

• Consideringastrategicfocusonthreekeychallenges for inclusion in all future outcomes frameworks which would benefit from collaboration. These are the prevention, recognition and management of:

- pneumonia, including community-acquired pneumonia (CAP) and pneumonia that is acquired as a result of health care

- urinary tract infections (UTIs)

- sepsis.

• Strengtheningtheroleofprimarycareandcommunity services such as general practice, community nursing, heath visiting, community mental health teams and care homes to have a greater role in embedding and supporting public health strategies. This will help reduce the burden of preventable long-term conditions and support population health to reduce the need for health care interventions.

Why focus on these issues?

Pneumonia and UTIs are two of the leading causes of sepsis (Parliamentary and Health Service Ombudsman, 2014). Pneumonia and UTIs can be health care associated and are estimated to be responsible for 19.7% and 13.9% of health care associated infections respectively (HPA, 2012). They are also common in community settings, often developing independently of

Introduction

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Figure 1

Pneumonia, UTIs and sepsis are associated with a number of preventative and improvement strategies associated with health and wider public health. This close interaction offers a unique opportunity to impact on current priorities such as antimicrobial resistance, nutrition and hydration, surveillance of infection, the reduction of health care costs and supporting self-care. Figure 1 illustrates this relationship.

Building an evidence base

The RCN and IPS acknowledge the current lack of evidence supporting the use of the commissioning process to improve patient outcomes through the prevention of infection. Both organisations are committed to contributing to the development of evidence in this area where possible and this toolkit is one example of how this activity has started. The process undertaken for revision of this version of the toolkit is described and includes a review of available evidence and a description of the toolkit development methodology.

Revision methodology

The first edition of the commissioning toolkit was published in 2012 in the absence of any existing guidance on the specific inclusion of IPC for commissioning purposes beyond the requirement to meet national indicators or targets. Developed through expert consensus advice and analysis of available evidence, the toolkit provided a selection of indicators

any contact with health care and are a leading cause of morbidity and mortality.

It is estimated that between 0.5% and 1% of adults will develop CAP every year in the UK. Pneumonia can be a serious illness and 1.2% to 10% of adults admitted to hospital with CAP require care in intensive care units. In these circumstances the estimated risk of dying is more than 30%, with pneumonia-related deaths more common in people aged 84 years and over (NICE, 2014).

The incidence of urinary tract infection increases with age and are the second most common clinical indication for empirical treatment with antibiotics in primary and secondary care (SIGN, 2012). Complications include pyelonephritis, exacerbation of underlying conditions such as diabetes and prostatitis in men. Successful treatment of UTIs is increasingly challenged by the presence of resistant bacteria (for example, extended-spectrum beta-lactamases [ESBL] producing organisms including E. coli, which require treatment with the use of discrete antibiotics which may be toxic, limited in their ability to treat infections successfully, and expensive.

Sepsis occurs as a result of infection and is a leading cause of death in the UK, causing between 36,000 and 64,000 deaths per year. For patients admitted with severe sepsis, there is an overall mortality rate of approximately 35% (Daniels, 2011). The importance of sepsis has been heightened following the publication of the Parliamentary and Health Service Ombudsman report (2014) and announcement on the introduction of a CQUIN to support recognition and management of sepsis.

UTI

CAP

SepsisThis publication is being reviewed in 2019



to support commissioners and providers of NHS care following the introduction of the Health and Social Care Act in 2012, which introduced a focus on clinically, as opposed to centralised commissioning.

This toolkit has been developed to support the principle that health and social care services must be commissioned to achieve high-quality care by delivering safe, effective and efficient services that reflect essential standards for quality and safety. The toolkit takes into account the importance of:

• publicandpopulationhealth

• increasingantimicrobialresistance

• theintroductionofstrategiestoreduceother‘harms’ and the increasing focus on patient safety

• agreateremphasisonoutcomesasameasureofquality.

Further revision of the toolkit provided an opportunity to learn from user feedback and reflect on the experience of clinically-based commissioning over the past two years. Reflection highlighted the need to ensure that IPC priorities remain current and are reflected in provider commissioning contracts, and that assurance processes are robust. This reflection also identified the need to strive to develop outcomes, as opposed to process or structural indicators.

The process for revision was:

• asearchforevidencedemonstratingthevalueoflocal commissioning generally and a systematic search for the impact of IPC as part of commissioning quality requirements

• developmentofindicatortablesthroughexpertknowledge (working group and consultation with professional IPC networks), signposting of applicable evidence and identification of gaps.

A search of the literature identified no prior publications or evidence to inform an established methodology for commissioning of IPC.


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• healthandsocialcareproviderorganisationsinboth acute and community settings

• providerorganisationsthatsub-contractservices

• generalpractitioners

• independentproviderorganisations(forexample,dental and optometry services)

• organisationsconsideringtenderingforNHSprovider services

• localauthoritiesandassociatedhealthandwellbeing boards

• IPCspecialistpractitionersanddirectorsofIPC.

This revised toolkit provides information to support professionals involved in the commissioning or assurance of health and social care services. It seeks to highlight organisational approaches to infection prevention and control across primary, secondary and social care settings.

It provides a series of optional indicators to support performance management and assurance against provider contracts. Where the indicators are used they should recognise and reflect local priorities. Commissioners may additionally wish to develop cross-organisational strategies to ensure consistency across local health economies.

This toolkit also provides an example HCAI reduction plan for commissioners to adapt for local use (see Appendix 5). A HCAI reduction plan is a contractual requirement for all commissioned provider contracts.

Who will find the toolkit useful?

The toolkit will be of particular value to commissioning organisations such as clinical commissioning groups (CCGs) and commissioning support units (CSUs).

It should be used together with expert infection prevention advice to identify priorities and ensure monitoring strategies are used appropriately and proportionally.

The toolkit may be a useful resource for:

• CCGs,commissioningleadswithresponsibilityforIPC, antimicrobial resistance and antimicrobial prescribing

• performancemonitoringteams

• safetyandqualityteams

• NHSEnglandanditsassociatedsub-groups

2How to use this toolkit




• Delivering for patients. The 2015/16 Accountability Framework for NHS trust boards (TDA 2015).

• Everyone counts: planning for patients 2014/15 to 2018/19 (NHSE, 2013).

• Commissioning for quality and innovation (CQUIN) 2015/16 guidance (NHSE, 2015).

• Adult Social Care Outcomes Framework 2015/16 (DH 2014).

• Public Health Outcomes Framework 2013-2016 (DH 2012 updated 2015).

• NationalInstituteforHealthandClinicalExcellence(NICE) guidelines or quality statements.

• Healthbuildingnotes,technicalmemorandaandthe Choice framework for local policy and procedures (CFPP) form a suite of evidence-based policy and guidance documents on the management and decontamination of reusable medical devices (DH, 2013).

• AchievingHCAIreductioninlinewithnationalandlocal objectives.

• Meetingtherequirementsofthe‘compositeindicator’ (when available in 2016).

• ReportingHCAIdeathsonanypartofthedeathcertificate according to local policy and procedures.

• Ensuringthatlessonslearnedfromanyincidentsorregulatory recommendations are completed in a timely way.

All commissioning organisations require assurance about the systems and processes that are in place. This should include evidence which can be used to provide a benchmark or demonstrate improvement in services provided and may include:

Expectations and the role of commissioning organisations

Commissioners and providers must not accept that HCAIs are an inevitable or acceptable risk in health or social care. Commissioning organisations will hold providers to account for their performance, and assess their contribution to sustained improvement in infection prevention and control practices that reduce HCAIs and antimicrobial resistance.

To achieve this they will evaluate local objectives systematically across the organisations they commission services from. They will ensure that there is proportionality to expectations associated with different care settings. Commissioning teams will review available surveillance data so that they can monitor progress against nationally set objectives for specific organisms, other agreed indicators and learning identified from post-infection reviews (PIR) or root cause analysis of incidents.

Commissioning organisations should be assured that all services commissioned or contracted by them, or on their behalf, are compliant with a range of guidance, policy and regulations, as detailed below.

• The NHS Mandate (DH, 2014).

• The NHS Outcomes Framework 2015-2016 (DH, 2015).

• The UK 5 year antimicrobial resistance strategy 2013-2018 (DH, 2013).

• The scope of registration (CQC, 2015).

• Guidance for providers on meeting the regulations (CQC, 2015)

• Risk assessment framework (Monitor, 2015).

Reducing the incidence of HCAI: moving towards a zero-tolerance approach

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• toactivelyengagewiththeprocessesforHCAI/IPCperformance and quality monitoring

• tobeactivemembersofanyrelevanthealtheconomy infection prevention group or other appropriate forums.

• evidenceofservicereview

• receiptofappropriateandadequateinformation

• evidenceofmonitoringinformation

• evidenceofactionbeingundertakenwhenconcernsare raised

• evidenceoffailuretomeetexpectedstandardordiscrepancies in data which been noted by the commissioner

• triangulationofdata–evidenceofimprovedoutcomes in relation to quality parameters of safety, effectiveness and patient experience.

Expectations of provider organisations

There is a legal requirement on all provider organisations to meet the standards described in the Code of practice on the prevention and control of infections and related guidance (DH, 2015). This is integral to CQC registration and ongoing compliance.

This toolkit emphasises further best practice requirements expected of provider organisations, which include:

• tohaveanassuranceframeworkthatreflectsthelocal commissioning organisation’s HCAI reduction plan and contractual requirements

• toundertakeassessmentsoftheircompliancewiththe Code of Practice (DH, 2015) at intervals agreed with the commissioning organisation

• tosubmitcompliancereportstotheboardforinternal assurance and the commissioning organisation for external assurance




should focus on the improvements needed, based on local requirements. Some commissioning and provider organisations may be more highly developed in measuring and reporting indicators than others. However, there should be a common aim to standardise these where possible, whilst developing additional opportunities for quality improvement at a local level. Ideally this should be a shared process between commissioners and providers based on local need and the aim of improving patient safety.

Mandatory indicators

At the time of publication there are only two mandatory objectives included in the national contract including the continued zero tolerance of MRSA blood stream infection and an ongoing focus on reducing C. difficile infections. Additional optional indicators supporting the achievement of these mandatory objectives are provided to support an integrated approach to prevention and management of these infections.

Indicators help organisations understand, compare, predict outcomes and improve care. They should align contractual requirements to compliance with NHS England’s Everyone counts, planning for patients 2014/15 to 2018/19 (2013) and Monitor’s Risk assessment framework (Monitor, 2015). They should be used to support the delivery of the Public health outcomes framework (DH, 2015). Indicators should also reflect requirements to implement national, regional and local best practice guidance. This will ensure that the priorities for infection prevention and control are in provider contracts.

Basket of suggested indicators

In addition to the mandatory indicators a further basket of optional general indicators is provided to meet the needs of different care settings (see appendices) developed by the RCN and the IPS.

An indicator (in the context of improving quality of care) is described as a summary measure that aims to describe in a few numbers as much detail as possible about a system, to help understand, compare, predict, improve, and innovate (RCN, 2009).

Health indicators include process and outcome indicators. Historically the focus has been on process indicators to reflect standards of care that patients receive. The RCN and IPS acknowledge the iterative development of outcome indicators to support improvements in IPC beyond MRSA bloodstream and C. difficile infections.

Using the IPC commissioning indicators

The IPS and the RCN have developed this toolkit for commissioning and provider health and social care organisations to support the commissioning of infection prevention and control and optimal use of antimicrobial agents. Our aim is that the toolkit is an enabling resource designed to support commissioner and provider organisations to communicate and agree the content and ambition of their contract. It is not an alternative to the Code of practice on the prevention and control of infections and related guidance (DH, 2015) but will support organisations to ensure that the quality and safety of care provided is continually improved.

The toolkit includes mandatory indicators, and a basket of indicators to consider for inclusion in local commissioning contracts (see Appendix 1). There is also an example of a local HCAI reduction plan that can be adapted by commissioners for local use (see Appendix 2).

Health and social care commissioners require provider organisations to guarantee clean environments and safe practices to prevent HCAIs. The assurance process should not mirror other compliance or regulations. It

Indicators

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collated, detailed information. Commissioners can also decide that specific assurance for some of the suggested indicators is not required because they are confident that practice is well-embedded. In effect, each provider should have its own unique set of indicators and information schedule requirements to facilitate the robust assurance of performance required on IPC for the specific provider. The IPS has developed quality improvement tools for infection prevention, which are available from the IPS website. They provide evidence-based tools for infection prevention, designed to measure baseline compliance with standards and identify areas for improvement.

Table 1 provides a summary overview of how the indicator overarching heading can be applied to different care settings.

The indicators for each setting have been grouped into several headings. Table 1 provides an overview of the indicators which have been applied to the different care settings.

By suggesting a focus on three key challenges (pneumonia, urinary tract infections and sepsis) relevant to all outcome frameworks this resource provides an opportunity for consideration and further exploration of joint IPC and public health activity, moving forward. Any future national indicators need to be developed over time with the support of leading national organisations and therefore these are included as ‘ambition indicators’ only, which describe generic requirements to help raise awareness and encourage organisations to consider their contribution to these issues. Indicators are presented in the format of the NHS national contract so that users can lift the detail and place it into individual provider contracts. This can also be adapted for inclusion in adult social care contracts.

Commissioners may choose the indicators based on local need and this may be informed by local surveillance data, information from provider compliance reports and other local intelligence. These can be included either as indicators or in the information schedule of the contract as regularly

Table 1

Secondary care Primary care Mental health Social care *

Ambition indicators x x x x

Organisational elements x x x x

Service user involvement x x x

MRSA, CDI and other significant HCAIs

x x x x

IPC practice x x x x

Prescribing x x x N/A*

medicines management

Monitoring x x N/A x

Vaccinations x x x x

Physical health N/A N/A x N/A

*Social care indicator basket has combined indicators proportionate to social care settings and not defined headings as per NHS provider services.




Quality requirement: threshold method of measurement and consequences of breach

Quantifiable measurements are used to reflect the critical success of an organisation, service or provider. As indicators reflect goals, each indicator has a target or plan. The quality requirement serves as a benchmark for comparison or guidance against which a breach may be applied.

Note about thresholds

The indicator baskets (Appendices 1-4) suggest thresholds that can be agreed through local negotiation between commissioner and provider to decide what is appropriate and proportionate.


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The suggested table of indicators are relevant to all health and adult social care settings based on expectations agreed by RCN/IPS members working in commissioning roles. It is anticipated that any indicators selected will be agreed following discussions between commissioner and provider organisations based on the service provided and patient population needs. Suggested indicators are exclusive of the requirements of the Health and Social Care Act (2008), Code of Practice on the prevention and control of infections and related guidance (DH, 2015).

The table reflects the NHS national contract and local quality requirements and is also mapped against the UK five-year antimicrobial resistance strategy (DH, 2013). The consequence of any breaches of quality requirements should be subject to the appropriate clause within local contracts.

Appendices: Infection prevention and control basket of suggested indicatorsThis publication is being reviewed in 2019



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s_R

epor

t_w

eb.p

df

NIC

E (

2015

) Q

ualit

y St

anda

rd U

rina

ry t

ract

infe

ctio

ns

in a

dult

s Q

S90

ww

w.n

ice.

org.

uk/

guid

ance

/qs9

0

NIC

E (

2013

) Q

ualit

y St

anda

rd U

rina

ry t

ract

infe

ctio

n in

infa

nts,

chi

ldre

n an

d yo

ung

peop

le u

nder

16

QS3

6 w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s36

NIC

E C

G 1

61 (

2013

) Fa

lls: a

sses

smen

t and

pre

vent

ion

of

falls

in o

lder

peo

ple

w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g161


http://www.nice.org.uk/guidance/CG191

http://www.ombudsman.org.uk/__data/assets/pdf_file/0004/22666/FINAL_Sepsis_Report_web.pdf

http://www.nice.org.uk/guidance/cg54

http://www.nice.org.uk/guidance/qs61






16


Return to contents

Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/gui

danc

e

Th

e pr

ovid

er h

as in

pl

ace

a st

rate

gy t

hat

de

scri

bes

acti

ons

to

reco

gnis

e, m

easu

re a

nd

man

age

susp

ecte

d ca

ses

of s

epsi

s

Evid

ence

of

stra

tegy

, in

clu

din

g h

ow it

will

be

rev

iew

ed a

nd

eval

uat

ed

Evid

ence

of

stra

tegy

an

d im

plem

enta

tion

pl

an

Stra

tegy

sh

ould

incl

ude

th

e ro

le o

f m

ult

i-di

scip

linar

y st

akeh

olde

rs

and

com

mu

nic

atio

n

path

way

s. S

trat

egy

may

be

dev

elop

ed a

nd

impl

emen

ted

in

colla

bora

tion

wit

h o

ther

pr

ovid

er o

rgan

isat

ion

s

1, 2

NH

S E

ngl

and

(201

5) C

omm

issi

onin

g fo

r qu

alit

y an

d in

nova

tion

(C

QU

IN)

Gui

danc

e fo

r 20

15/1

6

ww

w.e

ngl

and.

nh

s.u

k/w

p-co

nte

nt/

upl

oads

/201

5/03

/9-

cqu

in-g

uid

-201

5-16

.pdf

Parl

iam

enta

ry a

nd

Hea

lth

Ser

vice

s O

mbu

dsm

an

(201

4) T

ime

to A

ct, s

ever

e se

psis

: rap

id d

iagn

osis

and

tr

eatm

ent s

aves

live

s

ww

w.o

mbu

dsm

an.o

rg.u

k/__

data

/ass

ets/

pdf_

file

/000

4/22

666/

FIN

AL

_Sep

sis_

Rep

ort_

web

.pd

f

Org

anis

atio

nal e

lem

ents

IPC

is in

clu

ded

as a

re

gula

r ag

enda

item

in

rele

van

t pr

ovid

er

orga

nis

atio

n m

eeti

ngs

Rec

ord

of m

eeti

ngs

an

d IP

C t

opic

s di

scu

ssed

Min

ute

s of

mee

tin

gsP

rovi

der

to d

eter

min

e w

hic

h m

eeti

ngs

will

ro

uti

nel

y in

clu

de I

PC

di

scu

ssio

n

1B

est

prac

tice

NIC

E (

2014

) Q

ualit

y St

anda

rd I

nfec

tion

pre

vent

ion

and

Con

trol

QS6

1 w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s61

Th

e or

gan

isat

ion

de

velo

ps a

nd

own

s a

boar

d-ap

prov

ed H

CA

I re

duct

ion

pla

n a

nd

prog

ress

is r

epor

ted

agai

nst

th

is

Qu

arte

rly

com

plia

nce

re

por

tsQ

uar

terl

y re

ceip

t of

re

por

ts d

etai

ling

com

plia

nce

an

d pr

ogre

ss a

gain

st

plan

.

Th

e pr

ovid

er m

ay w

ish

to

use

th

e C

ode

of P

ract

ice

to d

evel

op a

n I

PC

pla

n

1N

HS

En

glan

d St

anda

rd C

ontr

act 2

015/

16 a

nd 2

016/

17

ww

w.e

ngl

and.

nh

s.u

k/n

hs-

stan

dard

-con

trac

t/15

-16/

w

ww

.en

glan

d.n

hs.

uk/

nh

s-st

anda

rd-c

ontr

act/

16-1

7/

An

tim

icro

bial

st

ewar

dsh

ip (

AM

S) is

in

clu

ded

as a

reg

ula

r ag

enda

item

in r

elev

ant

prov

ider

org

anis

atio

n

mee

tin

gs

Rec

ord

of m

eeti

ngs

an

d A

MS

top

ics

disc

uss

ed

Min

ute

s of

mee

tin

gsP

rovi

der

to d

eter

min

e w

hic

h m

eeti

ngs

will

ro

uti

nel

y in

clu

de A

MS

disc

uss

ion

2B

est

Pra

ctic

e

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al

stew

ards

hip:

sys

tem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/N

G15

/ch

apte

r/2-

Impl

emen

tati

on-g

etti

ng-

star

ted

NIC

E (

2014

) Q

ualit

y St

anda

rd I

nfec

tion

pre

vent

ion

and

Con

trol

QS6

1

ww

w.n

ice.

org.

uk/

guid

ance

/qs6

1 P

rovi

der

take

s in

to

acco

un

t ad

vice

from

sp

ecia

list

IP

C a

nd

AM

S pr

ovid

er/t

eam

s

Doc

um

enta

tion

an

d de

tails

of

deci

sion

/re

med

ial a

ctio

n

Wh

ere

spec

ialis

t IP

C/

AM

S ad

vice

is n

ot

follo

wed

, th

e ra

tion

ale

and

deci

sion

is

docu

men

ted

and

disc

uss

ed a

t th

e re

leva

nt

mee

tin

g (s

ee t

wo

indi

cato

rs a

bove

)

1B

est

Pra

ctic

e

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al

stew

ards

hip:

sys

tem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/N

G15

/ch

apte

r/2-

Impl

emen

tati

on-g

etti

ng-

star

ted


http://www.england.nhs.uk/wp-content/uploads/2015/03/9-cquin-guid-2015-16.pdf



http://www.england.nhs.uk/nhs-standard-contract/15-16/


http://www.nice.org.uk/guidance/NG15/chapter/2-Implementation-getting-started





Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/gui

danc

e

Th

e or

gan

isat

ion

em

ploy

s or

has

su

ffici

ent

acce

ss t

o a

suit

ably

re

sou

rced

an

d qu

alifi

ed

Infe

ctio

n P

reve

nti

on a

nd

Con

trol

Tea

m (

IPC

T),

A

nti

mic

robi

al

Stew

ards

hip

(A

MS)

te

am o

r sp

ecia

list

prac

titi

oner

to

mee

t th

eir

nee

ds

Spec

ialis

t ad

vise

rs

clea

rly

iden

tifi

able

Rec

ord

of

serv

ice

or

con

trac

t fo

r pr

ovis

ion

of

IPC

an

d A

MS

advi

ce

Con

trac

t m

ay b

e fo

r em

ploy

men

t or

adv

ice

and

shou

ld d

etai

l th

e n

um

ber

of h

ours

em

ploy

ed/c

ontr

acte

d,

role

des

crip

tion

, lin

es o

f co

mm

un

icat

ion

an

d go

vern

ance

str

uct

ure

s fo

r IP

C a

nd

wit

hin

pro

vide

r or

gan

isat

ion

1B

est

prac

tice

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

ww

w.n

ice.

org.

uk/

guid

ance

/QS6

1/ch

apte

r/L

ist-

of-

qual

ity-

stat

emen

ts

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al

stew

ards

hip:

sys

tem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/N

G15

/ch

apte

r/2-

Impl

emen

tati

on-g

etti

ng-

star

ted

Pro

vide

r co

ntr

ibu

tes

to

wh

ole

econ

omy

stra

tegi

c pl

ann

ing

disc

uss

ion

an

d de

cisi

on m

akin

g on

H

CA

I re

duct

ion

Rec

ord

of a

tten

dan

ce

and

con

trib

uti

onM

inu

tes

of m

eeti

ngs

Loca

l HC

AI

prov

ider

or

prof

essi

onal

net

wor

ks

can

be

use

d as

a m

eth

od

of d

emon

stra

tin

g en

gage

men

t in

dis

cuss

ion

an

d pl

ann

ing

1B

est

prac

tice

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

ww

w.n

ice.

org.

uk/

guid

ance

/qs6

1

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al

stew

ards

hip:

sys

tem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/N

G15

/ch

apte

r/2-

Impl

emen

tati

on-g

etti

ng-

star

ted

Cop

ies

of a

ll re

por

ts a

nd

asso

ciat

ed a

ctio

n p

lan

s in

res

pon

se t

o an

y ex

tern

al I

PC

focu

s vi

sits

/in

spec

tion

s (e

.g. f

rom

D

H, C

CG

, CQ

C, T

DA

, M

onit

or)

are

mad

e av

aila

ble

to t

he

com

mis

sion

er b

y th

e pr

ovid

er

Cop

ies

of r

epor

ts s

ent

to c

omm

issi

oner

w

ith

in fi

ve w

orki

ng

days

of

the

prov

ider

re

ceiv

ing

the

rep

ort

Rep

orts

are

rec

eive

d1

Bes

t pr

acti

ce

Boa

rd-a

ppro

ved

ann

ual

re

por

t in

clu

des

deta

ils

on I

PC

tea

m r

esou

rces

An

nu

al r

epor

t in

clu

des

deta

ils o

n

serv

ice

and

spec

ialis

t IP

C (

nu

rse/

doct

or/

supp

ort

staf

f)

reso

urc

e re

quir

emen

ts a

nd

iden

tifi

es w

her

e ga

ps

or r

isks

exi

st

Incl

usi

on in

an

nu

al

rep

ort

IPC

res

ourc

es s

hou

ld

incl

ude

a r

atio

nal

e fo

r st

affi

ng

requ

irem

ents

, in

clu

din

g ‘s

upp

ort’

staf

f su

ch a

s ad

min

, sta

tist

ical

an

alys

is, e

tc. a

nd

both

ac

tual

an

d ag

reed

re

sou

rces

1B

est

prac

tice


http://www.nice.org.uk/guidance/QS61/chapter/List-of-quality-statements




18


Return to contents

Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/gui

danc

e

Ser

vice

use

r in

volv

emen

tSe

rvic

e u

sers

are

in

clu

ded

in I

PC

an

nu

al

prog

ram

me

de

velo

pmen

t, w

ith

pa

tien

t ex

per

ien

ce u

sed

to s

hap

e ac

tivi

ty

Serv

ice

use

r vi

ews

are

acti

vely

sou

ght

and

reco

mm

enda

tion

s in

corp

orat

ed w

her

e ap

prop

riat

e

Evid

ence

an

d d

etai

l of

par

tici

pati

on in

an

nu

al r

epor

t

1,3

Bes

t pr

acti

ce

Serv

ice

use

rs a

re

invo

lved

in t

he

shap

ing

and

impl

emen

tati

on o

f lo

cal p

rogr

amm

es t

o im

prov

e h

and

hygi

ene

of

both

sta

ff a

nd

serv

ice

use

rs in

all

sett

ings

Serv

ice

use

rs a

re

invo

lved

in h

and

hygi

ene

prog

ram

mes

An

nu

al s

um

mar

y of

h

and

hygi

ene

prog

ram

me

acti

vity

, in

clu

din

g u

ser

invo

lvem

ent

1,3

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

ww

w.n

ice.

org.

uk/

guid

ance

/qs6

1

Pati

ents

wit

h in

vasi

ve

devi

ces

such

as

uri

nar

y ca

thet

er, v

ascu

lar

acce

ss

devi

ce o

r en

tera

l fee

din

g tu

be a

nd

thei

r ca

rers

w

ho

hel

p th

em w

ith

th

is

equ

ipm

ent

are

give

n

info

rmat

ion

an

d ad

vice

ab

out

how

to

look

aft

er

the

devi

ce s

afel

y an

d ef

fect

ivel

y

Serv

ice

use

rs a

re

prov

ided

wit

h a

dvic

e an

d ar

e in

volv

ed in

de

term

inin

g de

tail

of

info

rmat

ion

incl

ude

d

An

nu

al s

um

mar

y of

in

form

atio

n

avai

labl

e,

dist

ribu

tion

an

d ev

alu

atio

n in

clu

din

g pa

tien

t/ca

rer

feed

back

1,3

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

ww

w.n

ice.

org.

uk/

guid

ance

/qs6

1

NIC

E (

2012

) C

G 1

39 I

nfec

tion

: Pre

vent

ion

and

cont

rol

of h

ealt

hcar

e-as

soci

ated

infe

ctio

ns in

pri

mar

y an

d co

mm

unit

y ca

re

ww

w.n

ice.

org.

uk/

guid

ance

/cg1

39

MR

SA

, C. d

iffi

cile

and

oth

er s

igni

fica

nt H

CA

IsM

RSA

bac

tera

emia

cas

es

are

not

ified

by

prov

ider

to

com

mis

sion

er b

y n

ext

wor

kin

g da

y (r

efer

to

PIR

pro

cess

)

Not

ifica

tion

of

MR

SA

bact

erae

mia

Mon

thly

co

nfi

rmat

ion

of

per

cen

tage

of

case

s n

otifi

ed b

y n

ext

wor

kin

g da

y

1, 5

Bes

t pr

acti

ce

NH

S E

ngl

and

(201

4) Z

ero

tole

ranc

e

ww

w.e

ngl

and.

nh

s.u

k/pa

tien

tsaf

ety/

asso

ciat

ed-

infe

ctio

ns/

zero

-tol

eran

ce/This publication is being reviewed in 2019




http://www.england.nhs.uk/patientsafety/associated-infections/zero-tolerance/



Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/gui

danc

e

Th

e pr

ovid

er c

ontr

ibu

tes

to t

he

Post

In

fect

ion

R

evie

w (

PIR

) /

RC

A/‘

Lap

se in

car

e’

inve

stig

atio

ns

for

all

case

s of

HC

AI

Con

trib

uti

on t

o th

e P

IR p

roce

ss a

nd

imp

lem

enta

tion

of

acti

on p

lan

s an

d le

arn

ing

deri

ved

from

in

vest

igat

ion

rev

iew

s.

100%

att

enda

nce

at

inve

stig

atio

n

mee

tin

gs

Att

enda

nce

at

PIR

m

eeti

ngs

.

Mon

thly

rep

orti

ng

of a

ll M

RSA

cas

es

and

less

ons

lear

ned

.

Act

ion

pla

n r

epor

ts

are

rece

ived

an

d u

pda

ted

regu

larl

y,

wit

h le

arn

ing

shar

ed

acro

ss t

he

orga

nis

atio

n

Wit

h e

xcep

tion

s of

M

RSA

bac

tera

emia

an

d C

. dif

ficile

infe

ctio

n,

oth

er H

CA

Is t

hat

req

uir

e in

vest

igat

ion

are

to

be

dete

rmin

ed lo

cally

1N

HS

En

glan

d (2

014)

Zer

o to

lera

nce

w

ww

.en

glan

d.n

hs.

uk/

pati

ents

afet

y/as

soci

ated

-in

fect

ion

s/ze

ro-t

oler

ance

/

NH

S E

ngl

and

(201

5) C

lost

ridi

um

dif

fici

le in

fect

ion

obje

ctiv

es fo

r N

HS

orga

nisa

tion

s in

201

5/16

and

gu

idan

ce o

n sa

ncti

on im

plem

enta

tion

w

ww

.en

glan

d.n

hs.

uk/

wp-

con

ten

t/u

ploa

ds/2

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02/

clos

trid

m-d

iffi

cile

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ct-1

5-16

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id-f

eb15

.pd

f

Pati

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o m

eet

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eria

for

MR

SA

scre

enin

g ar

e m

anag

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as p

er lo

cally

agr

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ocol

s an

d al

l pos

itiv

e re

sult

s ar

e ac

ted

up

on

Mon

thly

co

nfi

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ion

of

per

cen

tage

of

elig

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ca

ses

scre

ened

for

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SA

Mon

thly

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eip

t of

sc

reen

ing

data

D

etai

l of

mea

sure

men

t m

eth

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o be

det

erm

ined

lo

cally

, i.e

. pro

toco

l for

el

igib

ility

.

100%

com

plia

nce

is fo

r lo

cal d

eter

min

atio

n

1N

HS

En

glan

d (2

014)

Zer

o to

lera

nce

w

ww

.en

glan

d.n

hs.

uk/

pati

ents

afet

y/as

soci

ated

-in

fect

ion

s/ze

ro-t

oler

ance

/

DH

(20

14)

Impl

emen

tati

on o

f mod

ified

adm

issi

on

MR

SA s

cree

ning

gui

danc

e fo

r N

HS

w

ww

.gov

.uk/

gove

rnm

ent/

upl

oads

/sys

tem

/up

load

s/at

tach

men

t_da

ta/fi

le/3

4514

4/Im

plem

enta

tion

_of_

mod

ified

_adm

issi

on_M

RSA

_scr

een

ing_

guid

ance

_fo

r_N

HS.

pdf

Com

plia

nce

wit

h lo

cally

ag

reed

MR

SA c

are

path

way

Qu

arte

rly

con

firm

atio

n o

f p

erce

nta

ge o

f

MR

SA-p

osit

ive

pati

ents

wh

o fo

llow

an

d co

mpl

ete

the

MR

SA c

are

pat

hway

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arte

rly

rece

ipt

of

MR

SA c

are

path

way

co

mpl

ian

ce d

ata

Car

e pa

thw

ays

shou

ld b

e de

fin

ed lo

cally

an

d al

l pr

ovid

ers

shou

ld b

e aw

are

of t

hes

e an

d co

mpl

y w

ith

th

em.

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side

r in

clu

sion

of

audi

t of

flag

gin

g of

M

RSA

sta

tus

acro

ss a

ll pa

tien

t ad

min

istr

atio

n

syst

ems

acro

ss t

he

path

way

.

Perc

enta

ge c

ompl

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ce

and

met

hod

of

mea

sure

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t fo

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cal

dete

rmin

atio

n

1N

HS

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glan

d (2

014)

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ww

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glan

d.n

hs.

uk/

pati

ents

afet

y/as

soci

ated

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fect

ion

s/ze

ro-t

oler

ance

/This publication is being reviewed in 2019

http://www.england.nhs.uk/wp-content/uploads/2015/02/clostridm-difficile-infect-objct-15-16-guid-feb15.pdf

http://www.england.nhs.uk/ourwork/patientsafety/zero-tolerance/DH

http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/345144/Implementation_of_modified_admission_MRSA_screening_guidance_for_NHS.pdf



20


Return to contents

Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

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mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/gui

danc

e

Com

plia

nce

wit

h lo

cally

ag

reed

C. d

iffic

ile c

are

path

way

Qu

arte

rly

con

firm

atio

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f p

erce

nta

ge o

f C

. di

ffici

le p

atie

nts

wh

o fo

llow

an

d co

mpl

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the

care

pat

hway

Qu

arte

rly

rece

ipt

of

C. d

iffic

ile c

are

path

way

com

plia

nce

da

ta

Car

e pa

thw

ays

shou

ld b

e de

fin

ed lo

cally

an

d al

l pr

ovid

ers

shou

ld b

e aw

are

of t

hem

an

d co

ntr

ibu

te w

her

e re

leva

nt.

Con

side

r in

clu

sion

of

audi

t of

fl

aggi

ng

of C

. dif

ficile

st

atu

s ac

ross

all

pati

ent

adm

inis

trat

ion

sys

tem

s ac

ross

th

e pa

thw

ay.

Perc

enta

ge o

f co

mpl

ian

ce

and

met

hod

of

mea

sure

men

t fo

r lo

cal

dete

rmin

atio

n

1B

est

prac

tice

Pro

vide

r co

ntr

ibu

tes

to

revi

ew o

f al

l CD

I ca

ses

if

invo

lved

in p

rovi

sion

of

care

to

pati

ent

100%

com

plia

nce

w

ith

invo

lvem

ent

in

revi

ew o

f an

y C

DI

case

th

at t

he

prov

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ass

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ted

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Qu

arte

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on o

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iden

ce

dem

onst

rati

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prov

ider

in

volv

emen

t in

re

view

mee

tin

gs a

nd

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ress

wit

h a

ctio

ns

Det

ail o

f m

easu

rem

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to

be d

eter

min

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lly

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HS

En

glan

d (2

015)

Clo

stri

diu

m d

iffi

cile

infe

ctio

n ob

ject

ives

for

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S or

gani

sati

ons

in 2

015/

16 a

nd

guid

ance

on

sanc

tion

impl

emen

tati

on a

t:

ww

w.e

ngl

and.

nh

s.u

k/w

p-co

nte

nt/

upl

oads

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5/02

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ostr

idm

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fici

le-i

nfe

ct-o

bjct

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16-g

uid

-feb

15.p

df

Seri

ous

inci

den

ts

occu

rrin

g in

pri

mar

y ca

re a

re r

epor

ted

to t

he

com

mis

sion

er a

nd

loca

l h

ealt

h p

rote

ctio

n t

eam

w

ith

in o

ne

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kin

g da

y

Not

ifica

tion

of

inci

den

t to

co

mm

issi

oner

wit

hin

on

e w

orki

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day

Mon

thly

rep

orti

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Defi

nit

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of

seri

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inci

den

t to

be

dete

rmin

ed b

y pr

ovid

er

follo

win

g ag

reem

ent

wit

h

com

mis

sion

er.

Ver

ifica

tion

mea

sure

–

STE

IS, N

RL

S, R

CA

, P

IR, p

atie

nt

com

plai

nts

1N

HS

En

glan

d (2

013)

Ser

ious

Inc

iden

t Fra

mew

ork

ww

w.e

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and.

nh

s.u

k/w

p-co

nte

nt/

upl

oads

/201

3/03

/si

f-gu

ide.

pdf

HPA

(20

12)

Hea

lthc

are

Ass

ocia

ted

Infe

ctio

n O

pera

tion

al G

uida

nce

and

Stan

dard

s fo

r H

ealt

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n U

nits

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w.g

ov.u

k/go

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t/pu

blic

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ns/

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n-h

cai-

oper

atio

nal

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idan

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nd-

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dard

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Peri

ods

of I

ncr

ease

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cide

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IIs)

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aks

are

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orte

d to

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e co

mm

issi

oner

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tbre

aks

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orte

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th

e n

ext

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kin

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y

Mon

thly

rep

orti

ng

1,5

CQ

C (

2015

) C

QC

gui

danc

e

ww

w.c

qc.o

rg.u

k/co

nte

nt/

not

ifica

tion

s-n

on-n

hs-

tru

st-

prov

ider

s


http://www.england.nhs.uk/wp-content/uploads/2013/03/sif-guide.pdf

http://www.gov.uk/government/publications/healthcare-associated-infection-hcai-operational-guidance-and-standards

http://www.cqc.org.uk/content/notifications-non-nhs-trust-providers




Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

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Evid

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Com

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wit

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Car

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Con

side

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of

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t of

fl

aggi

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of C

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ficile

st

atu

s ac

ross

all

pati

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adm

inis

trat

ion

sys

tem

s ac

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e pa

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ay.

Perc

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and

met

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of

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cal

dete

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atio

n

1B

est

prac

tice

Pro

vide

r co

ntr

ibu

tes

to

revi

ew o

f al

l CD

I ca

ses

if

invo

lved

in p

rovi

sion

of

care

to

pati

ent

100%

com

plia

nce

w

ith

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lvem

ent

in

revi

ew o

f an

y C

DI

case

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at t

he

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16 a

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guid

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emen

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on a

t:

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w.e

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Seri

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Not

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of

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den

t to

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mm

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nit

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ovid

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g ag

reem

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mis

sion

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Ver

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3/03

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pdf

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pat

ien

t p

opu

lati

on a

nd

serv

ice

spec

ifica

tion

bu

t ca

n

incl

ude

th

e el

emen

ts

outl

ined

in A

ppen

dix

5

1, 3

,5B

est

prac

tice

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

ww

w.n

ice.

org.

uk/

guid

ance

/qs6

1

NIC

E C

G 1

39 (

2012

) In

fect

ion:

Pre

vent

ion

and

cont

rol

of h

ealt

hcar

e-as

soci

ated

infe

ctio

ns in

pri

mar

y an

d co

mm

unit

y ca

re

ww

w.n

ice.

org.

uk/

guid

ance

/cg1

39


http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215835/dh_123292.pdf

http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/329227/Acute_trust_toolkit_for_the_early_detection.pdf

http://www2.rcn.org.uk/__data/assets/pdf_file/0006/481515/004310.pdf



22


Return to contents

Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/gui

danc

e

Th

e pr

ovid

er h

as in

pl

ace

a st

rate

gy a

nd

syst

ems

to p

reve

nt

infe

ctio

ns

asso

ciat

ed

wit

h t

he

use

of

intr

aven

ous

(IV

) th

erap

y

Evid

ence

of

stra

tegy

an

d pr

oces

ses

in u

se

are

prov

ided

to

the

com

mis

sion

er

Six-

mon

thly

re

por

tin

g of

pro

gres

s in

str

ateg

y

IV t

her

apy

incl

ude

s dr

ug

adm

inis

trat

ion

(e.

g.

anti

biot

ics,

ch

emot

her

apy)

, IV

flu

id

ther

apy

or p

aren

tera

l n

utr

itio

n a

dmin

iste

red

via

an in

trav

ascu

lar

acce

ss d

evic

e.

Req

uir

emen

ts a

re fo

r lo

cal d

eter

min

atio

n

base

d on

pat

ien

t p

opu

lati

on a

nd

serv

ice

spec

ifica

tion

bu

t ca

n

incl

ude

ele

men

ts

incl

ude

d w

ith

in

App

endi

x 5

1B

est

prac

tice

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

ww

w.n

ice.

org.

uk/

guid

ance

/qs6

1

Th

e pr

ovid

er h

as in

pl

ace

a st

rate

gy a

nd

syst

ems

to p

reve

nt

infe

ctio

ns

asso

ciat

ed

wit

h t

he

use

of

ente

ral

feed

ing

Evid

ence

of

stra

tegy

an

d pr

oces

ses

in u

se

are

prov

ided

to

the

com

mis

sion

er

Six-

mon

thly

re

por

tin

g of

pro

gres

s in

str

ateg

y

Req

uir

emen

ts a

re fo

r lo

cal d

eter

min

atio

n

base

d on

pat

ien

t p

opu

lati

on a

nd

serv

ice

spec

ifica

tion

bu

t ca

n

incl

ude

th

e el

emen

ts

outl

ined

in A

ppen

dix

5

1,3

Bes

t pr

acti

ce

NIC

E C

G 1

39 (

2012

) In

fect

ion:

Pre

vent

ion

and

cont

rol

of h

ealt

hcar

e-as

soci

ated

infe

ctio

ns in

pri

mar

y an

d co

mm

unit

y ca

re

ww

w.n

ice.

org.

uk/

guid

ance

/cg1

39

Com

plia

nce

wit

h

infe

ctio

n p

reve

nti

on

care

bu

nd

les

(e.g

. hig

h

impa

ct in

terv

enti

ons

(HII

))

Mon

thly

rep

orti

ng

of

com

plia

nce

M

onth

ly

con

firm

atio

n o

f 10

0% c

ompl

ian

ce

Perc

enta

ge o

f co

mpl

ian

ce

and

met

hod

of

mea

sure

men

t fo

r lo

cal

dete

rmin

atio

n

1B

est

prac

tice

100%

pat

ien

ts is

olat

ed

as p

er a

gree

d pr

ovid

er

pol

icy/

adv

ice

from

IP

C

team

Rep

ort

com

plia

nce

w

ith

isol

atio

n p

olic

yQ

uar

terl

y re

por

tin

g in

clu

din

g ex

cep

tion

s of

var

iati

on t

o p

olic

y

Pro

vide

r or

gan

isat

ion

s sh

ould

con

side

r pr

esen

tati

on o

f da

ta t

o in

clu

de n

on-i

sola

tion

of

pati

ents

per

pat

ien

t be

d da

y

1B

est

prac

tice

Com

plia

nce

wit

h

prov

ider

’s h

and

hygi

ene

pol

icy

Bi-

mon

thly

rep

ort

Com

plia

nce

as

sura

nce

wit

h h

and

hygi

ene

pol

icy

Perc

enta

ge o

f co

mpl

ian

ce

and

met

hod

of

mea

sure

men

t fo

r lo

cal

dete

rmin

atio

n

1N

ICE

(20

14)

Qua

lity

Stan

dard

QS6

1 w

ww

.nic

e.or

g.u

k/gu

idan

ce/Q

S61/

chap

ter/

Lis

t-of

-qu

alit

y-st

atem

ents







Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/gui

danc

e

Loca

lly d

eter

min

ed I

PC

tr

ain

ing

prog

ram

me

is

deliv

ered

as

per

loca

lly

agre

ed p

lan

for

each

st

aff

grou

p

Bi-

ann

ual

rep

orts

an

d ev

alu

atio

n o

f tr

ain

ing

prog

ram

me

is

rece

ived

Bi-

ann

ual

rep

orti

ng

Perc

enta

ge o

f co

mpl

ian

ce

and

met

hod

of

mea

sure

men

t fo

r lo

cal

dete

rmin

atio

n

1,3

Alig

ns

wit

h D

H (

2015

) C

ode

of P

ract

ice

Pres

crib

ing

Th

e pr

ovid

er h

as o

r co

ntr

ibu

tes

to a

n

anti

biot

ic s

tew

ard

ship

pr

ogra

mm

e th

at s

pan

s ca

re s

etti

ngs

loca

lly

Evid

ence

of

atte

nda

nce

at

rele

van

t m

eeti

ngs

an

d co

ntr

ibu

tion

to

loca

l A

MS

prog

ram

me

Rep

orti

ng

of

prog

ress

wit

h A

MS

prog

ram

me

Perc

enta

ge o

f co

mpl

ian

ce, m

eth

od o

f m

easu

rem

ent,

incl

usi

on

crit

eria

an

d fr

equ

ency

of

com

plia

nce

ass

essm

ent

for

loca

l det

erm

inat

ion

2,3

Bes

t pr

acti

ce

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al

stew

ards

hip:

sys

tem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/N

G15

/ch

apte

r/2-

Impl

emen

tati

on-g

etti

ng-

star

ted

An

an

tibi

otic

pol

icy

is in

pl

ace

that

refl

ects

n

atio

nal

pre

scri

bin

g gu

idan

ce

Pre

sen

ce o

f an

tibi

otic

p

olic

yA

nn

ual

con

firm

atio

n

of p

olic

y in

pla

cePo

licy

shou

ld b

e re

view

ed m

inim

um

of

two-

year

ly u

nle

ss n

ew

nat

ion

al g

uid

ance

issu

ed

2N

ICE

Gu

idel

ine

NG

15 (

2015

) A

ntim

icro

bial

st

ewar

dshi

p: s

yste

ms

and

proc

esse

s fo

r ef

fect

ive

anti

mic

robi

al m

edic

ine

use

ww

w.n

ice.

org.

uk/

guid

ance

/NG

15/c

hap

ter/

2-Im

plem

enta

tion

-get

tin

g-st

arte

d

Com

plia

nce

wit

h lo

cal

anti

biot

ic p

olic

ies

Rep

orti

ng

of

com

plia

nce

, in

clu

din

g if

th

ere

is e

vide

nce

of

just

ifiab

le c

linic

al

reas

ons

for

devi

atio

n

from

set

form

ula

ry

Au

dit

of c

ompl

ian

ce

wit

h t

he

anti

biot

ic

pres

crib

ing

form

ula

ry

Perc

enta

ge o

f co

mpl

ian

ce, m

eth

od o

f m

easu

rem

ent,

incl

usi

on

crit

eria

an

d fr

equ

ency

of

com

plia

nce

ass

essm

ent

for

loca

l det

erm

inat

ion

2N

ICE

Gu

idel

ine

NG

15 (

2015

) A

ntim

icro

bial

st

ewar

dshi

p: s

yste

ms

and

proc

esse

s fo

r ef

fect

ive

anti

mic

robi

al m

edic

ine

use

ww

w.n

ice.

org.

uk/

guid

ance

/NG

15/c

hap

ter/

2-Im

plem

enta

tion

-get

tin

g-st

arte

d

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

ww

w.n

ice.

org.

uk/

guid

ance

/qs6

1

DH

(20

11)

Star

t SM

AR

T th

en F

ocus

w

ww

.gov

.uk/

gove

rnm

ent/

publ

icat

ion

s/an

tim

icro

bial

-st

ewar

dsh

ip-s

tart

-sm

art-

then

-foc

us

Pre

scri

bers

mee

t th

eir

prof

essi

onal

sta

nda

rds

of

edu

cati

on a

nd

com

pet

ency

An

nu

al r

epor

t of

tr

ain

ing

and

com

pet

ency

An

nu

al r

epor

t an

d an

alys

is a

gain

st

qual

ity

requ

irem

ent

Info

rmat

ion

sh

ould

be

prov

ided

on

th

e n

um

bers

of

dif

fere

nt

prof

essi

onal

gr

oups

rec

eivi

ng

trai

nin

g an

d co

mp

eten

cy

asse

ssm

ent

com

pare

d to

th

ose

that

are

elig

ible

2,3

Pu

blic

Hea

lth

En

glan

d (2

013)

Ant

imic

robi

al

pres

crib

ing

and

Stew

ards

hip

com

pete

ncie

s

ww

w.g

ov.u

k/go

vern

men

t/u

ploa

ds/s

yste

m/u

plo

ads/

atta

chm

ent_

data

/file

/253

094/

AR

HA

Ipre

scrc

omp

eten

cies

__2_

.pdf






http://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus

http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/253094/ARHAIprescrcompetencies__2_.pdf

24


Return to contents

Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/gui

danc

e

Hea

lth

car

e pr

ofes

sion

als

rece

ive

edu

cati

on a

s pa

rt

of t

he

prov

ider

’s

ongo

ing

trai

nin

g re

spon

sibi

lity

on

anti

mic

robi

al r

esis

tan

ce,

incl

udi

ng

best

pra

ctic

e in

med

icin

es

opti

mis

atio

n

An

nu

al r

epor

t of

tr

ain

ing

nu

mbe

rs a

nd

per

cen

tage

of

thos

e w

ho

hav

e co

mpl

eted

tr

ain

ing

Evid

ence

an

d d

etai

l of

par

tici

pati

on in

an

nu

al s

tate

men

t

Edu

cati

on s

hou

ld fo

cus

on a

n h

olis

tic

appr

oach

to

an

tim

icro

bial

age

nts

, in

clu

din

g th

erap

euti

c m

anag

emen

t, pr

escr

ibin

g an

d di

spen

sin

g ad

vice

to

pati

ents

2,3

Bes

t pr

acti

ce

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al

stew

ards

hip:

sys

tem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/N

G15

/ch

apte

r/2-

Impl

emen

tati

on-g

etti

ng-

star

ted

DH

(20

13)

UK

five

yea

r an

tim

icro

bial

res

ista

nce

stra

tegy

201

3-8

ww

w.g

ov.u

k/go

vern

men

t/pu

blic

atio

ns/

uk-

5-ye

ar-

anti

mic

robi

al-r

esis

tan

ce-s

trat

egy-

2013

-to-

2018

Hea

lth

Edu

cati

on E

ngl

and

(201

5) P

reve

ntio

n an

d P

ublic

Hea

lth

acti

on p

lan

htt

ps:/

/hee

.nh

s.u

k/ou

r-w

ork/

hos

pita

ls-p

rim

ary-

com

mu

nit

y-ca

re/p

reve

nti

on-

publ

ic-h

ealt

h-w

ellb

ein

g-0

Th

e or

gan

isat

ion

pa

rtic

ipat

es a

nn

ual

ly in

aw

aren

ess-

rais

ing

prog

ram

mes

th

at

supp

ort

best

pra

ctic

e in

an

tim

icro

bial

pr

escr

ibin

g/u

se, e

.g.

Eu

rop

ean

An

tibi

otic

A

war

enes

s D

ay (

EA

AD

) an

d W

orld

An

tibi

otic

A

war

enes

s W

eek

(WA

AW

)

Incl

usi

on in

an

nu

al

IPC

rep

ort

Evid

ence

an

d d

etai

l of

par

tici

pati

on in

an

nu

al r

epor

t

Typ

e of

act

ivit

y fo

r lo

cal

dete

rmin

atio

n2,

3,7

Bes

t pr

acti

ce

EC

DC

web

site

htt

p://

ecdc

.eu

ropa

.eu

/en

/EA

AD

/Pag

es/

Hom

e.as

px

Th

e pr

ovid

er h

as in

pl

ace

a pl

an t

o ac

hie

ve a

re

duct

ion

in t

he

nu

mbe

r of

an

tibi

otic

s pr

escr

ibed

Th

e pr

ovid

er c

an

dem

onst

rate

a 1

% o

r gr

eate

r re

duct

ion

in

the

nu

mbe

r of

an

tibi

otic

s pr

escr

ibed

As

per

Qu

alit

y P

rem

ium

det

ail

Typ

e of

act

ivit

y fo

r lo

cal

dete

rmin

atio

n2

NH

S E

ngl

and

(201

5) Q

ualit

y P

rem

ium

: 201

5/16

G

uida

nce

for

CC

Gs

ww

w.e

ngl

and.

nh

s.u

k/w

p-co

nte

nt/

upl

oads

/201

5/04

/qu

al-p

rem

-gu

id-1

516.

pdf



http://www.gov.uk/government/publications/uk-5-year-antimicrobial-resistance-strategy-2013-to-2018

https://hee.nhs.uk/our-work/hospitals-primary-community-care/prevention-public-health-wellbeing-0

http://ecdc.europa.eu/en/EAAD/Pages/Home.aspx

http://www.england.nhs.uk/wp-content/uploads/2015/04/qual-prem-guid-1516.pdf



Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/gui

danc

e

Th

e pr

ovid

er h

as in

pl

ace

a pl

an t

o ac

hie

ve a

re

duct

ion

in t

he

prop

orti

on o

f br

oad-

spec

tru

m a

nti

biot

ics

pres

crib

ed

Th

e pr

ovid

er c

an

dem

onst

rate

th

at t

he

nu

mbe

r of

ce

phal

osp

orin

s,

quin

olon

es a

nd

co-a

mox

icla

v as

a

per

cen

tage

of

the

tota

l nu

mbe

r of

an

tibi

otic

s pr

escr

ibed

is

red

uce

d by

10%

or

belo

w t

he

curr

ent

med

ian

pro

por

tion

fo

r E

ngl

ish

CC

Gs

(wh

ich

ever

is m

et

firs

t)

As

per

Qu

alit

y P

rem

ium

det

ail

Typ

e of

act

ivit

y fo

r lo

cal

dete

rmin

atio

n2

NH

S E

ngl

and

(201

5) Q

ualit

y P

rem

ium

: 201

5/16

G

uida

nce

for

CC

Gs

ww

w.e

ngl

and.

nh

s.u

k/w

p-co

nte

nt/

upl

oads

/201

5/04

/qu

al-p

rem

-gu

id-1

516.

pdf

Mon

itor

ing

Surg

ical

sit

e in

fect

ion

su

rvei

llan

ce is

pla

nn

ed

and

rep

orte

d

A s

urv

eilla

nce

pr

ogra

mm

e is

in

plac

e to

mon

itor

su

rgic

al in

terv

enti

ons

un

dert

aken

in

seco

nda

ry c

are

Evid

ence

an

d d

etai

l of

su

rvei

llan

ce

prog

ram

me,

de

fin

itio

ns

and

data

Perc

enta

ge o

f co

mpl

ian

ce

and

met

hod

of

mea

sure

men

t fo

r lo

cal

dete

rmin

atio

n a

nd

may

in

clu

de c

olla

bora

tion

w

ith

oth

er p

rovi

ders

.

Defi

nit

ion

of

surg

ical

pr

oced

ure

to

be d

efin

ed

loca

lly w

ith

co

mm

issi

oner

1B

est

prac

tice

Vacc

inat

ion

Rep

orti

ng

on

com

plia

nce

wit

h h

ealt

h

care

wor

ker

vacc

inat

ion

pr

ogra

mm

e

An

nu

al c

onfi

rmat

ion

of

% a

ctu

al n

um

bers

an

d ty

pes

of

vacc

inat

ion

aga

inst

el

igib

le s

taff

An

nu

al r

epor

tin

g in

clu

din

g ex

cep

tion

s of

var

iati

on t

o p

olic

y

Lin

ks t

o cr

iter

ion

10,

DH

(2

015)

Cod

e of

Pra

ctic

e1

Bes

t pr

acti

ce



26


Return to contents

Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/gui

danc

e

Pati

ents

iden

tifi

ed a

s el

igib

le fo

r va

ccin

atio

n

stat

us

are

asse

ssed

an

d h

ave

outs

tan

din

g va

ccin

atio

ns

offe

red

by

prov

ider

Rep

orti

ng

of n

um

ber

of p

atie

nts

fou

nd

to

be e

ligib

le fo

r va

ccin

atio

ns

agai

nst

to

tal p

atie

nt

pop

ula

tion

Bi-

ann

ual

rep

orti

ng

of n

um

ber

of

pati

ents

fou

nd

to b

e el

igib

le fo

r va

ccin

atio

ns

Rep

orti

ng

shou

ld in

clu

de

brea

kdow

n o

f va

ccin

atio

ns

outs

tan

din

g.

Vac

cin

atio

n is

re

com

men

ded

not

m

anda

ted

1B

est

prac

tice

Inte

rnat

ion

al L

onge

vity

Cen

tre

(201

3) A

dult

va

ccin

atio

n –

a ke

y co

mpo

nent

of h

ealt

hy a

gein

g

ww

w.il

cuk.

org.

uk/

inde

x.ph

p/pu

blic

atio

ns/

publ

icat

ion

_det

ails

/adu

lt_v

acci

nat

ion

_a_k

ey_

com

pon

ent_

of_h

ealt

hy_a

gein

g

Pu

blic

Hea

lth

En

glan

d (2

013)

Im

mun

isat

ion

agai

nst

infe

ctio

us d

isea

se (

Gre

en b

ook)

w

ww

.gov

.uk/

gove

rnm

ent/

colle

ctio

ns/

imm

un

isat

ion

-ag

ain

st-i

nfe

ctio

us-

dise

ase-

the-

gree

n-b

ook


http://www.ilcuk.org.uk/index.php/publications/publication_details/adult_vaccination_a_key_component_of_healthy_ageing

http://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book



App

endi

x 2:

Infe

ctio

n pr

even

tion

and

con

trol

bas

ket o

f sug

gest

ed in

dica

tors

– p

rim

ary

and

com

mun

ity

care

The

term

pri

mar

y ca

re in

clud

es (b

ut is

not

lim

ited

to) t

he fo

llow

ing

exam

ples

of N

HS

heal

th c

are

serv

ices

, suc

h as

thos

e pr

ovid

ed b

y ge

nera

l pra

ctiti

oner

s, c

omm

unity

/dis

tric

t nu

rsin

g se

rvic

es, d

entis

ts, o

ptom

etri

sts,

hea

lth v

isiti

ng, s

choo

l nur

ses,

pod

iatr

ists

, inf

usio

n th

erap

y se

rvic

es (i

nclu

ding

OPA

T) a

nd se

xual

hea

lth se

rvic

es.

Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

expe

ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(n

ote

whe

re s

peci

fic

guid

ance

is n

ot p

rese

nt th

is is

in

dica

ted

as ‘b

est p

ract

ice’

)

Am

biti

on in

dica

tors

Th

e pr

ovid

er h

as in

pl

ace

a st

rate

gy t

hat

de

scri

bes

its

visi

on

and

acti

ons

over

ti

me

to d

iagn

ose,

m

easu

re, p

reve

nt

and

man

age

pneu

mon

ia

Evid

ence

of

stra

tegy

, in

clu

din

g h

ow it

will

be

rev

iew

ed a

nd

eval

uat

ed

Evid

ence

of

stra

tegy

an

d im

plem

enta

tion

pl

an

Stra

tegy

sh

ould

incl

ude

th

e ro

le o

f m

ult

i-di

scip

linar

y st

akeh

olde

rs

and

com

mu

nic

atio

n

path

way

s. S

trat

egy

may

be

dev

elop

ed a

nd

impl

emen

ted

in

colla

bora

tion

wit

h o

ther

pr

ovid

er o

rgan

isat

ion

s

1B

est

prac

tice

NIC

E C

G19

1 (2

014)

Pne

umon

ia: D

iagn

osis

and

man

agem

ent

of c

omm

unit

y- a

nd h

ospi

tal-

acqu

ired

pne

umon

ia in

adu

lts

ww

w.n

ice.

org.

uk/

guid

ance

/CG

191

Parl

iam

enta

ry a

nd

Hea

lth

Ser

vice

s O

mbu

dsm

an (

2014

) T

ime

to A

ct, s

ever

e se

psis

: rap

id d

iagn

osis

and

tre

atm

ent

save

s liv

es w

ww

.om

buds

man

.org

.uk/

__da

ta/a

sset

s/pd

f_fi

le/0

004/

2266

6/FI

NA

L_S

epsi

s_R

epor

t_w

eb.p

df

Th

e pr

ovid

er h

as in

pl

ace

a st

rate

gy t

hat

de

scri

bes

its

visi

on

and

acti

ons

over

ti

me

to s

upp

ort

pati

ents

in t

he

prev

enti

on,

diag

nos

is a

nd

man

agem

ent

of

uri

nar

y tr

act

infe

ctio

ns,

incl

udi

ng

thos

e th

at a

re n

ot

rela

ted

to t

he

use

of

uri

nar

y ca

thet

ers

Evid

ence

of

stra

tegy

, in

clu

din

g h

ow it

will

be

rev

iew

ed a

nd

eval

uat

ed

Evid

ence

of

stra

tegy

an

d im

plem

enta

tion

pl

an

Stra

tegy

sh

ould

incl

ude

th

e ro

le o

f m

ult

i-di

scip

linar

y st

akeh

olde

rs

and

com

mu

nic

atio

n

path

way

s. S

trat

egy

may

be

dev

elop

ed a

nd

impl

emen

ted

in

colla

bora

tion

wit

h o

ther

pr

ovid

er o

rgan

isat

ion

s.

Not

e: m

ay a

lign

wit

h

prac

tice

indi

cato

rs o

n

falls

an

d C

AU

TI

(pag

e 33

)

1,5

Bes

t pr

acti

ce

NIC

E C

G54

(20

07)

Uri

nary

tra

ct in

fect

ion

in c

hild

ren:

D

iagn

osis

, tre

atm

ent a

nd lo

ng-t

erm

man

agem

ent

ww

w.n

ice.

org.

uk/

guid

ance

/cg5

4

NIC

E (

2014

) Q

ualit

y St

anda

rd I

nfec

tion

pre

vent

ion

and

Con

trol

QS6

1 w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s61

NIC

E C

G 1

39 (

2012

) In

fect

ion:

Pre

vent

ion

and

cont

rol o

f he

alth

care

-ass

ocia

ted

infe

ctio

ns in

pri

mar

y an

d co

mm

unit

y ca

re w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g139

Parl

iam

enta

ry a

nd

Hea

lth

Ser

vice

s O

mbu

dsm

an (

2014

)

Tim

e to

Act

, sev

ere

seps

is: r

apid

dia

gnos

is a

nd t

reat

men

t sa

ves

lives

ww

w.o

mbu

dsm

an.o

rg.u

k/__

data

/ass

ets/

pdf_

file

/000

4/22

666/

FIN

AL

_Sep

sis_

Rep

ort_

web

.pdf

NIC

E (

2015

) Q

ualit

y St

anda

rd U

rina

ry t

ract

infe

ctio

ns in

ad

ults

QS9

0 w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s90

NIC

E (

2013

) Q

ualit

y St

anda

rd U

rina

ry t

ract

infe

ctio

n in

in

fant

s, c

hild

ren

and

youn

g pe

ople

und

er 1

6 Q

S36

w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s36

NIC

E G

uid

elin

e C

G16

1 (2

013)

Fal

ls: a

sses

smen

t and

pr

even

tion

of f

alls

in o

lder

peo

ple

ww

w.n

ice.

org.

uk/

guid

ance

/cg1

61 This publication is being reviewed in 2019










28


Return to contents

Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

expe

ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(not

e w

here

spe

cifi

c gu

idan

ce is

not

pre

sent

this

is in

dica

ted

as ‘b

est

prac

tice

’)

Th

e pr

ovid

er h

as in

pl

ace

a st

rate

gy t

hat

de

scri

bes

acti

ons

to

reco

gnis

e m

easu

re

and

man

age

susp

ecte

d ca

ses

of

seps

is

Evid

ence

of

stra

tegy

, in

clu

din

g h

ow it

will

be

rev

iew

ed a

nd

eval

uat

ed

Evid

ence

of

stra

tegy

an

d im

plem

enta

tion

p

lan

Stra

tegy

sh

ould

incl

ude

th

e ro

le o

f m

ult

i-di

scip

linar

y st

akeh

olde

rs

and

com

mu

nic

atio

n

path

way

s. S

trat

egy

may

be

dev

elop

ed a

nd

impl

emen

ted

in

colla

bora

tion

wit

h o

ther

pr

ovid

er o

rgan

isat

ion

s

1, 2

NH

S E

ngl

and

(201

5) C

omm

issi

onin

g fo

r qu

alit

y an

d in

nova

tion

(C

QU

IN)

Gui

danc

e fo

r 20

15/1

6

ww

w.e

ngl

and.

nh

s.u

k/w

p-co

nte

nt/

upl

oads

/201

5/03

/9-c

quin

-gu

id-2

015-

16.p

df

Parl

iam

enta

ry a

nd

Hea

lth

Ser

vice

s O

mbu

dsm

an (

2014

) T

ime

to A

ct, s

ever

e se

psis

: rap

id d

iagn

osis

and

tre

atm

ent

save

s liv

es w

ww

.om

buds

man

.org

.uk/

__da

ta/a

sset

s/pd

f_fi

le/0

004/

2266

6/FI

NA

L_S

epsi

s_R

epor

t_w

eb.p

df

Org

anis

atio

nal e

lem

ents

IPC

is in

clu

ded

as a

re

gula

r ag

enda

item

in

rel

evan

t pr

ovid

er

orga

nis

atio

n

mee

tin

gs

Rec

ord

of m

eeti

ngs

an

d IP

C t

opic

s d

iscu

ssed

Min

ute

s of

mee

tin

gsP

rovi

der

to d

eter

min

e w

hic

h m

eeti

ngs

will

ro

uti

nel

y in

clu

de I

PC

di

scu

ssio

n

1B

est

prac

tice

NIC

E (

2014

) Q

ualit

y St

anda

rd I

nfec

tion

pre

vent

ion

and

Con

trol

QS6

1 w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s61

Th

e or

gan

isat

ion

de

velo

ps a

nd

own

s a

boar

d-ap

prov

ed

HC

AI

redu

ctio

n

plan

an

d pr

ogre

ss is

re

por

ted

agai

nst

th

is

Qu

arte

rly

com

plia

nce

rep

orts

Qu

arte

rly

rece

ipt

of

rep

orts

det

ailin

g co

mpl

ian

ce a

nd

prog

ress

aga

inst

pl

an

Th

e pr

ovid

er m

ay w

ish

to

use

th

e C

ode

of P

ract

ice

to d

evel

op a

n I

PC

pla

n

1N

HS

En

glan

d St

anda

rd C

ontr

act 2

015/

16 a

nd 2

016/

17

ww

w.e

ngl

and.

nh

s.u

k/n

hs-

stan

dard

-con

trac

t/15

-16/

w

ww

.en

glan

d.n

hs.

uk/

nh

s-st

anda

rd-c

ontr

act/

16-1

7/

An

tim

icro

bial

st

ewar

dsh

ip (

AM

S)

(in

clu

din

g lo

cal

prog

ram

mes

an

d

surv

eilla

nce

) is

in

clu

ded

as a

reg

ula

r ag

enda

item

in

rele

van

t pr

ovid

er

orga

nis

atio

n

mee

tin

gs

Rec

ord

of m

eeti

ngs

an

d A

MS

top

ics

dis

cuss

ed

Min

ute

s of

mee

tin

gsP

rovi

der

to d

eter

min

e w

hic

h m

eeti

ngs

will

ro

uti

nel

y in

clu

de A

MS

disc

uss

ion

2B

est

prac

tice

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al s

tew

ards

hip:

sy

stem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/N

G15

/ch

apte

r/2-

Impl

emen

tati

on-g

etti

ng-

star

ted

NIC

E (

2014

) Q

ualit

y St

anda

rd I

nfec

tion

pre

vent

ion

and

Con

trol

QS6

1 w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s61

Pro

vide

r ta

kes

into

ac

cou

nt

advi

ce fr

om

spec

ialis

t I

PC

an

d A

MS

prov

ider

/tea

ms

Doc

um

enta

tion

an

d de

tails

of

deci

sion

/re

med

ial a

ctio

n

Wh

ere

spec

ialis

t IP

C/

AM

S ad

vice

is n

ot

follo

wed

, th

e ra

tion

ale

and

deci

sion

is

docu

men

ted

and

disc

uss

ed a

t th

e re

leva

nt

mee

tin

g (s

ee t

wo

indi

cato

rs a

bove

)

1B

est

prac

tice

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al s

tew

ards

hip:

sy

stem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/N

G15

/ch

apte

r/2-

Impl

emen

tati

on-g

etti

ng-

star

tedThis publication is being reviewed in 2019











Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

expe

ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(not

e w

here

spe

cifi

c gu

idan

ce is

not

pre

sent

this

is in

dica

ted

as ‘b

est

prac

tice

’)

Th

e or

gan

isat

ion

em

ploy

s or

has

su

ffici

ent

acce

ss t

o a

suit

ably

res

ourc

ed

and

qual

ified

In

fect

ion

Pre

ven

tion

an

d C

ontr

ol T

eam

(I

PC

T),

A

nti

mic

robi

al

Stew

ards

hip

(A

MS)

te

am o

r sp

ecia

list

prac

titi

oner

to

mee

t th

eir

nee

ds

Spec

ialis

t ad

vise

rs

clea

rly

iden

tifi

able

Rec

ord

of s

ervi

ce o

r co

ntr

act

for

prov

isio

n o

f IP

C

and

AM

S ad

vice

Con

trac

t m

ay b

e fo

r em

ploy

men

t or

adv

ice

and

shou

ld d

etai

l th

e n

um

ber

of h

ours

em

ploy

ed/c

ontr

acte

d,

role

des

crip

tion

, lin

es o

f co

mm

un

icat

ion

an

d go

vern

ance

str

uct

ure

s fo

r IP

C a

nd

wit

hin

pro

vide

r or

gan

isat

ion

1N

ICE

Gu

idel

ine

NG

15 (

2015

) A

ntim

icro

bial

ste

war

dshi

p:

syst

ems

and

proc

esse

s fo

r ef

fect

ive

anti

mic

robi

al m

edic

ine

use

ww

w.n

ice.

org.

uk/

guid

ance

/NG

15/c

hap

ter/

2-Im

plem

enta

tion

-get

tin

g-st

arte

d

Alig

ns

wit

h D

H (

2015

) C

ode

of P

ract

ice

crit

eria

th

ree

Pro

vide

r co

ntr

ibu

tes

to w

hol

e ec

onom

y st

rate

gic

plan

nin

g di

scu

ssio

n a

nd

deci

sion

mak

ing

on

HC

AI

redu

ctio

n/

AM

S

Rec

ord

of a

tten

dan

ce

and

con

trib

uti

onM

inu

tes

of m

eeti

ngs

Loca

l pro

fess

ion

al

net

wor

ks c

an b

e u

sed

as a

m

eth

od o

f de

mon

stra

tin

g en

gage

men

t in

dis

cuss

ion

an

d pl

ann

ing

1B

est

prac

tice

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

ww

w.n

ice.

org.

uk/

guid

ance

/qs6

1

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al s

tew

ards

hip:

sy

stem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

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k/gu

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Impl

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etti

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star

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Cop

ies

of a

ll re

por

ts

and

asso

ciat

ed

acti

on p

lan

s in

re

spon

se t

o an

y ex

tern

al I

PC

focu

s vi

sits

/in

spec

tion

s (e

.g. f

rom

CC

G,

CQ

C)

are

mad

e av

aila

ble

to t

he

com

mis

sion

er b

y th

e pr

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Cop

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of r

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hin

five

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f th

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rece

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e re

por

t

Rep

orts

are

rec

eive

d1

Bes

t pr

acti

ce





30


Return to contents

Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

expe

ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(not

e w

here

spe

cifi

c gu

idan

ce is

not

pre

sent

this

is in

dica

ted

as ‘b

est

prac

tice

’)

Pra

ctic

es

com

mis

sion

ed t

o pr

ovid

e en

han

ced

serv

ices

, e.g

. nam

ed

GPs

for

care

hom

e/s

are

able

to

dem

onst

rate

ap

prop

riat

e tr

ain

ing

and

capa

city

Nam

ed s

taff

fully

aw

are

of c

lien

t gr

oup

nee

ds a

nd

pot

enti

al

surg

e re

quir

emen

ts

Serv

ice

spec

ifica

tion

, an

nu

al

revi

ews,

sta

ff

trai

nin

g re

cord

s,

surg

e pl

an

An

exa

mpl

e of

su

rge

requ

irem

ents

may

be

addi

tion

al c

apac

ity

requ

ired

for

flu

im

mu

nis

atio

n, o

utb

reak

s an

d w

inte

r co

ver

to a

void

h

ospi

tal a

dmis

sion

1B

est

prac

tice

Ser

vice

use

r in

volv

emen

tSe

rvic

e u

sers

are

in

clu

ded

in I

PC

an

nu

al p

rogr

amm

e

deve

lopm

ent,

wit

h

pati

ent

exp

erie

nce

u

sed

to s

hap

e ac

tivi

ty

Serv

ice

use

r vi

ews

are

acti

vely

sou

ght

and

reco

mm

end

atio

ns

inco

rpor

ated

wh

ere

appr

opri

ate

Evid

ence

an

d d

etai

l of

par

tici

pat

ion

in

ann

ual

rep

ort

1,3

Bes

t pr

acti

ce

Serv

ice

use

rs a

re

invo

lved

in t

he

shap

ing

and

impl

emen

tati

on o

f lo

cal p

rogr

amm

es t

o im

prov

e h

and

hygi

ene

of b

oth

sta

ff

and

serv

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use

rs in

al

l set

tin

gs

Serv

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use

rs a

re

invo

lved

in h

and

hygi

ene

prog

ram

mes

An

nu

al s

um

mar

y of

h

and

hygi

ene

prog

ram

me

acti

vity

in

clu

din

g u

ser

invo

lvem

ent

1,3

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

ww

w.n

ice.

org.

uk/

guid

ance

/qs6

1

NIC

E C

G 1

39 (

2012

) In

fect

ion:

Pre

vent

ion

and

cont

rol o

f he

alth

care

-ass

ocia

ted

infe

ctio

ns in

pri

mar

y an

d co

mm

unit

y ca

re w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g139

Peop

le w

ith

inva

sive

de

vice

s su

ch a

s a

uri

nar

y ca

thet

er,

vasc

ula

r ac

cess

de

vice

or

ente

ral

feed

ing

tube

an

d th

eir

care

rs w

ho

hel

p

them

wit

h t

his

eq

uip

men

t ar

e gi

ven

in

form

atio

n a

nd

advi

ce a

bou

t h

ow t

o lo

ok a

fter

th

e de

vice

sa

fely

an

d ef

fect

ivel

y

Serv

ice

use

rs a

re

prov

ided

wit

h a

dvic

e an

d a

re in

volv

ed in

de

term

inin

g de

tail

of

info

rmat

ion

in

clu

ded

An

nu

al s

um

mar

y of

in

form

atio

n

avai

labl

e,

dist

ribu

tion

an

d ev

alu

atio

n in

clu

din

g pa

tien

t/ca

rer

feed

back

1,3

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

ww

w.n

ice.

org.

uk/

guid

ance

/qs6

1

NIC

E C

G 1

39 (

2012

) In

fect

ion:

Pre

vent

ion

and

cont

rol o

f he

alth

care

-ass

ocia

ted

infe

ctio

ns in

pri

mar

y an

d co

mm

unit

y ca

re w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g139








Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

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ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(not

e w

here

spe

cifi

c gu

idan

ce is

not

pre

sent

this

is in

dica

ted

as ‘b

est

prac

tice

’)

MR

SA

and

C. d

iffi

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and

oth

er s

igni

fica

nt H

CA

IsC

ontr

ibu

tion

to

the

Post

In

fect

ion

R

evie

w/R

CA

/‘L

apse

in

car

e’

inve

stig

atio

ns

for

all

case

s of

HC

AI

Con

trib

uti

on t

o th

e P

IR p

roce

ss a

nd

im

plem

enta

tion

of

acti

on p

lan

s an

d le

arn

ing

deri

ved

from

inve

stig

atio

n

revi

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100%

att

enda

nce

at

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stig

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mee

tin

gs

Att

end

ance

at

PIR

m

eeti

ngs

.

Act

ion

pla

n r

epor

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are

rece

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an

d u

pdat

ed r

egu

larl

y,

wit

h le

arn

ing

shar

ed

acro

ss t

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orga

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atio

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h e

xcep

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s of

M

RSA

bac

tera

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d C

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hat

req

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vest

igat

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are

to

be

dete

rmin

ed lo

cally

1N

HS

En

glan

d (2

014)

Zer

o to

lera

nce

ww

w.e

ngl

and.

nh

s.u

k/pa

tien

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asso

ciat

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(201

5) C

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nd g

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on s

anct

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impl

emen

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on

ww

w.e

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nh

s.u

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nte

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upl

oads

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16-g

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Com

plia

nce

wit

h

loca

lly a

gree

d M

RSA

ca

re p

athw

ay

Qu

arte

rly

con

firm

atio

n o

f p

erce

nta

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f M

RSA

-pos

itiv

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tien

ts w

ho

follo

w

and

com

ple

te t

he

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SA c

are

path

way

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arte

rly

rece

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of

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are

path

way

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mpl

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ata

Car

e pa

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ld b

e de

fin

ed lo

cally

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d al

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ovid

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shou

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e aw

are

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hes

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mpl

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ith

th

em.

Con

side

r in

clu

sion

of

audi

t of

flag

gin

g of

M

RSA

sta

tus

acro

ss a

ll pa

tien

t ad

min

istr

atio

n

syst

ems

acro

ss t

he

path

way

.

Perc

enta

ge o

f co

mpl

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ce

and

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hod

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014)

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k/pa

tien

tsaf

ety/

asso

ciat

ed-i

nfe

ctio

ns/

zero

-tol

eran

ce/





32


Return to contents

Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

expe

ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(not

e w

here

spe

cifi

c gu

idan

ce is

not

pre

sent

this

is in

dica

ted

as ‘b

est

prac

tice

’)

Com

plia

nce

wit

h

loca

lly a

gree

d C

. di

ffici

le c

are

path

way

Qu

arte

rly

con

firm

atio

n o

f p

erce

nt

of C

. dif

ficile

p

atie

nts

wh

o fo

llow

an

d co

mpl

ete

the

care

pat

hway

Qu

arte

rly

rece

ipt

of

C. d

iffic

ile c

are

pat

hway

com

plia

nce

d

ata

Car

e pa

thw

ays

shou

ld b

e de

fin

ed lo

cally

an

d al

l pr

ovid

ers

shou

ld b

e aw

are

of t

hem

an

d co

ntr

ibu

te w

her

e re

leva

nt.

Con

side

r in

clu

sion

of

audi

t of

fl

aggi

ng

of C

. dif

ficile

st

atu

s ac

ross

all

pati

ent

adm

inis

trat

ion

sys

tem

s ac

ross

th

e pa

thw

ay.

Perc

enta

ge o

f co

mpl

ian

ce

and

met

hod

of

mea

sure

men

t fo

r lo

cal

dete

rmin

atio

n

1B

est

prac

tice

Pro

vide

r co

ntr

ibu

tes

to r

evie

w o

f al

l CD

I ca

ses

if in

volv

ed in

pr

ovis

ion

of

care

to

pati

ent

100%

com

plia

nce

w

ith

invo

lvem

ent

in

revi

ew o

f an

y C

DI

case

th

at t

he

prov

ider

is a

ssoc

iate

d w

ith

Qu

arte

rly

subm

issi

on o

f ev

iden

ce

dem

onst

rati

ng

prov

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in

volv

emen

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re

view

mee

tin

gs a

nd

prog

ress

wit

h

acti

ons

Det

ail o

f m

easu

rem

ent

met

hod

to

be d

eter

min

ed

loca

lly

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HS

En

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015)

Clo

stri

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infe

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n ob

ject

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fo

r N

HS

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nisa

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s in

201

5/16

and

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danc

e on

san

ctio

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plem

enta

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at

ww

w.e

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and.

nh

s.u

k/w

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nt/

upl

oads

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5/02

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stri

dm-d

iffi

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fect

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ct-1

5-16

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id-f

eb15

.pdf

Seri

ous

inci

den

ts

occu

rrin

g in

pri

mar

y ca

re a

re r

epor

ted

to

the

com

mis

sion

er

wit

hin

on

e w

orki

ng

day

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ifica

tion

of

inci

den

t to

co

mm

issi

oner

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hin

tw

o w

orki

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days

Qu

arte

rly

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nit

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of

seri

ous

inci

den

t to

be

defi

ned

by

prov

ider

follo

win

g ag

reem

ent

wit

h

com

mis

sion

er.

Ver

ifica

tion

mea

sure

–

STE

IS, N

RL

S, R

CA

, P

IR, p

atie

nt

com

plai

nts

1H

PA (

2012

) H

ealt

hcar

e as

soci

ated

infe

ctio

n op

erat

iona

l gu

idan

ce a

nd s

tand

ards

for

heal

th p

rote

ctio

n un

its

w

ww

.gov

.uk/

gove

rnm

ent/

publ

icat

ion

s/h

ealt

hca

re-

asso

ciat

ed-i

nfe

ctio

n-h

cai-

oper

atio

nal

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idan

ce-a

nd

-st

anda

rds

NH

S E

ngl

and

(201

5) S

erio

us in

cide

nt fr

amew

ork

w

ww

.en

glan

d.n

hs.

uk/

pati

ents

afet

y/se

riou

s-in

cide

nt/

IPC

prac

tice

Th

e or

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isat

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C l

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RC

N (

2011

) R

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link

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se fr

amew

ork

ww

w2.

rcn

.org

.uk/

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ta/a

sset

s/pd

f_fi

le/0

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http://www.england.nhs.uk/patientsafety/serious-incident/




Qua

lity

re

quir

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resh

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Met

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Th

e pr

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as in

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rate

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syst

ems

to p

reve

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ns

asso

ciat

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wit

h t

he

use

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(IV

) th

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Evid

ence

of

stra

tegy

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d pr

oces

ses

in u

se

are

prov

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to

the

com

mis

sion

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Six-

mon

thly

re

por

tin

g of

pr

ogre

ss in

str

ateg

y

IV t

her

apy

incl

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s dr

ug

adm

inis

trat

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(e.

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biot

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ch

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, IV

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id

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apy

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Req

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eter

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opu

lati

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nd

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spec

ifica

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bu

t ca

n

incl

ude

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men

ts

incl

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d w

ith

in

App

endi

x 5

1B

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prac

tice

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

w

ww

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g.u

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Th

e pr

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pl

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nd

syst

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to p

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ctio

ns

asso

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wit

h t

he

use

of

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eedi

ng

Evid

ence

of

stra

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d p

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mon

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opu

lati

on a

nd

serv

ice

spec

ifica

tion

bu

t ca

n

incl

ude

th

e el

emen

ts

outl

ined

in A

ppen

dix

5

1,3

Bes

t pr

acti

ce

NIC

E C

G 1

39 (

2012

) In

fect

ion:

Pre

vent

ion

and

cont

rol o

f he

alth

care

-ass

ocia

ted

infe

ctio

ns in

pri

mar

y an

d co

mm

unit

y ca

re w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g139

Th

e pr

ovid

er h

as in

pl

ace

a st

rate

gy a

nd

syst

ems

to e

nsu

re t

he

prev

enti

on a

nd

reco

gnit

ion

of

cath

eter

-ass

ocia

ted

uri

nar

y tr

act

infe

ctio

ns

(CA

UT

I)

Evid

ence

of

stra

tegy

an

d p

roce

sses

in u

se

are

prov

ided

to

the

com

mis

sion

er

Six-

mon

thly

re

por

tin

g of

pr

ogre

ss in

str

ateg

y

Req

uir

emen

ts a

re fo

r lo

cal d

eter

min

atio

n

base

d on

pat

ien

t p

opu

lati

on a

nd

serv

ice

spec

ifica

tion

bu

t ca

n

incl

ude

th

e el

emen

ts

outl

ined

in A

ppen

dix

5

1, 3

,5B

est

prac

tice

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s61

NIC

E C

G 1

39 (

2012

) In

fect

ion:

Pre

vent

ion

and

cont

rol o

f he

alth

care

-ass

ocia

ted

infe

ctio

ns in

pri

mar

y an

d co

mm

unit

y ca

re w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g139

All

staf

f h

ave

acce

ss

to r

esou

rces

to

supp

ort

han

d hy

gien

e at

th

e p

oin

t of

car

e w

hen

in

dica

ted

Evid

ence

of

how

re

sou

rces

are

se

lect

ed, p

rovi

ded

and

use

d in

pra

ctic

e

Six-

mon

thly

rev

iew

an

d e

valu

atio

n o

f pr

odu

ct u

se

Req

uir

emen

ts a

re fo

r lo

cal d

eter

min

atio

n

base

d on

pat

ien

t p

opu

lati

on a

nd

serv

ice

sett

ing

1N

ICE

(20

14)

Qua

lity

Stan

dard

QS6

1

ww

w.n

ice.

org.

uk/

guid

ance

/qs6

1

NIC

E C

G 1

39 (

2012

) In

fect

ion:

Pre

vent

ion

and

cont

rol o

f he

alth

care

-ass

ocia

ted

infe

ctio

ns in

pri

mar

y an

d co

mm

unit

y ca

re w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g139








34


Return to contents

Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

expe

ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(not

e w

here

spe

cifi

c gu

idan

ce is

not

pre

sent

this

is in

dica

ted

as ‘b

est

prac

tice

’)

Pres

crib

ing

Th

e pr

ovid

er h

as o

r co

ntr

ibu

tes

to a

n

anti

biot

ic

stew

ards

hip

pr

ogra

mm

e th

at

span

s ca

re s

etti

ngs

lo

cally

Evid

ence

of

atte

nda

nce

at

rele

van

t m

eeti

ngs

an

d co

ntr

ibu

tion

to

loca

l AM

S pr

ogra

mm

e

Rep

orti

ng

of

prog

ress

wit

h A

MS

prog

ram

me

Perc

enta

ge o

f co

mpl

ian

ce, m

eth

od o

f m

easu

rem

ent,

incl

usi

on

crit

eria

an

d fr

equ

ency

of

com

plia

nce

ass

essm

ent

for

loca

l det

erm

inat

ion

2,3

Bes

t pr

acti

ce

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al s

tew

ards

hip:

sy

stem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/N

G15

/ch

apte

r/2-

Impl

emen

tati

on-g

etti

ng-

star

ted

An

an

tibi

otic

pol

icy/

guid

elin

e is

in p

lace

th

at r

eflec

ts n

atio

nal

pr

escr

ibin

g gu

idan

ce

Pre

sen

ce o

f an

tibi

otic

pol

icy

An

nu

al

con

firm

atio

n o

f p

olic

y in

pla

ce

Polic

y sh

ould

be

revi

ewed

min

imu

m o

f tw

o-ye

arly

un

less

new

n

atio

nal

gu

idan

ce is

sued

2N

ICE

Gu

idel

ine

NG

15 (

2015

) A

ntim

icro

bial

ste

war

dshi

p:

syst

ems

and

proc

esse

s fo

r ef

fect

ive

anti

mic

robi

al m

edic

ine

use

ww

w.n

ice.

org.

uk/

guid

ance

/NG

15/c

hap

ter/

2-Im

plem

enta

tion

-get

tin

g-st

arte

dC

ompl

ian

ce w

ith

lo

cal a

nti

biot

ic

pol

icie

s/gu

idel

ines

Rep

orti

ng

of

com

plia

nce

, in

clu

din

g if

th

ere

is

evid

ence

of

just

ifiab

le c

linic

al

reas

ons

for

devi

atio

n

from

set

form

ula

ry

Au

dit

of c

ompl

ian

ce

wit

h t

he

anti

biot

ic

pres

crib

ing

form

ula

ry

Perc

enta

ge o

f co

mpl

ian

ce, m

eth

od o

f m

easu

rem

ent,

incl

usi

on

crit

eria

an

d fr

equ

ency

of

com

plia

nce

ass

essm

ent

for

loca

l det

erm

inat

ion

2,3

RC

GP

TA

RG

ET

ant

ibio

tic

tool

kit

ww

w.r

cgp.

org.

uk/

targ

etan

tibi

otic

s/

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al s

tew

ards

hip:

sy

stem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/N

G15

/ch

apte

r/2-

Impl

emen

tati

on-g

etti

ng-

star

ted

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s61

Pre

scri

bers

mee

t th

eir

prof

essi

onal

st

anda

rds

of

edu

cati

on a

nd

com

pet

ency

An

nu

al r

epor

t of

tr

ain

ing

and

co

mp

eten

cy

An

nu

al r

epor

t an

d

anal

ysis

aga

inst

qu

alit

y re

quir

emen

t

Info

rmat

ion

sh

ould

be

prov

ided

on

th

e n

um

bers

of

dif

fere

nt

prof

essi

onal

gr

oups

rec

eivi

ng

trai

nin

g an

d co

mp

eten

cy

asse

ssm

ent

com

pare

d to

th

ose

that

are

elig

ible

2,3

Pu

blic

Hea

lth

En

glan

d (2

013)

Ant

imic

robi

al p

resc

ribi

ng a

nd

stew

ards

hip

com

pete

ncie

s w

ww

.gov

.uk/

gove

rnm

ent/

up

load

s/sy

stem

/upl

oads

/att

ach

men

t_da

ta/fi

le/2

5309

4/A

RH

AIp

resc

rcom

pet

enci

es__

2_.p

df

Hea

lth

car

e pr

ofes

sion

als

rece

ive

edu

cati

on a

s pa

rt o

f th

e pr

ovid

ers,

on

goin

g tr

ain

ing

resp

onsi

bilit

y on

an

tim

icro

bial

re

sist

ance

, in

clu

din

g be

st p

ract

ice

in

med

icin

es

opti

mis

atio

n

An

nu

al r

epor

t of

tr

ain

ing

nu

mbe

rs

and

per

cen

tage

of

thos

e w

ho

hav

e co

mp

lete

d tr

ain

ing

Evid

ence

an

d de

tail

of p

arti

cipa

tion

in

ann

ual

sta

tem

ent

Edu

cati

on s

hou

ld fo

cus

on a

n h

olis

tic

appr

oach

to

an

tim

icro

bial

age

nts

, in

clu

din

g th

erap

euti

c m

anag

emen

t, pr

escr

ibin

g an

d di

spen

sin

g ad

vice

to

pati

ents

2,3

Bes

t pr

acti

ce

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al s

tew

ards

hip:

sy

stem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/N

G15

/ch

apte

r/2-

Impl

emen

tati

on-g

etti

ng-

star

ted

DH

(20

13)

UK

five

yea

r an

tim

icro

bial

res

ista

nce

stra

tegy

20

13-8

ww

w.g

ov.u

k/go

vern

men

t/pu

blic

atio

ns/

uk-

5-ye

ar-

anti

mic

robi

al-r

esis

tan

ce-s

trat

egy-

2013

-to-

2018

Hea

lth

Edu

cati

on E

ngl

and

(201

5) P

reve

ntio

n an

d pu

blic

he

alth

act

ion

plan

htt

ps:/

/hee

.nh

s.u

k/ou

r-w

ork/

hos

pit

als-

prim

ary-

com

mu

nit

y-ca

re/p

reve

nti

on-p

ubl

ic-h

ealt

h-

wel

lbei

ng-

0




http://www.rcgp.org.uk/targetantibiotics/









Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

expe

ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(not

e w

here

spe

cifi

c gu

idan

ce is

not

pre

sent

this

is in

dica

ted

as ‘b

est

prac

tice

’)

Th

e pr

ovid

er h

as a

sy

stem

in p

lace

to

mea

sure

an

d m

onit

or a

nti

biot

ic

pres

crib

ing

prac

tice

s

An

nu

al r

evie

wA

nn

ual

rep

ort

and

an

alys

is a

gain

st

qual

ity

requ

irem

ent

App

lies

to d

enti

sts

and

oth

ers

wh

o ca

n p

resc

ribe

bu

t w

ho

aren

’t a

ffec

ted

by Q

ual

ity

Pre

miu

m

2,3

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al s

tew

ards

hip:

sy

stem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/N

G15

/ch

apte

r/2-

Impl

emen

tati

on-g

etti

ng-

star

ted

Th

e pr

ovid

er

part

icip

ates

an

nu

ally

in

aw

aren

ess-

rais

ing

prog

ram

mes

th

at

supp

ort

best

pra

ctic

e in

an

tim

icro

bial

pr

escr

ibin

g/u

se, e

.g.

Eu

rop

ean

An

tibi

otic

A

war

enes

s D

ay

(EA

AD

) an

d W

orld

A

nti

biot

ic A

war

enes

s W

eek

(WA

AW

)

Incl

usi

on in

an

nu

al

stat

emen

tEv

iden

ce a

nd

deta

il of

par

tici

pati

on in

an

nu

al s

tate

men

t

Typ

e of

act

ivit

y fo

r lo

cal

dete

rmin

atio

n2,

3,7

Bes

t pr

acti

ce

EC

DC

web

site

htt

p://

ecdc

.eu

ropa

.eu

/en

/Pag

es/h

ome.

asp

x

Th

e pr

ovid

er h

as in

pl

ace

a pl

an t

o ac

hie

ve a

red

uct

ion

in

th

e n

um

ber

of

anti

biot

ics

pres

crib

ed

The

pro

vide

r ca

n

dem

onst

rate

a 1

% o

r gr

eate

r re

duct

ion

in

the

nu

mbe

r of

an

tibi

otic

s pr

escr

ibed

in

pri

mar

y ca

re

acro

ss th

e C

CG

As

per

qu

alit

y pr

emiu

m d

etai

l2

NH

S E

ngl

and

(201

5) Q

ualit

y P

rem

ium

: 201

5/16

Gui

danc

e fo

r C

CG

s w

ww

.en

glan

d.n

hs.

uk/

wp-

con

ten

t/u

ploa

ds/2

015/

04/q

ual

-pre

m-g

uid

-151

6.pd

f

Th

e pr

ovid

er h

as in

pl

ace

a pl

an t

o ac

hie

ve a

red

uct

ion

in

th

e pr

opor

tion

of

broa

d-sp

ectr

um

an

tibi

otic

s pr

escr

ibed

The

pro

vide

r ca

n

dem

onst

rate

that

the

nu

mbe

r of

ce

phal

ospo

rin

s,

quin

olon

es a

nd

co-a

mox

icla

v as

a

perc

enta

ge o

f th

e to

tal n

um

ber

of

anti

biot

ics

pres

crib

ed

is r

edu

ced

by 1

0% o

r be

low

the

curr

ent

med

ian

pro

port

ion

fo

r E

ngl

ish

CC

Gs

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chev

er is

met

fi

rst)

As

per

qu

alit

y pr

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m d

etai

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S E

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(201

5) Q

ualit

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rem

ium

: 201

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Gui

danc

e fo

r C

CG

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ww

.en

glan

d.n

hs.

uk/

wp-

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ten

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ds/2

015/

04/q

ual

-pre

m-g

uid

-151

6.pd

f



http://ecdc.europa.eu/en/Pages/home.aspx



36


Return to contents

Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

expe

ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(not

e w

here

spe

cifi

c gu

idan

ce is

not

pre

sent

this

is in

dica

ted

as ‘b

est

prac

tice

’)

Mon

itor

ing

Wh

ere

min

or

surg

ery

is

un

dert

aken

, su

rgic

al

site

infe

ctio

n

surv

eilla

nce

is

plan

ned

an

d re

por

ted

A s

urv

eilla

nce

pr

ogra

mm

e is

in

pla

ce t

o m

onit

or

surg

ical

in

terv

enti

ons

un

dert

aken

in

prim

ary

care

Evid

ence

an

d d

etai

l of

su

rvei

llan

ce

prog

ram

me,

de

fin

itio

ns

and

data

Perc

enta

ge o

f co

mpl

ian

ce

and

met

hod

of

mea

sure

men

t fo

r lo

cal

dete

rmin

atio

n a

nd

may

in

clu

de c

olla

bora

tion

w

ith

oth

er p

rovi

ders

.

Defi

nit

ion

of

surg

ical

pr

oced

ure

to

be d

efin

ed

loca

lly w

ith

co

mm

issi

oner

1B

est

prac

tice

Vacc

inat

ions

R

epor

tin

g on

co

mpl

ian

ce o

f h

ealt

h

care

wor

ker

vacc

inat

ion

pr

ogra

mm

e

An

nu

al c

onfi

rmat

ion

of

per

cen

tage

of

actu

al n

um

bers

an

d ty

pes

of

vacc

inat

ion

ag

ain

st e

ligib

le s

taff

An

nu

al r

epor

tin

g in

clu

din

g ex

cep

tion

s of

var

iati

on t

o p

olic

y

Vac

cin

atio

n is

re

com

men

ded

not

m

anda

ted

1A

lign

s w

ith

DH

(20

15)

Cod

e of

Pra

ctic

e cr

iter

ion

10

Pati

ents

iden

tifi

ed a

s el

igib

le fo

r va

ccin

atio

n s

tatu

s ar

e as

sess

ed a

nd

hav

e ou

tsta

ndi

ng

vacc

inat

ion

s of

fere

d by

pro

vide

r

Rep

orti

ng

of n

um

ber

of v

acci

nat

ion

s of

fere

d an

d ad

min

iste

red

Bi-

ann

ual

rep

orti

ng

Rep

orti

ng

to in

clu

de

brea

kdow

n p

er

vacc

inat

ion

cat

egor

y

1B

est

prac

tice

Inte

rnat

ion

al L

onge

vity

Cen

tre

(201

3) A

dult

vac

cina

tion

– a

ke

y co

mpo

nent

of h

ealt

hy a

gein

g w

ww

.ilcu

k.or

g.u

k/in

dex.

php/

publ

icat

ion

s/pu

blic

atio

n_d

etai

ls/a

dult

_vac

cin

atio

n_a

_ke

y_co

mp

onen

t_of

_hea

lthy

_age

ing

Pu

blic

Hea

lth

En

glan

d (2

014)

Im

mun

isat

ion

agai

nst

infe

ctio

us d

isea

se (

Gre

en b

ook)

ww

w.g

ov.u

k/go

vern

men

t/co

llect

ion

s/im

mu

nis

atio

n-a

gain

st-i

nfe

ctio

us-

dise

ase-

the-

gree

n-b

ook






Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

expe

ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(not

e w

here

spe

cifi

c gu

idan

ce is

not

pre

sent

this

is in

dica

ted

as ‘b

est

prac

tice

’)

Mon

itor

ing

Wh

ere

min

or

surg

ery

is

un

dert

aken

, su

rgic

al

site

infe

ctio

n

surv

eilla

nce

is

plan

ned

an

d re

por

ted

A s

urv

eilla

nce

pr

ogra

mm

e is

in

pla

ce t

o m

onit

or

surg

ical

in

terv

enti

ons

un

dert

aken

in

prim

ary

care

Evid

ence

an

d d

etai

l of

su

rvei

llan

ce

prog

ram

me,

de

fin

itio

ns

and

data

Perc

enta

ge o

f co

mpl

ian

ce

and

met

hod

of

mea

sure

men

t fo

r lo

cal

dete

rmin

atio

n a

nd

may

in

clu

de c

olla

bora

tion

w

ith

oth

er p

rovi

ders

.

Defi

nit

ion

of

surg

ical

pr

oced

ure

to

be d

efin

ed

loca

lly w

ith

co

mm

issi

oner

1B

est

prac

tice

Vacc

inat

ions

R

epor

tin

g on

co

mpl

ian

ce o

f h

ealt

h

care

wor

ker

vacc

inat

ion

pr

ogra

mm

e

An

nu

al c

onfi

rmat

ion

of

per

cen

tage

of

actu

al n

um

bers

an

d ty

pes

of

vacc

inat

ion

ag

ain

st e

ligib

le s

taff

An

nu

al r

epor

tin

g in

clu

din

g ex

cep

tion

s of

var

iati

on t

o p

olic

y

Vac

cin

atio

n is

re

com

men

ded

not

m

anda

ted

1A

lign

s w

ith

DH

(20

15)

Cod

e of

Pra

ctic

e cr

iter

ion

10

Pati

ents

iden

tifi

ed a

s el

igib

le fo

r va

ccin

atio

n s

tatu

s ar

e as

sess

ed a

nd

hav

e ou

tsta

ndi

ng

vacc

inat

ion

s of

fere

d by

pro

vide

r

Rep

orti

ng

of n

um

ber

of v

acci

nat

ion

s of

fere

d an

d ad

min

iste

red

Bi-

ann

ual

rep

orti

ng

Rep

orti

ng

to in

clu

de

brea

kdow

n p

er

vacc

inat

ion

cat

egor

y

1B

est

prac

tice

Inte

rnat

ion

al L

onge

vity

Cen

tre

(201

3) A

dult

vac

cina

tion

– a

ke

y co

mpo

nent

of h

ealt

hy a

gein

g w

ww

.ilcu

k.or

g.u

k/in

dex.

php/

publ

icat

ion

s/pu

blic

atio

n_d

etai

ls/a

dult

_vac

cin

atio

n_a

_ke

y_co

mp

onen

t_of

_hea

lthy

_age

ing

Pu

blic

Hea

lth

En

glan

d (2

014)

Im

mun

isat

ion

agai

nst

infe

ctio

us d

isea

se (

Gre

en b

ook)

ww

w.g

ov.u

k/go

vern

men

t/co

llect

ion

s/im

mu

nis

atio

n-a

gain

st-i

nfe

ctio

us-

dise

ase-

the-

gree

n-b

ook

3: In

fect

ion

prev

enti

on a

nd c

ontr

ol b

aske

t of s

ugge

sted

indi

cato

rs –

men

tal h

ealt

h

The

indi

cato

rs fo

r con

side

ratio

n be

low

refle

ct b

oth

NH

S pr

ovid

er in

-pat

ient

and

com

mun

ity se

rvic

e re

quir

emen

ts b

ased

on

patie

nt n

eed.

Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(not

e w

here

spe

cifi

c gu

idan

ce is

not

pre

sent

this

is in

dica

ted

as ‘b

est

prac

tice

’)

Am

biti

on in

dica

tors

Th

e pr

ovid

er h

as in

pla

ce

a st

rate

gy t

hat

des

crib

es

its

visi

on a

nd

acti

ons

over

tim

e to

dia

gnos

e,

mea

sure

, pre

ven

t an

d m

anag

e al

l cas

es o

f pn

eum

onia

, in

clu

din

g bu

t n

ot li

mit

ed t

o th

ose

that

are

hea

lth

car

e ac

quir

ed

Evid

ence

of

stra

tegy

, in

clu

din

g h

ow it

will

be

rev

iew

ed a

nd

eval

uat

ed

Evid

ence

of

stra

tegy

an

d im

plem

enta

tion

p

lan

Stra

tegy

sh

ould

incl

ude

th

e ro

le o

f m

ult

i-di

scip

linar

y st

akeh

olde

rs

and

com

mu

nic

atio

n

path

way

s. S

trat

egy

may

be

dev

elop

ed a

nd

impl

emen

ted

in

colla

bora

tion

wit

h o

ther

pr

ovid

er o

rgan

isat

ion

s

1B

est

prac

tice

NIC

E C

G19

1 (2

014)

Pne

umon

ia: D

iagn

osis

and

m

anag

emen

t of c

omm

unit

y- a

nd h

ospi

tal-

acqu

ired

pn

eum

onia

in a

dult

s w

ww

.nic

e.or

g.u

k/gu

idan

ce/C

G19

1

Parl

iam

enta

ry a

nd

Hea

lth

Ser

vice

s O

mbu

dsm

an

(201

4) T

ime

to A

ct, s

ever

e se

psis

: rap

id d

iagn

osis

and

tr

eatm

ent s

aves

live

s w

ww

.om

buds

man

.org

.uk/

__d

ata/

asse

ts/p

df_fi

le/0

004/

2266

6/FI

NA

L_S

epsi

s_R

epor

t_w

eb.p

df

Th

e pr

ovid

er h

as in

pla

ce

a st

rate

gy t

hat

des

crib

es

its

visi

on a

nd

acti

ons

over

tim

e to

su

ppor

t pa

tien

ts in

th

e pr

even

tion

, dia

gnos

is

and

man

agem

ent

of

uri

nar

y tr

act

infe

ctio

ns,

in

clu

din

g th

ose

that

are

n

ot r

elat

ed t

o th

e u

se o

f u

rin

ary

cath

eter

s

Evid

ence

of

stra

tegy

, in

clu

din

g h

ow it

will

be

rev

iew

ed a

nd

eval

uat

ed

Evid

ence

of

stra

tegy

an

d im

plem

enta

tion

p

lan

Stra

tegy

sh

ould

incl

ude

th

e ro

le o

f m

ult

i-di

scip

linar

y st

akeh

olde

rs

and

com

mu

nic

atio

n

path

way

s.

Stra

tegy

may

be

deve

lop

ed a

nd

impl

emen

ted

in

colla

bora

tion

wit

h o

ther

pr

ovid

er o

rgan

isat

ion

s.

Not

e: m

ay a

lign

wit

h

prac

tice

indi

cato

rs o

n

falls

an

d C

AU

TI

(App

endi

x 3)

1B

est

prac

tice

NIC

E C

G54

(20

07)

Uri

nary

tra

ct in

fect

ion

in c

hild

ren:

D

iagn

osis

, tre

atm

ent a

nd lo

ng-t

erm

man

agem

ent

ww

w.n

ice.

org.

uk/

guid

ance

/cg5

4

NIC

E (

2014

) Q

ualit

y St

anda

rd I

nfec

tion

pre

vent

ion

and

cont

rol Q

S61

ww

w.n

ice.

org.

uk/

guid

ance

/qs6

1

NIC

E C

G 1

39 (

2012

) In

fect

ion:

Pre

vent

ion

and

cont

rol

of h

ealt

hcar

e-as

soci

ated

infe

ctio

ns in

pri

mar

y an

d co

mm

unit

y ca

re w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g139

Parl

iam

enta

ry a

nd

Hea

lth

Ser

vice

s O

mbu

dsm

an

(201

4) T

ime

to A

ct, s

ever

e se

psis

: rap

id d

iagn

osis

and

tr

eatm

ent s

aves

live

s w

ww

.om

buds

man

.org

.uk/

__d

ata/

asse

ts/p

df_fi

le/0

004/

2266

6/FI

NA

L_S

epsi

s_R

epor

t_w

eb.p

df

NIC

E (

2015

) Q

ualit

y St

anda

rd U

rina

ry t

ract

infe

ctio

ns

in a

dult

s Q

S90

ww

w.n

ice.

org.

uk/

guid

ance

/qs9

0

NIC

E (

2013

) Q

ualit

y St

anda

rd U

rina

ry t

ract

infe

ctio

n in

infa

nts,

chi

ldre

n an

d yo

ung

peop

le u

nder

16

QS3

6 w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s36

NIC

E g

uid

elin

es C

G16

1 (2

013)

Fal

ls: a

sses

smen

t an

d pr

even

tion

of f

alls

in o

lder

peo

ple

w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g161











38


Return to contents

Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(not

e w

here

spe

cifi

c gu

idan

ce is

not

pre

sent

this

is in

dica

ted

as ‘b

est

prac

tice

’)

Th

e pr

ovid

er h

as in

pla

ce

a st

rate

gy t

hat

des

crib

es

acti

ons

to r

ecog

nis

e m

easu

re a

nd

man

age

susp

ecte

d ca

ses

of s

epsi

s

Evid

ence

of

stra

tegy

, in

clu

din

g h

ow it

will

be

rev

iew

ed a

nd

eval

uat

ed

Evid

ence

of

stra

tegy

an

d im

plem

enta

tion

pl

an

Stra

tegy

sh

ould

incl

ude

th

e ro

le o

f m

ult

i-di

scip

linar

y st

akeh

olde

rs

and

com

mu

nic

atio

n

path

way

s.

Stra

tegy

may

be

deve

lop

ed a

nd

impl

emen

ted

in

colla

bora

tion

wit

h o

ther

pr

ovid

er o

rgan

isat

ion

s

1, 2

NH

S E

ngl

and

(201

5) C

omm

issi

onin

g fo

r qu

alit

y an

d in

nova

tion

(C

QU

IN)

Gui

danc

e fo

r 20

15/1

6

ww

w.e

ngl

and.

nh

s.u

k/w

p-co

nte

nt/

upl

oads

/201

5/03

/9-

cqu

in-g

uid

-201

5-16

.pdf

Parl

iam

enta

ry a

nd

Hea

lth

Ser

vice

s O

mbu

dsm

an

(201

4) T

ime

to A

ct, s

ever

e se

psis

: rap

id d

iagn

osis

and

tr

eatm

ent s

aves

live

s w

ww

.om

buds

man

.org

.uk/

__d

ata/

asse

ts/p

df_fi

le/0

004/

2266

6/FI

NA

L_S

epsi

s_R

epor

t_w

eb.p

df

Org

anis

atio

nal e

lem

ents

IPC

is in

clu

ded

as a

re

gula

r ag

enda

item

in

prov

ider

org

anis

atio

n

mee

tin

gs

Rec

ord

of m

eeti

ngs

an

d IP

C t

opic

s di

scu

ssed

Min

ute

s of

m

eeti

ngs

Pro

vide

r to

det

erm

ine

wh

ich

mee

tin

gs w

ill

rou

tin

ely

incl

ude

IP

C

disc

uss

ion

1B

est

prac

tice

NIC

E (

2014

) Q

ualit

y St

anda

rd I

nfec

tion

pre

vent

ion

and

Con

trol

QS6

1 w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s61

Th

e or

gan

isat

ion

de

velo

ps a

nd

own

s a

boar

d-ap

prov

ed H

CA

I re

duct

ion

pla

n a

nd

prog

ress

is r

epor

ted

ag

ain

st t

his

Qu

arte

rly

com

plia

nce

rep

orts

Qu

arte

rly

rece

ipt

of r

epor

ts d

etai

ling

com

plia

nce

an

d pr

ogre

ss a

gain

st

pla

n

Th

e pr

ovid

er m

ay w

ish

to

use

th

e C

ode

of P

ract

ice

to

deve

lop

an I

PC

pla

n

1N

HS

En

glan

d St

anda

rd C

ontr

act

ww

w.e

ngl

and.

nh

s.u

k/n

hs-

stan

dard

-con

trac

t/15

-16/

NH

S E

ngl

and

Stan

dard

Con

trac

t 201

5/16

and

201

6/17

w

ww

.en

glan

d.n

hs.

uk/

nh

s-st

anda

rd-c

ontr

act/

15-1

6/

ww

w.e

ngl

and.

nh

s.u

k/n

hs-

stan

dard

-con

trac

t/16

-17/

An

tim

icro

bial

st

ewar

dsh

ip (

AM

S) is

in

clu

ded

as a

reg

ula

r ag

enda

item

in p

rovi

der

orga

nis

atio

n m

eeti

ngs

Rec

ord

of m

eeti

ngs

an

d A

MS

top

ics

disc

uss

ed

Min

ute

s of

m

eeti

ngs

Pro

vide

r to

det

erm

ine

wh

ich

mee

tin

gs w

ill

rou

tin

ely

incl

ude

AM

S di

scu

ssio

n

2B

est

prac

tice

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al

stew

ards

hip:

sys

tem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/

NG

15/c

hap

ter/

2-Im

plem

enta

tion

-get

tin

g-st

arte

d

NIC

E (

2014

) Q

ualit

y St

anda

rd I

nfec

tion

pre

vent

ion

and

cont

rol Q

S61

ww

w.n

ice.

org.

uk/

guid

ance

/qs6

1 P

rovi

der

take

s in

to

acco

un

t ad

vice

from

sp

ecia

list

IP

C a

nd

AM

S pr

ovid

er/t

eam

s

Doc

um

enta

tion

an

d de

tails

of

deci

sion

/re

med

ial a

ctio

n

Rec

ords

of

deci

sion

in

min

ute

s/ot

her

do

cum

enta

tion

Wh

ere

spec

ialis

t IP

C/

AM

S ad

vice

is n

ot

follo

wed

, th

e ra

tion

ale

and

deci

sion

is

docu

men

ted

and

disc

uss

ed a

t th

e re

leva

nt

mee

tin

g (s

ee t

wo

indi

cato

rs a

bove

)

1, 2

Bes

t pr

acti

ce

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al

stew

ards

hip:

sys

tem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/

NG

15/c

hap

ter/

2-Im

plem

enta

tion

-get

tin

g-st

arte

d













Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(not

e w

here

spe

cifi

c gu

idan

ce is

not

pre

sent

this

is in

dica

ted

as ‘b

est

prac

tice

’)

Th

e or

gan

isat

ion

em

ploy

s or

has

su

ffici

ent

acce

ss t

o a

suit

ably

re

sou

rced

an

d qu

alifi

ed

Infe

ctio

n P

reve

nti

on a

nd

C

ontr

ol T

eam

(IP

CT

),

An

tim

icro

bial

St

ewar

dsh

ip (

AM

S) t

eam

or

sp

ecia

list

prac

titi

oner

to

mee

t th

eir

nee

ds

Spec

ialis

t ad

vise

rs

are

clea

rly

iden

tifi

able

Rec

ord

of s

ervi

ce

or c

ontr

act

for

prov

isio

n o

f IP

C

and

AM

S ad

vice

Con

trac

t m

ay b

e fo

r em

ploy

men

t or

adv

ice

and

shou

ld d

etai

l th

e n

um

ber

of h

ours

em

ploy

ed/c

ontr

acte

d,

role

des

crip

tion

, lin

es o

f co

mm

un

icat

ion

an

d go

vern

ance

str

uct

ure

s fo

r IP

C a

nd

wit

hin

pro

vide

r or

gan

isat

ion

1B

est

prac

tice

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

ww

w.n

ice.

org.

uk/

guid

ance

/QS6

1/ch

apte

r/L

ist-

of-q

ual

ity-

stat

emen

ts

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al

stew

ards

hip:

sys

tem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/

NG

15/c

hap

ter/

2-Im

plem

enta

tion

-get

tin

g-st

arte

d

Pro

vide

r co

ntr

ibu

tes

to

wh

ole

econ

omy

stra

tegi

c pl

ann

ing

disc

uss

ion

an

d de

cisi

on m

akin

g on

H

CA

I re

duct

ion

Rec

ord

of

atte

nda

nce

an

d co

ntr

ibu

tion

Min

ute

s of

m

eeti

ngs

Loca

l HC

AI

prov

ider

or

prof

essi

onal

net

wor

ks

can

be

use

d as

a m

eth

od

of d

emon

stra

tin

g en

gage

men

t in

dis

cuss

ion

an

d pl

ann

ing

1B

est

prac

tice

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s61

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al

stew

ards

hip:

sys

tem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/

NG

15/c

hap

ter/

2-Im

plem

enta

tion

-get

tin

g-st

arte

d

Cop

ies

of a

ll re

por

ts a

nd

asso

ciat

ed a

ctio

n p

lan

s in

re

spon

se t

o an

y ex

tern

al

IPC

focu

s vi

sits

/in

spec

tion

s (e

.g. f

rom

D

H, C

CG

, CQ

C, T

DA

, M

onit

or)

are

mad

e av

aila

ble

to t

he

com

mis

sion

er b

y th

e pr

ovid

er

Cop

ies

of r

epor

ts

sen

t to

co

mm

issi

oner

w

ith

in fi

ve w

orki

ng

days

of

the

prov

ider

re

ceiv

ing

the

rep

ort

Rep

orts

are

re

ceiv

ed1

Bes

t pr

acti

ce

Ser

vice

use

r in

volv

emen

tSe

rvic

e u

sers

are

in

clu

ded

in I

PC

an

nu

al

prog

ram

me

de

velo

pmen

t, w

ith

pa

tien

t ex

per

ien

ce u

sed

to s

hap

e ac

tivi

ty

Serv

ice

use

r vi

ews

are

acti

vely

sou

ght

and

reco

mm

enda

tion

s in

corp

orat

ed w

her

e ap

prop

riat

e

Evid

ence

an

d de

tail

of p

arti

cipa

tion

in

ann

ual

rep

ort

1,3

Bes

t pr

acti

ce






40


Return to contents

Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(not

e w

here

spe

cifi

c gu

idan

ce is

not

pre

sent

this

is in

dica

ted

as ‘b

est

prac

tice

’)

Serv

ice

use

rs a

re in

volv

ed

in t

he

shap

ing

and

impl

emen

tati

on o

f lo

cal

prog

ram

mes

to

impr

ove

han

d hy

gien

e of

bot

h

staf

f an

d se

rvic

e u

sers

in

all s

etti

ngs

Serv

ice

use

rs a

re

invo

lved

in h

and

hygi

ene

prog

ram

mes

An

nu

al s

um

mar

y of

han

d hy

gien

e pr

ogra

mm

e ac

tivi

ty, i

ncl

udi

ng

use

r in

volv

emen

t

1,3

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s61

NIC

E C

G 1

39 (

2012

) In

fect

ion:

Pre

vent

ion

and

cont

rol

of h

ealt

hcar

e-as

soci

ated

infe

ctio

ns in

pri

mar

y an

d co

mm

unit

y ca

re w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g139

Pati

ents

wit

h in

vasi

ve

devi

ces

such

as

a u

rin

ary

cath

eter

, vas

cula

r ac

cess

de

vice

or

ente

ral f

eedi

ng

tube

, as

wel

l as

thei

r ca

rers

, are

giv

en

info

rmat

ion

an

d ad

vice

ab

out

how

to

look

aft

er

the

equ

ipm

ent

safe

ly a

nd

effe

ctiv

ely

Serv

ice

use

rs a

re

prov

ided

wit

h

advi

ce a

nd

are

invo

lved

in

dete

rmin

ing

deta

il of

info

rmat

ion

in

clu

ded

An

nu

al s

um

mar

y of

info

rmat

ion

av

aila

ble,

d

istr

ibu

tion

an

d ev

alu

atio

n

incl

udi

ng

pat

ien

t/ca

rer

feed

back

1,3

NIC

E (

2014

) Q

ualit

y St

anda

rd Q

S61

w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s61

NIC

E C

G 1

39 (

2012

) In

fect

ion:

Pre

vent

ion

and

cont

rol

of h

ealt

hcar

e-as

soci

ated

infe

ctio

ns in

pri

mar

y an

d co

mm

unit

y ca

re w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g139

MR

SA

, C. d

iffi

cile

and

oth

er s

igni

fica

nt H

CA

IsT

he

prov

ider

con

trib

ute

s to

th

e Po

st I

nfe

ctio

n

Rev

iew

/ R

CA

/‘L

apse

in

care

’ inv

esti

gati

ons

for

all

case

s of

HC

AI

Con

trib

uti

on t

o th

e P

IR p

roce

ss a

nd

impl

emen

tati

on o

f ac

tion

pla

ns

and

lear

nin

g de

rive

d fr

om in

vest

igat

ion

re

view

s.

100%

att

enda

nce

at

inve

stig

atio

n

mee

tin

gs

Att

end

ance

at

PIR

m

eeti

ngs

.

Act

ion

pla

n r

epor

ts

are

rece

ived

an

d

upd

ated

reg

ula

rly,

w

ith

lear

nin

g sh

ared

acr

oss

the

orga

nis

atio

n

Wit

h e

xcep

tion

s of

M

RSA

bac

tera

emia

an

d C

. dif

ficile

infe

ctio

n,

oth

er H

CA

Is t

hat

req

uir

e in

vest

igat

ion

are

to

be

dete

rmin

ed lo

cally

1, 2

, 5N

HS

En

glan

d (2

014)

Zer

o to

lera

nce

ww

w.e

ngl

and

.nh

s.u

k/pa

tien

tsaf

ety/

asso

ciat

ed-i

nfe

ctio

ns/

zero

-tol

eran

ce/

NH

S E

ngl

and

(201

5) C

lost

ridi

um

dif

fici

le in

fect

ion

obje

ctiv

es fo

r N

HS

orga

nisa

tion

s in

201

5/16

and

gu

idan

ce o

n sa

ncti

on im

plem

enta

tion

ww

w.e

ngl

and

.nh

s.u

k/w

p-co

nte

nt/

upl

oads

/201

5/02

/clo

stri

dm-d

iffi

cile

-in

fect

-obj

ct-1

5-16

-gu

id-f

eb15

.pdf










Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(not

e w

here

spe

cifi

c gu

idan

ce is

not

pre

sent

this

is in

dica

ted

as ‘b

est

prac

tice

’)

Com

plia

nce

wit

h lo

cally

ag

reed

MR

SA c

are

path

way

Qu

arte

rly

con

firm

atio

n o

f p

erce

nta

ge o

f M

RSA

-pos

itiv

e pa

tien

ts w

ho

follo

w

and

com

plet

e th

e M

RSA

car

e pa

thw

ay

Qu

arte

rly

rece

ipt

of M

RSA

car

e pa

thw

ay

com

plia

nce

dat

a

Car

e pa

thw

ays

shou

ld b

e de

fin

ed lo

cally

an

d al

l pr

ovid

ers

shou

ld b

e aw

are

of t

hes

e an

d co

mpl

y w

ith

th

em.

Con

side

r in

clu

sion

of

audi

t of

flag

gin

g of

M

RSA

sta

tus

acro

ss a

ll pa

tien

t ad

min

istr

atio

n

syst

ems

acro

ss t

he

path

way

.

Perc

enta

ge o

f co

mpl

ian

ce

and

met

hod

of

mea

sure

men

t fo

r lo

cal

dete

rmin

atio

n

1N

HS

En

glan

d (2

014)

Zer

o to

lera

nce

ww

w.e

ngl

and

.nh

s.u

k/pa

tien

tsaf

ety/

asso

ciat

ed-i

nfe

ctio

ns/

zero

-tol

eran

ce/

Pati

ents

wh

o m

eet

the

crit

eria

for

MR

SA

scre

enin

g ar

e m

anag

ed a

s p

er lo

cally

agr

eed

prot

ocol

s an

d al

l pos

itiv

e re

sult

s ar

e ac

ted

up

on

Mon

thly

co

nfi

rmat

ion

of

per

cen

tage

of

elig

ible

cas

es

scre

ened

for

MR

SA

Mon

thly

rec

eip

t of

sc

reen

ing

data

D

etai

l of

mea

sure

men

t m

eth

od t

o be

det

erm

ined

lo

cally

, e.g

. pro

toco

l for

el

igib

ility

.

100%

com

plia

nce

is fo

r lo

cal d

eter

min

atio

n

1,5

NH

S E

ngl

and

(201

4) Z

ero

tole

ranc

e w

ww

.en

glan

d.n

hs.

uk/

pati

ents

afet

y/as

soci

ated

-in

fect

ion

s/ze

ro-t

oler

ance

/

DH

(20

14)

Impl

emen

tati

on o

f mod

ified

adm

issi

on

MR

SA s

cree

ning

gui

danc

e fo

r N

HS

(201

4) w

ww

.gov

.uk/

gove

rnm

ent/

upl

oads

/sys

tem

/upl

oads

/att

ach

men

t_da

ta/fi

le/3

4514

4/Im

plem

enta

tion

_of_

mod

ified

_ad

mis

sion

_MR

SA_s

cree

nin

g_gu

idan

ce_f

or_N

HS.

pd

f

Com

plia

nce

wit

h lo

cally

ag

reed

C. d

iffic

ile c

are

path

way

Qu

arte

rly

con

firm

atio

n o

f p

erce

nta

ge o

f C

. di

ffici

le p

atie

nts

wh

o fo

llow

an

d co

mpl

ete

the

care

pat

hway

Qu

arte

rly

rece

ipt

of C

. dif

ficile

car

e p

athw

ay

com

plia

nce

dat

a

Car

e pa

thw

ays

shou

ld b

e de

fin

ed lo

cally

an

d al

l pr

ovid

ers

shou

ld b

e aw

are

of t

hem

an

d co

ntr

ibu

te w

her

e re

leva

nt.

Con

side

r in

clu

sion

of

audi

t of

fl

aggi

ng

of C

. dif

ficile

st

atu

s ac

ross

all

pati

ent

adm

inis

trat

ion

sys

tem

s ac

ross

th

e pa

thw

ay.

Perc

enta

ge o

f co

mpl

ian

ce

and

met

hod

of

mea

sure

men

t fo

r lo

cal

dete

rmin

atio

n

1B

est

prac

tice





42


Return to contents

Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(not

e w

here

spe

cifi

c gu

idan

ce is

not

pre

sent

this

is in

dica

ted

as ‘b

est

prac

tice

’)

Pro

vide

r co

ntr

ibu

tes

to

revi

ew o

f al

l C. d

iffic

ile

infe

ctio

n (

CD

I) c

ases

if

invo

lved

in p

rovi

sion

of

care

to

pati

ent

100%

com

plia

nce

w

ith

invo

lvem

ent

in

revi

ew o

f an

y C

DI

case

th

at t

he

prov

ider

is

asso

ciat

ed w

ith

Qu

arte

rly

subm

issi

on o

f ev

iden

ce

dem

onst

rati

ng

prov

ider

in

volv

emen

t in

re

view

mee

tin

gs

and

prog

ress

wit

h

acti

ons

Det

ail o

f m

easu

rem

ent

met

hod

to

be d

eter

min

ed

loca

lly

1N

HS

En

glan

d (2

015)

Clo

stri

diu

m d

iffi

cile

infe

ctio

n ob

ject

ives

for

NH

S or

gani

sati

ons

in 2

015/

16 a

nd

guid

ance

on

sanc

tion

impl

emen

tati

on a

t w

ww

.en

glan

d.

nh

s.u

k/w

p-co

nte

nt/

upl

oads

/201

5/02

/clo

stri

dm-

diffi

cile

-in

fect

-obj

ct-1

5-16

-gu

id-f

eb15

.pdf

All

susp

ecte

d in

fect

ion

s an

d co

nfi

rmed

ou

tbre

aks

are

rep

orte

d to

th

e co

mm

issi

oner

an

d lo

cal

hea

lth

pro

tect

ion

tea

m

wit

hou

t de

lay

All

con

firm

ed o

r ou

tbre

aks

are

rep

orte

d by

th

e n

ext

wor

kin

g d

ay

Mon

thly

rep

orti

ng

1,5

Car

e Q

ual

ity

Com

mis

sion

web

site

ww

w.c

qc.o

rg.u

k/co

nte

nt/

not

ifica

tion

s-n

on-n

hs-

tru

st-p

rovi

ders

Seri

ous

inci

den

ts a

re

rep

orte

d to

th

e co

mm

issi

oner

wit

hin

on

e w

orki

ng

day

Not

ifica

tion

of

inci

den

t to

co

mm

issi

oner

w

ith

in t

wo

wor

kin

g da

ys

Qu

arte

rly

rep

orti

ng

Defi

nit

ion

of

seri

ous

inci

den

t to

be

defi

ned

by

prov

ider

follo

win

g ag

reem

ent

wit

h

com

mis

sion

er.

Ver

ifica

tion

mea

sure

–

STE

IS, N

RL

S, R

CA

, P

IR, p

atie

nt

com

plai

nts

1H

PA (

2012

) H

ealt

hcar

e as

soci

ated

infe

ctio

n op

erat

iona

l gu

idan

ce a

nd s

tand

ards

for

heal

th p

rote

ctio

n un

its

w

ww

.gov

.uk/

gove

rnm

ent/

publ

icat

ion

s/h

ealt

hca

re-

asso

ciat

ed-i

nfe

ctio

n-h

cai-

oper

atio

nal

-gu

idan

ce-a

nd

-st

anda

rds

NH

S E

ngl

and

(201

5) S

erio

us in

cide

nt fr

amew

ork

w

ww

.en

glan

d.n

hs.

uk/

pati

ents

afet

y/se

riou

s-in

cide

nt/

Th

e pr

ovid

er h

as a

sy

stem

in p

lace

to

supp

ort

prep

ared

nes

s or

m

anag

emen

t of

pat

ien

ts

carr

yin

g ca

rbap

enae

mas

e-pr

odu

cin

g E

nte

roba

cter

iace

ae

(CP

E)

in li

ne

wit

h P

HE

C

PE

gu

idan

ce

Th

e pr

ovid

er h

as a

p

olic

y in

pla

ce fo

r th

e m

anag

emen

t of

C

PE

an

d h

as

con

side

red

the

impl

icat

ion

s of

its

impl

emen

tati

on o

n

its

serv

ice

Con

firm

atio

n o

f p

olic

y in

pla

ce1

PH

E (

2015

) To

olki

t for

man

agin

g ca

rbap

enem

ase-

prod

ucin

g En

tero

bact

eria

ceae

in n

on-a

cute

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44


Return to contents

Qua

lity

requ

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46


Return to contents

Qua

lity

requ

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s,

quin

olon

es a

nd

co-a

mox

icla

v as

a

per

cen

tage

of

the

tota

l nu

mbe

r of

an

tibi

otic

s pr

escr

ibed

is

redu

ced

by 1

0% o

r be

low

th

e cu

rren

t m

edia

n p

rop

orti

on

for

En

glis

h C

CG

s (w

hic

hev

er is

met

fi

rst)

As

per

Qu

alit

y P

rem

ium

det

ail

2N

HS

En

glan

d (2

015)

Qua

lity

Pre

miu

m: 2

015/

16

guid

ance

for

CC

Gs

ww

w.e

ngl

and.

nh

s.u

k/w

p-co

nte

nt/

upl

oads

/201

5/04

/qu

al-p

rem

-gu

id-1

516.

pdf

Phy

sica

l hea

lth

Org

anis

atio

n h

as in

pla

ce

a m

ult

i-di

scip

linar

y tr

ain

ing

and

com

pet

ency

as

sess

men

t fo

r th

e ca

re o

f pa

tien

ts w

ith

phy

sica

l h

ealt

h n

eeds

to

supp

ort

wel

lbei

ng

and

the

prev

enti

on o

f in

fect

ion

Trai

nin

g an

d co

mp

eten

cy

prog

ram

me

is in

pl

ace

Bi-

ann

ual

re

por

tin

g of

co

mp

eten

cy

asse

ssm

ent

agai

nst

el

igib

le s

taff

Pro

gram

me

may

be

inco

rpor

ated

as

part

of

prof

essi

onal

s P

DR

pr

oces

s

1B

est

prac

tice

NH

SE (

2014

) C

QU

IN 2

014/

5 ad

diti

onal

gui

danc

e on

th

e m

enta

l hea

lth

indi

cato

r w

ww

.en

glan

d.n

hs.

uk/

wp-

con

ten

t/u

ploa

ds/2

014/

06/c

quin

-add

-mh

-gu

id.p

df

Vacc

inat

ions

Pa

tien

ts id

enti

fied

as

elig

ible

for

vacc

inat

ion

st

atu

s ar

e as

sess

ed a

nd

hav

e ou

tsta

ndi

ng

vacc

inat

ion

s of

fere

d by

pr

ovid

er

Rep

orti

ng

of

nu

mbe

r of

va

ccin

atio

ns

offe

red

and

adm

inis

tere

d

Bi-

ann

ual

re

por

tin

gR

epor

tin

g to

incl

ude

br

eakd

own

per

va

ccin

atio

n c

ateg

ory

1B

est

prac

tice

Inte

rnat

ion

al L

onge

vity

Cen

tre

(201

3) A

dult

va

ccin

atio

n –

a ke

y co

mpo

nent

of h

ealt

hy a

gein

g w

ww

.ilc

uk.

org.

uk/

inde

x.ph

p/pu

blic

atio

ns/

publ

icat

ion

_de

tails

/adu

lt_v

acci

nat

ion

_a_k

ey_c

omp

onen

t_of

_h

ealt

hy_a

gein

g

PH

E (

2014

) Im

mun

isat

ion

agai

nst i

nfec

tiou

s di

seas

e (G

reen

boo

k) w

ww

.gov

.uk/

gove

rnm

ent/

colle

ctio

ns/

imm

un

isat

ion

-aga

inst

-in

fect

iou

s-di

seas

e-th

e-gr

een

-bo

ok



http://www.england.nhs.uk/wp-content/uploads/2014/06/cquin-add-mh-guid.pdf





Qua

lity

requ

irem

ent

Thre

shol

d (r

epor

ting

ex

pect

atio

n)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(not

e w

here

spe

cifi

c gu

idan

ce is

not

pre

sent

this

is in

dica

ted

as ‘b

est

prac

tice

’)

Rep

orti

ng

on c

ompl

ian

ce

of h

ealt

h c

are

wor

ker

vacc

inat

ion

pro

gram

me

An

nu

al

con

firm

atio

n o

f p

erce

nta

ge o

f ac

tual

n

um

bers

an

d ty

pes

of

vac

cin

atio

n

agai

nst

elig

ible

sta

ff

An

nu

al r

epor

tin

g,

incl

udi

ng

exce

pti

ons

of

vari

atio

n t

o p

olic

y

Vac

cin

atio

n is

re

com

men

ded

not

m

anda

ted

1A

lign

s w

ith

DH

(20

15)

Cod

e of

pra

ctic

e cr

iter

ion

10


48


Return to contents

App

endi

x 4:

Infe

ctio

n pr

even

tion

and

con

trol

bas

ket o

f sug

gest

ed in

dica

tors

– s

ocia

l car

e

Th

is in

dica

tor

bask

et r

ecog

nis

es a

dev

elop

men

tal a

ppro

ach

to

impr

ovem

ents

in in

fect

ion

pre

ven

tion

an

d co

ntr

ol in

adu

lt s

ocia

l car

e se

ttin

gs. I

t ac

know

ledg

es t

he

wid

e va

riat

ion

in s

ize

and

typ

e of

car

e de

liver

ed in

soc

ial c

are

sett

ings

. Sta

ge o

ne

aim

s to

su

ppor

t pr

ovid

ers

to e

nsu

re t

hei

r or

gan

isat

ion

al r

equ

irem

ents

alig

n fu

lly t

o co

mm

issi

onin

g or

gan

isat

ion

s’ e

xpec

tati

ons

of t

he

Cod

e of

Pra

ctic

e (D

H, 2

015)

. Sta

ge t

wo

build

s on

sta

ge o

ne

to fu

rth

er e

mbe

d in

fect

ion

pre

ven

tion

an

d co

ntr

ol

wit

hin

th

e or

gan

isat

ion

.

Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

expe

ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(n

ote

whe

re s

peci

fic

guid

ance

is n

ot p

rese

nt th

is is

indi

cate

d as

‘b

est p

ract

ice’

)

Sta

ge 1

. Com

mis

sion

ing

the

fund

amen

tals

of c

lean

, saf

e ca

reA

mbi

tion

indi

cato

rsT

he

prov

ider

has

in

plac

e a

stra

tegy

th

at d

escr

ibes

its

visi

on a

nd

acti

ons

over

tim

e to

di

agn

ose,

mea

sure

, pr

even

t an

d m

anag

e pn

eum

onia

Evid

ence

of

stra

tegy

, in

clu

din

g h

ow it

will

be

revi

ewed

an

d ev

alu

ated

Evid

ence

of

stra

tegy

an

d im

plem

enta

tion

pl

an

Stra

tegy

sh

ould

in

clu

de t

he

role

of

mu

lti-

disc

iplin

ary

stak

ehol

ders

an

d co

mm

un

icat

ion

pa

thw

ays.

Stra

tegy

may

be

deve

lop

ed a

nd

imp

lem

ente

d in

co

llabo

rati

on w

ith

ot

her

pro

vide

r or

gan

isat

ion

s

1B

est

prac

tice

NIC

E C

G19

1 (2

014)

Pne

umon

ia: D

iagn

osis

and

man

agem

ent o

f co

mm

unit

y- a

nd h

ospi

tal-

acqu

ired

pne

umon

ia in

adu

lts

w

ww

.nic

e.or

g.u

k/gu

idan

ce/C

G19

1

Parl

iam

enta

ry a

nd

Hea

lth

Ser

vice

s O

mbu

dsm

an (

2014

) T

ime

to A

ct, s

ever

e se

psis

: rap

id d

iagn

osis

and

tre

atm

ent s

aves

live

s w

ww

.om

buds

man

.org

.u

k/__

data

/ass

ets/

pdf_

file

/000

4/22

666/

FIN

AL

_Sep

sis_

Rep

ort_

web

.pd

f

Th

e pr

ovid

er h

as in

pl

ace

a st

rate

gy

that

des

crib

es it

s vi

sion

an

d ac

tion

s ov

er t

ime

to

supp

ort

pati

ents

in

the

prev

enti

on,

diag

nos

is a

nd

man

agem

ent

of

uri

nar

y tr

act

infe

ctio

ns,

in

clu

din

g th

ose

that

are

not

rel

ated

to

th

e u

se o

f u

rin

ary

cath

eter

s

Evid

ence

of

stra

tegy

, in

clu

din

g h

ow it

will

be

revi

ewed

an

d ev

alu

ated

Evid

ence

of

stra

tegy

an

d im

plem

enta

tion

pl

an

Stra

tegy

sh

ould

in

clu

de t

he

role

of

mu

lti-

disc

iplin

ary

stak

ehol

ders

an

d co

mm

un

icat

ion

pa

thw

ays.

Stra

tegy

may

be

deve

lop

ed a

nd

imp

lem

ente

d in

co

llabo

rati

on w

ith

ot

her

pro

vide

r or

gan

isat

ion

s.

Not

e: m

ay a

lign

wit

h

indi

cato

r to

red

uce

th

e n

um

ber

of

un

nec

essa

ry in

vasi

ve

devi

ces

and

know

ledg

e/u

se o

f p

olic

ies

(pag

e xx

)

1, 5

Bes

t pr

acti

ce

NIC

E C

G54

(20

07)

Uri

nary

tra

ct in

fect

ion

in c

hild

ren:

Dia

gnos

is, t

reat

men

t an

d lo

ng-t

erm

man

agem

ent w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g54

NIC

E (

2014

) Q

ualit

y St

anda

rd I

nfec

tion

pre

vent

ion

and

cont

rol Q

S61

w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s61

NIC

E C

G 1

39 (

2012

) In

fect

ion:

Pre

vent

ion

and

cont

rol o

f hea

lthc

are-

asso

ciat

ed in

fect

ions

in p

rim

ary

and

com

mun

ity

care

w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g139

Parl

iam

enta

ry a

nd

Hea

lth

Ser

vice

s O

mbu

dsm

an (

2014

) T

ime

to A

ct, s

ever

e se

psis

: rap

id d

iagn

osis

and

tre

atm

ent s

aves

live

s w

ww

.om

buds

man

.org

.u

k/__

data

/ass

ets/

pdf_

file

/000

4/22

666/

FIN

AL

_Sep

sis_

Rep

ort_

web

.pd

f

NIC

E (

2015

) Q

ualit

y St

anda

rd U

rina

ry t

ract

infe

ctio

ns in

adu

lts

QS9

0

ww

w.n

ice.

org.

uk/

guid

ance

/qs9

0

NIC

E (

2013

) Q

ualit

y St

anda

rd U

rina

ry t

ract

infe

ctio

n in

infa

nts,

chi

ldre

n an

d yo

ung

peop

le u

nder

16

QS3

6 w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s36

NIC

E C

G16

1 (2

013)

Fal

ls: a

sses

smen

t and

pre

vent

ion

of fa

lls in

old

er p

eopl

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g161













App

endi

x 4:

Infe

ctio

n pr

even

tion

and

con

trol

bas

ket o

f sug

gest

ed in

dica

tors

– s

ocia

l car

e

Th

is in

dica

tor

bask

et r

ecog

nis

es a

dev

elop

men

tal a

ppro

ach

to

impr

ovem

ents

in in

fect

ion

pre

ven

tion

an

d co

ntr

ol in

adu

lt s

ocia

l car

e se

ttin

gs. I

t ac

know

ledg

es t

he

wid

e va

riat

ion

in s

ize

and

typ

e of

car

e de

liver

ed in

soc

ial c

are

sett

ings

. Sta

ge o

ne

aim

s to

su

ppor

t pr

ovid

ers

to e

nsu

re t

hei

r or

gan

isat

ion

al r

equ

irem

ents

alig

n fu

lly t

o co

mm

issi

onin

g or

gan

isat

ion

s’ e

xpec

tati

ons

of t

he

Cod

e of

Pra

ctic

e (D

H, 2

015)

. Sta

ge t

wo

build

s on

sta

ge o

ne

to fu

rth

er e

mbe

d in

fect

ion

pre

ven

tion

an

d co

ntr

ol

wit

hin

th

e or

gan

isat

ion

.

Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

expe

ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(n

ote

whe

re s

peci

fic

guid

ance

is n

ot p

rese

nt th

is is

indi

cate

d as

‘b

est p

ract

ice’

)

Sta

ge 1

. Com

mis

sion

ing

the

fund

amen

tals

of c

lean

, saf

e ca

reA

mbi

tion

indi

cato

rsT

he

prov

ider

has

in

plac

e a

stra

tegy

th

at d

escr

ibes

its

visi

on a

nd

acti

ons

over

tim

e to

di

agn

ose,

mea

sure

, pr

even

t an

d m

anag

e pn

eum

onia

Evid

ence

of

stra

tegy

, in

clu

din

g h

ow it

will

be

revi

ewed

an

d ev

alu

ated

Evid

ence

of

stra

tegy

an

d im

plem

enta

tion

pl

an

Stra

tegy

sh

ould

in

clu

de t

he

role

of

mu

lti-

disc

iplin

ary

stak

ehol

ders

an

d co

mm

un

icat

ion

pa

thw

ays.

Stra

tegy

may

be

deve

lop

ed a

nd

imp

lem

ente

d in

co

llabo

rati

on w

ith

ot

her

pro

vide

r or

gan

isat

ion

s

1B

est

prac

tice

NIC

E C

G19

1 (2

014)

Pne

umon

ia: D

iagn

osis

and

man

agem

ent o

f co

mm

unit

y- a

nd h

ospi

tal-

acqu

ired

pne

umon

ia in

adu

lts

w

ww

.nic

e.or

g.u

k/gu

idan

ce/C

G19

1

Parl

iam

enta

ry a

nd

Hea

lth

Ser

vice

s O

mbu

dsm

an (

2014

) T

ime

to A

ct, s

ever

e se

psis

: rap

id d

iagn

osis

and

tre

atm

ent s

aves

live

s w

ww

.om

buds

man

.org

.u

k/__

data

/ass

ets/

pdf_

file

/000

4/22

666/

FIN

AL

_Sep

sis_

Rep

ort_

web

.pd

f

Th

e pr

ovid

er h

as in

pl

ace

a st

rate

gy

that

des

crib

es it

s vi

sion

an

d ac

tion

s ov

er t

ime

to

supp

ort

pati

ents

in

the

prev

enti

on,

diag

nos

is a

nd

man

agem

ent

of

uri

nar

y tr

act

infe

ctio

ns,

in

clu

din

g th

ose

that

are

not

rel

ated

to

th

e u

se o

f u

rin

ary

cath

eter

s

Evid

ence

of

stra

tegy

, in

clu

din

g h

ow it

will

be

revi

ewed

an

d ev

alu

ated

Evid

ence

of

stra

tegy

an

d im

plem

enta

tion

pl

an

Stra

tegy

sh

ould

in

clu

de t

he

role

of

mu

lti-

disc

iplin

ary

stak

ehol

ders

an

d co

mm

un

icat

ion

pa

thw

ays.

Stra

tegy

may

be

deve

lop

ed a

nd

imp

lem

ente

d in

co

llabo

rati

on w

ith

ot

her

pro

vide

r or

gan

isat

ion

s.

Not

e: m

ay a

lign

wit

h

indi

cato

r to

red

uce

th

e n

um

ber

of

un

nec

essa

ry in

vasi

ve

devi

ces

and

know

ledg

e/u

se o

f p

olic

ies

(pag

e xx

)

1, 5

Bes

t pr

acti

ce

NIC

E C

G54

(20

07)

Uri

nary

tra

ct in

fect

ion

in c

hild

ren:

Dia

gnos

is, t

reat

men

t an

d lo

ng-t

erm

man

agem

ent w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g54

NIC

E (

2014

) Q

ualit

y St

anda

rd I

nfec

tion

pre

vent

ion

and

cont

rol Q

S61

w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s61

NIC

E C

G 1

39 (

2012

) In

fect

ion:

Pre

vent

ion

and

cont

rol o

f hea

lthc

are-

asso

ciat

ed in

fect

ions

in p

rim

ary

and

com

mun

ity

care

w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g139

Parl

iam

enta

ry a

nd

Hea

lth

Ser

vice

s O

mbu

dsm

an (

2014

) T

ime

to A

ct, s

ever

e se

psis

: rap

id d

iagn

osis

and

tre

atm

ent s

aves

live

s w

ww

.om

buds

man

.org

.u

k/__

data

/ass

ets/

pdf_

file

/000

4/22

666/

FIN

AL

_Sep

sis_

Rep

ort_

web

.pd

f

NIC

E (

2015

) Q

ualit

y St

anda

rd U

rina

ry t

ract

infe

ctio

ns in

adu

lts

QS9

0

ww

w.n

ice.

org.

uk/

guid

ance

/qs9

0

NIC

E (

2013

) Q

ualit

y St

anda

rd U

rina

ry t

ract

infe

ctio

n in

infa

nts,

chi

ldre

n an

d yo

ung

peop

le u

nder

16

QS3

6 w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s36

NIC

E C

G16

1 (2

013)

Fal

ls: a

sses

smen

t and

pre

vent

ion

of fa

lls in

old

er p

eopl

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g161

Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

expe

ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(n

ote

whe

re s

peci

fic

guid

ance

is n

ot p

rese

nt th

is is

indi

cate

d as

‘b

est p

ract

ice’

)

Th

e pr

ovid

er h

as in

pl

ace

a st

rate

gy

that

des

crib

es

acti

ons

to r

ecog

nis

e m

easu

re a

nd

man

age

susp

ecte

d ca

ses

of s

epsi

s

Evid

ence

of

stra

tegy

, in

clu

din

g h

ow it

will

be

revi

ewed

an

d ev

alu

ated

Evid

ence

of

stra

tegy

an

d im

plem

enta

tion

pl

an

Stra

tegy

sh

ould

in

clu

de t

he

role

of

mu

lti-

disc

iplin

ary

stak

ehol

ders

an

d co

mm

un

icat

ion

pa

thw

ays.

St

rate

gy m

ay b

e de

velo

ped

an

d im

ple

men

ted

in

colla

bora

tion

wit

h

oth

er p

rovi

der

orga

nis

atio

ns

1, 2

NH

S E

ngl

and

(201

5) C

omm

issi

onin

g fo

r qu

alit

y an

d in

nova

tion

(C

QU

IN)

Gui

danc

e fo

r 20

15/1

6 w

ww

.en

glan

d.n

hs.

uk/

wp-

con

ten

t/u

ploa

ds/2

015/

03/9

-cqu

in-g

uid

-201

5-16

.pdf

Parl

iam

enta

ry a

nd

Hea

lth

Ser

vice

s O

mbu

dsm

an (

2014

) T

ime

to A

ct, s

ever

e se

psis

: rap

id d

iagn

osis

and

tre

atm

ent s

aves

live

s w

ww

.om

buds

man

.org

.u

k/__

data

/ass

ets/

pdf_

file

/000

4/22

666/

FIN

AL

_Sep

sis_

Rep

ort_

web

.pd

f

An

infe

ctio

n

prev

enti

on le

ad is

id

enti

fied

an

d cl

earl

y vi

sibl

e in

th

e or

gan

isat

ion

Nam

e of

lead

Incl

ude

d in

an

nu

al s

tate

men

t an

d is

pu

blic

ally

av

aila

ble

A r

ole

desc

rip

tion

an

d/or

job

desc

rip

tion

sh

ould

be

avai

labl

e

1A

lign

s w

ith

DH

(20

15)

Cod

e of

pra

ctic

e

Polic

ies

are

in p

lace

an

d st

aff

are

awar

e of

th

eir

con

ten

t in

th

e fo

llow

ing

key

area

s

Pri

orit

ised

p

olic

ies

rela

tin

g to

IP

C in

clu

de:

• han

d hy

gien

e

• env

iron

men

tal

clea

nlin

ess

• sta

nda

rd

prec

auti

ons

• man

agem

ent

of

uri

nar

y ca

thet

ers

• en

tera

l fee

din

g

• IV

th

erap

y

To b

e av

aila

ble

at

tim

e of

in

spec

tion

or

qual

ity

revi

ew

visi

t an

d m

ade

publ

icly

ava

ilabl

e

Loca

l pro

fess

ion

al

net

wor

ks c

an b

e u

sed

as a

met

hod

of

deve

lopi

ng

pol

icie

s an

d gu

idan

ce

1A

lign

s w

ith

DH

(20

15)

Cod

e of

pra

ctic

e

NIC

E (

2012

) C

G 1

39 I

nfec

tion

: Pre

vent

ion

and

cont

rol o

f hea

lthc

are-

asso

ciat

ed in

fect

ions

in p

rim

ary

and

com

mun

ity

care

w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g139





50


Return to contents

Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

expe

ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(n

ote

whe

re s

peci

fic

guid

ance

is n

ot p

rese

nt th

is is

indi

cate

d as

‘b

est p

ract

ice’

)

Loca

l med

icin

es

man

agem

ent

pol

icie

s in

clu

de

anti

biot

ic

pres

crib

ing

and

adm

inis

trat

ion

. R

eflec

ts n

atio

nal

pr

escr

ibin

g gu

idan

ce

Pre

sen

ce o

f m

edic

ines

m

anag

emen

t p

olic

y

An

nu

al

con

firm

atio

n o

f p

olic

y in

pla

ce

and

evid

ence

of

colla

bora

tive

w

orki

ng

wit

h

oth

er a

gen

cies

(n

ote:

may

cro

ss-

refe

ren

ce w

ith

pr

imar

y an

d co

mm

un

ity

bask

et)

Polic

y ca

n b

e de

velo

ped

wit

h lo

cal

prim

ary

care

pr

ovid

ers

(GPs

) to

su

ppor

t st

and

ardi

sati

on o

f pr

acti

ce fo

r an

tibi

otic

pr

escr

ibin

g. P

olic

y sh

ould

be

revi

ewed

m

inim

um

of

two-

year

ly u

nle

ss n

ew

nat

ion

al g

uid

ance

is

sued

2N

ICE

SC

1 (2

014)

Man

agin

g m

edic

ines

in c

are

hom

es

ww

w.n

ice.

org.

uk/

guid

ance

/sc1

Alig

ns

wit

h D

H (

2015

) C

ode

of p

ract

ice

NIC

E (

2014

) Q

ualit

y St

anda

rd I

nfec

tion

pre

vent

ion

and

cont

rol Q

S61

ww

w.n

ice.

org.

uk/

guid

ance

/qs6

1

NIC

E G

uid

elin

e N

G15

(20

15)

Ant

imic

robi

al s

tew

ards

hip:

sys

tem

s an

d pr

oces

ses

for

effe

ctiv

e an

tim

icro

bial

med

icin

e us

e w

ww

.nic

e.or

g.u

k/gu

idan

ce/

NG

15/c

hap

ter/

2-Im

plem

enta

tion

-get

tin

g-st

arte

d

All

staf

f h

ave

acce

ss

to r

esou

rces

to

supp

ort

han

d hy

gien

e at

th

e p

oin

t of

car

e w

hen

in

dica

ted

Evid

ence

of

how

re

sou

rces

are

pr

ovid

ed a

nd

use

d in

pra

ctic

e

Six-

mon

thly

re

view

Req

uir

emen

ts a

re fo

r lo

cal d

eter

min

atio

n

base

d on

pat

ien

t p

opu

lati

on a

nd

serv

ice

sett

ing

1N

ICE

(20

14)

Qua

lity

Stan

dard

QS6

1 w

ww

.nic

e.or

g.u

k/gu

idan

ce/q

s61

NIC

E C

G 1

39 (

2012

) In

fect

ion:

Pre

vent

ion

and

cont

rol o

f hea

lthc

are-

asso

ciat

ed in

fect

ions

in p

rim

ary

and

com

mun

ity

care

w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g139

Pro

vide

r’s

inci

den

t re

por

tin

g sy

stem

in

clu

des

infe

ctio

n

inci

den

ts

Infe

ctio

n

inci

den

ts a

re

reco

rded

an

d

rep

orte

d to

th

e co

mm

issi

oner

Mon

thly

re

por

tin

gE

xam

ples

of

inci

den

ts in

clu

de

indw

ellin

g de

vice

-re

late

d in

fect

ion

s,

nu

mbe

r of

clo

sed

hom

e da

ys/b

eds

1D

H (

2015

) C

ode

of p

ract

ice

NH

S E

ngl

and

(201

3) S

erio

us in

cide

nt fr

amew

ork

w

ww

.en

glan

d.n

hs.

uk/

wp-

con

ten

t/u

ploa

ds/2

013/

03/s

if-g

uid

e.pd

f

HPA

(20

12)

Hea

lthc

are

asso

ciat

ed in

fect

ion

oper

atio

nal g

uida

nce

and

stan

dard

s fo

r he

alth

pro

tect

ion

unit

s w

ww

.gov

.uk/

gove

rnm

ent/

pu

blic

atio

ns/

hea

lth

care

-ass

ocia

ted-

infe

ctio

n-h

cai-

oper

atio

nal

-gu

idan

ce-a

nd

-sta

nd

ard

s

IPC

is in

clu

ded

as a

re

gula

r ag

enda

it

em in

pro

vide

r or

gan

isat

ion

m

eeti

ngs

Rec

ord

of

mee

tin

gs a

nd

IPC

to

pics

dis

cuss

ed

Min

ute

s of

m

eeti

ngs

Pro

vide

r to

de

term

ine

wh

ich

m

eeti

ngs

will

ro

uti

nel

y in

clu

de I

PC

di

scu

ssio

n

1B

est

prac

tice


http://www.nice.org.uk/guidance/sc1









Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

expe

ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(n

ote

whe

re s

peci

fic

guid

ance

is n

ot p

rese

nt th

is is

indi

cate

d as

‘b

est p

ract

ice’

)

Cop

ies

of a

ll re

por

ts a

nd

asso

ciat

ed a

ctio

n

plan

s in

res

pon

se

to a

ny e

xter

nal

IP

C

focu

s vi

sits

/in

spec

tion

s (e

.g.

from

CC

G, C

QC

, Lo

cal A

uth

orit

y)

are

mad

e av

aila

ble

to t

he

com

mis

sion

er b

y th

e pr

ovid

er

Cop

ies

of r

epor

ts

sen

t to

co

mm

issi

oner

w

ith

in fi

ve

wor

kin

g d

ays

of

the

prov

ider

re

ceiv

ing

the

rep

ort

Rep

orts

are

re

ceiv

ed1

Bes

t pr

acti

ce

Edu

cati

on/t

rain

ing

All

staf

f re

ceiv

e IP

C t

rain

ing

at

indu

ctio

n

An

nu

al

rep

orti

ng

of

per

cen

tage

, n

amed

pro

vide

r of

tra

inin

g an

d ou

tlin

e of

th

e pr

ogra

mm

e

1,3

Alig

ns

wit

h D

H (

2015

) C

ode

of p

ract

ice

NIC

E C

G 1

39 (

2012

) In

fect

ion:

Pre

vent

ion

and

cont

rol o

f hea

lthc

are-

asso

ciat

ed in

fect

ions

in p

rim

ary

and

com

mun

ity

care

w

ww

.nic

e.or

g.u

k/gu

idan

ce/c

g139

Th

e pr

ovid

er

deve

lops

a

prog

ram

me

of

infe

ctio

n

prev

enti

on a

udi

ts

linke

d to

cor

e IP

C

pol

icie

s

Evid

ence

of

audi

t pr

ogra

mm

e,

com

ple

ted

audi

t re

sult

s an

d an

y as

soci

ated

act

ion

pl

ans

Qu

arte

rly

rep

orti

ng.

In

form

atio

n t

o be

ava

ilabl

e at

ti

me

of

insp

ecti

on o

r qu

alit

y re

view

vi

sit

and

avai

labl

e to

th

e pu

blic

in I

PC

an

nu

al r

epor

t

1A

lign

s w

ith

DH

(20

15)

Cod

e of

pra

ctic

e



52


Return to contents

Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

expe

ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(n

ote

whe

re s

peci

fic

guid

ance

is n

ot p

rese

nt th

is is

indi

cate

d as

‘b

est p

ract

ice’

)

Pro

vide

r co

ntr

ibu

tes

and

coop

erat

es w

ith

th

e Po

st I

nfe

ctio

n

Rev

iew

(P

IR)

/R

CA

/ ‘L

apse

in

care

’ inv

esti

gati

ons

for

all c

ases

of

HC

AI,

incl

udi

ng

MR

SA b

acte

raem

ia

and

C. d

iffic

ile

infe

ctio

n

Con

trib

uti

on t

o th

e P

IR p

roce

ss

and

im

plem

enta

tion

of

act

ion

pla

ns

and

lear

nin

g de

rive

d fr

om

inve

stig

atio

n

revi

ews.

10

0% a

tten

dan

ce

at in

vest

igat

ion

m

eeti

ngs

Att

enda

nce

at

PIR

mee

tin

gs.

Act

ion

pla

n

rep

orts

are

re

ceiv

ed a

nd

upd

ated

wh

ere

appl

icab

le

regu

larl

y by

pr

ovid

er, w

ith

le

arn

ing

shar

ed

acro

ss t

he

orga

nis

atio

n

Wit

h e

xcep

tion

s of

M

RSA

bac

tera

emia

an

d C

. dif

ficile

in

fect

ion

, oth

er

HC

AIs

th

at r

equ

ire

inve

stig

atio

n a

re t

o be

det

erm

ined

loca

lly

1N

HS

En

glan

d (2

014)

Zer

o to

lera

nce

w

ww

.en

glan

d.n

hs.

uk/

pati

ents

afet

y/as

soci

ated

-in

fect

ion

s/ze

ro-t

oler

ance

/

NH

S E

ngl

and

(201

5) C

lost

ridi

um

dif

fici

le in

fect

ion

obje

ctiv

es fo

r N

HS

orga

nisa

tion

s in

201

5/16

and

gui

danc

e on

san

ctio

n im

plem

enta

tion

w

ww

.en

glan

d.n

hs.

uk/

wp-

con

ten

t/u

ploa

ds/2

015/

02/c

lost

ridm

-dif

fici

le-

infe

ct-o

bjct

-15-

16-g

uid

-feb

15.p

df

Susp

ecte

d or

co

nfi

rmed

ou

tbre

aks

are

rep

orte

d to

th

e co

mm

issi

oner

an

d lo

cal h

ealt

h

prot

ecti

on t

eam

All

outb

reak

s ar

e re

por

ted

on t

he

sam

e da

y

Mon

thly

re

por

tin

g to

th

e co

mm

issi

oner

1,5

Car

e Q

ual

ity

Com

mis

sion

(20

15)

guid

ance

w

ww

.cqc

.org

.uk/

con

ten

t/n

otifi

cati

ons-

non

-nh

s-tr

ust

-pro

vide

rs

Th

e pr

ovid

er h

as a

sy

stem

in p

lace

to

supp

ort

prep

ared

nes

s or

m

anag

emen

t of

pa

tien

ts c

arry

ing

carb

apen

emas

e-pr

odu

cin

g E

nte

roba

cter

iace

ae

(CP

E)

in li

ne

wit

h

PH

E C

PE

gu

idan

ce

Th

e pr

ovid

er h

as

a p

olic

y in

pla

ce

for

the

man

agem

ent

of

CP

E a

nd

has

co

nsi

dere

d th

e im

plic

atio

ns

of it

s im

plem

enta

tion

on

its

serv

ice

Con

firm

atio

n o

f p

olic

y in

pla

ce1

PH

E (

2015

) to

olki

t for

man

agin

g ca

rbap

enem

ase-

prod

ucin

g En

tero

bact

eria

ceae

in n

on-a

cute

and

com

mun

ity

sett

ings

ww

w.g

ov.u

k/go

vern

men

t/u

ploa

ds/s

yste

m/u

ploa

ds/a

ttac

hm

ent_

data

/file

/439

801/

CP

E-N

on-A

cute

Tool

kit_

CO

RE

.pdf





http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/439801/CPE-Non-AcuteToolkit_CORE.pdf



Qua

lity

re

quir

emen

tTh

resh

old

(rep

orti

ng

expe

ctat

ion)

Met

hod

of

mea

sure

men

tCo

mm

ents

CMO

st

rate

gy

acti

on

area

Evid

ence

/su

ppor

ting

sou

rce

(n

ote

whe

re s

peci

fic

guid

ance

is n

ot p

rese

nt th

is is

indi

cate

d as

‘b

est p

ract

ice’

)

Rep

orti

ng

on

com

plia

nce

of

hea

lth

car

e w

orke

r va

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• Commissionersshouldengagewithsocialcareproviderstoassistintheirattainmentof,andcompliancewith,theCode of practice,forexampleinrelationtofundednursingcareplacementsandthecontractsthatCCGsmayhavewithnursinghomestodeliverthis;however,thiscouldalsobeajointcommissioningrelationshipbetweenhealthandsocialcare.

Contracting and setting standards

Aim: to ensure national and local IPC standards are set at the correct level and included in contracts with provider organisations.

• EnsurethereareservicespecificationsforIPC,specific/relevantkeyperformanceindicators(KPIs)andqualityindicatorsinprovidercontracts.AsaminimumthesemustbeconsistentwithThe NHS Planning Guidance 2016/17 – 2020/21andothernationalmandatorypolicies.Seethebasketofsuggestedindicators.

• SupportengagementwithqualityimprovementinitiativesasappropriatethroughCommissioning for quality and innovation(CQUIN)development(NHSE,2015).

• Accesslocalinfectionpreventionteams/expertstoensureinfectionpreventioninputoccursinthedevelopmentofallnewcontracts,servicesandpathways.

Objective: to have a collaborative approach to the prevention and management of HCAI and antimicrobial resistance (AMR) in the health and social care economy.

Aim: to develop systems in collaboration with all stakeholders that are fit for purpose, and which will support delivery of the HCAI/safety agenda.

• NHSEngland,clinicalcommissioninggroups(CCGs)andlocalauthoritiesworkingwithhealthandsocialcareprovidersshouldhaveappropriatestrategiesforthepreventionandcontrolofhealthcareassociatedinfectionswithclearresponsibilities.

• Ahealthandsocialcareeconomy-wideHCAIandAMRnetwork.

• Ahealthandsocialcareeconomycollaborativemeetingthathassign-upfromchiefexecutivesanddirectors.

• Infectionpreventionandcontrol(IPC)strategybasedonajointstrategicneedsassessment,whichissupportedbyandagreedbythehealtheconomy.ThisinturnwillsupportindividualproviderorganisationIPCstrategies,andsitaspartoftheoverarchingqualityandsafetystrategyforthecommissioningorganisation.

• Commissionersshouldusethehealtheconomynetworktoinitiateandleadontheimplementationofnational/regionalandlocalprogrammes,inlinewithNHSEnglandpolicies:

- Everyone counts, planning for patients 2014/15 to 2018/19;

- NHS outcomes framework 2015/16

- Adult social care outcomes framework 2015/16.

Appendix 5: Leading and developing the health care associated infection (HCAI) system




Quality assurance

Aim: to monitor performance against all shared objectives and KPIs from all providers.

• Commissionerorganisationsshouldparticipateinperformance monitoring and quality assurance arrangements for each provider. For example, through:

- attendance at provider infection prevention committees and review meetings with provider IPC leads as agreed locally

- regular formal HCAI performance monitoring meetings with contract management staff

- input into the overarching contract quality meeting/clinical quality review groups

- receipt of regular infection prevention/HCAI dashboards from providers

- inspections and visits.

• Commissioningorganisationsshouldhaveaccesstoappropriate IPC expertise to interpret data or information received from providers.

• Analyseinformationsubmittedbyprovidersanddetermine whether the information offers the required assurance.

• Commissionersshouldbeincludedininternalperformance monitoring arrangements for primary care, such as the performance management group or annual contract review processes. It is through this mechanism that environmental audits to assess environmental fitness for purpose can be fed into the overarching performance framework.

• IPCshouldfeatureinthecommissioningframework about fitness to practise, as commissioning decisions are made about the transfer of care from secondary to primary. For example, is the environment fit for purpose?

• Engagewithprimarycarecontractingtodeveloprobust assurance of infection prevention practice across primary care providers as the commissioning processes evolve.

• EnsurethatthereisspecialistIPCpractitionerinputwithin provider settings into IPC-related contracts such as:

- cleaning

- catering

- planned preventive maintenance (PPM)

- building construction and refurbishment

- waste management.

Health care associated infection reduction plan

The provider must have an HCAI reduction plan for each contract year and must comply with its obligations under that plan. The HCAI reduction plan must reflect local and national priorities relating to HCAI, including AMR (NHS Standard Contract, NHS England 2015).

The purpose of an HCAI reduction plan is to outline the provider’s approach to the prevention and control of HCAIs and AMR. All providers will be expected to have in place annual programmes of work to ensure that standards and objectives are met according to agreed contractual indicators and national and local objectives for reducing HCAI and AMR. This activity will be monitored on a locally agreed basis through formal reporting mechanisms established through the integrated quality teams and contract and performance monitoring systems, ensuring key expectations are fulfilled.


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• IPCcommissioningarrangementsareembeddedinthe commissioning organisation’s governance processes.

• Thereisanescalationprocessinplace.HCAI/AMRis added, where necessary, to the corporate risk register of the commissioning organisation.

• Infectionpreventionisanintegralpartofthecapital programme for new build premises and refurbishments to ensure IPC standards are met and buildings are fit-for-purpose.

• IPCisincludedaspartoftheemergencyplanningprocess.

• Engageproactivelywithhealthandwellbeingboards to provide assurance that local population risks and needs are adequately understood, addressed and evaluated via existing commissioning processes in relation to IPC and antimicrobial resistance (AMR).

Organisational accountability in commissioning organisations

Aim: to ensure infection prevention and control is embedded and that board accountability/assurance is demonstrated.

• Thecommissioningorganisationhasaclearunderstanding of its commissioned services, IPC status and risks and has sufficient specialist IPC support/resources available to enable it to meet its responsibilities for quality and safety of the services provided. IPC is included as an integral part of the commissioning organisation’s internal quality and safety monitoring and assurance systems.

• Thecommissioningorganisationhasaclearprocessfor providing assurance to NHS England with regard to HCAI and AMR standards and risks.

• Thecommissioningorganisationhasastrategicandoperational plan for reducing HCAI and AMR and sustaining improvement of infection prevention practices. Accurate and timely information that includes the quality dashboard and all other relevant performance matrix is reported to the organisational governance framework, and shared with relevant commissioning bodies.

• Informationismonitoredmonthlybytheinfectionprevention and integrated quality teams. Formal reports analysing quality and performance, action plans and exceptions are made to the approved committee in the commissioning organisation. Annual reports provide a summary of activity, assurance and risks to the board.




Department of Health (2015) Code of practice on the prevention and control of infections and related guidance www.gov.uk/government/publications/the-health-and-social-care-act-2008-code-of-practice-on-the-prevention-and-control-of-infections-and-related-guidance

Health Education England (2015) Prevention and public health action plan https://hee.nhs.uk/our-work/hospitals-primary-community-care/prevention-public-health-wellbeing-0

Health Matters blog https://publichealthmatters.blog.gov.uk/2015/12/10/health-matters-tackling-antimicrobial-resistance/

Health Protection Agency (2012) English national point prevalence survey on healthcare-associated infections and antimicrobial use, 2011. Preliminary data. London: Health Protection Agency. www.gov.uk/government/uploads/system/uploads/attachment_data/file/331871/English_National_Point_Prevalence_Survey_on_Healthcare_associated_Infections_and_Antimicrobial_Use_2011.pdf

Health Protection Agency (2012) Healthcare associated infection operational guidance and standards for health protection units www.gov.uk/government/publications/healthcare-associated-infection-hcai-operational-guidance-and-standards

International Longevity Centre (2013) Adult vaccination – a key component of healthy ageing www.ilcuk.org.uk/index.php/publications/publication_details/adult_vaccination_a_key_component_of_healthy_ageing

Monitor (2015) Risk assessment framework. London: Monitor. www.gov.uk/government/publications/risk-assessment-framework-raf

NHS England (2013) Everyone counts, planning for patients 2014/15 to 2018/19. London: NHSE. www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf

Care Quality Commission (2015) Guidance for providers on meeting the regulations www.cqc.org.uk/content/regulations-service-providers-and-managers

Care Quality Commission (2015) The scope of registration. London: CQC. www.cqc.org.uk/file/4525

Daniels R (2011) Surviving the first hours in sepsis: getting the basics right (an intensivist’s perspective). Journal of Antimicrobial Chemotherapy; 66 (Suppl ii): 11-23

Department of Health (2011) Start SMART then focus www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus

Department of Health (2013) The NHS outcomes framework 2015/165. London: DH. Available at www.gov.uk/government/publications/nhs-outcomes-framework-2015-to-2016

Department of Health (2014) Implementation of modified admission MRSA screening guidance for NHS www.gov.uk/government/uploads/system/uploads/attachment_data/file/345144/Implementation_of_modified_admission_MRSA_screening_guidance_for_NHS.pdf

Department of Health (2014) The mandate. A mandate to the Government to NHS England: April 2014 to March 2015, London. DH. www.gov.uk/government/uploads/system/uploads/attachment_data/file/383495/2902896_DoH_Mandate_Accessible_v0.2.pdf

Department of Health (2015) Public health outcomes framework www.gov.uk/government/publications/healthy-lives-healthy-people-improving-outcomes-and-supporting-transparency

Department of Health (2015) The adult social care outcomes framework 2015 to 2016 www.gov.uk/government/publications/the-adult-social-care-outcomes-framework-2013-to-2014

References and further reading

5


http://www.gov.uk/government/publications/the-health-and-social-care-act-2008-code-of-practice-on-the-prevention-and-control-of-infections-and-related-guidance


https://publichealthmatters.blog.gov.uk/2015/12/10/health-matters-tackling-antimicrobial-resistance/

http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/331871/English_National_Point_Prevalence_Survey_on_Healthcare_associated_Infections_and_Antimicrobial_Use_2011.pdf



http://www.gov.uk/government/publications/risk-assessment-framework-raf

http://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf

http://www.cqc.org.uk/content/regulations-service-providers-and-managers

http://www.cqc.org.uk/file/4525

http://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus

http://www.gov.uk/government/publications/nhs-outcomes-framework-2015-to-2016


http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/383495/2902896_DoH_Mandate_Accessible_v0.2.pdf

http://www.gov.uk/government/publications/healthy-lives-healthy-people-improving-outcomes-and-supporting-transparency

http://www.gov.uk/government/publications/the-adult-social-care-outcomes-framework-2013-to-2014

60


Return to contents

NHS England (2013) Serious incident framework www.england.nhs.uk/wp-content/uploads/2013/03/sif-guide.pdf

NHS England (2014) CQUIN 2014/5 additional guidance on the mental health indicator www.england.nhs.uk/wp-content/uploads/2014/06/cquin-add-mh-guid.pdf

NHS England (2014) Five year forward view www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

NHS England (2014) Zero tolerance www.england.nhs.uk/patientsafety/associated-infections/zero-tolerance/

NHS England (2015) Commissioning for quality and innovation (CQUIN) Guidance for 2015/16 www.england.nhs.uk/wp-content/uploads/2015/03/9-cquin-guid-2015-16.pdf

NHS England (2015) Standard contract www.england.nhs.uk/nhs-standard-contract/15-16/

NHS England (2015) Clostridium difficile infection objectives for NHS organisations in 2015/16 and guidance on sanction implementation www.england.nhs.uk/wp-content/uploads/2015/02/clostridm-difficile-infect-objct-15-16-guid-feb15.pdf

NHS Trust Development Authority (2015) Delivering for patients: the 2015/16 accountability framework for NHS trust boards.

National Institute for Health and Care Excellence (2007) CG54 Urinary tract infection in children: Diagnosis, treatment and long-term management www.nice.org.uk/guidance/cg54

National Institute for Health and Care Excellence (2012) CG 139 Infection: Prevention and control of healthcare-associated infections in primary and community care www.nice.org.uk/guidance/cg139

National Institute for Health and Care Excellence (2013) Guidelines CG161 Falls in older people: assessing risk and prevention www.nice.org.uk/guidance/cg161

National Institute for Health and Care Excellence (2013) Quality standard QS36 urinary tract infection in infants, children and young people under 16 www.nice.org.uk/guidance/qs36

National Institute for Health and Care Excellence (2014) Clinical guideline 191. Pneumonia. Diagnosis and management of community- and hospital-acquired pneumonia in adults.

National Institute for Health and Care Excellence (2014) Managing medicines in care homes www.nice.org.uk/guidance/sc1

National Institute for Health and Care Excellence (2014) Quality Standard Infection prevention and control QS61 www.nice.org.uk/guidance/qs61

National Institute for Health and Care Excellence (2015) Quality Standard Urinary tract infections in adults QS90 www.nice.org.uk/guidance/qs90

National Institute for Health and Care Excellence (2015) Guideline NG15 Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use www.nice.org.uk/guidance/NG15/chapter/2-Implementation-getting-started

Parliamentary and Health Service Ombudsman (2014) Time to Act. Severe sepsis: rapid diagnosis and treatment. London. Parliamentary and Health Service Ombudsman available at http://sepsisappg.com/wp-content/uploads/2014/02/FINAL_Sepsis_Report_web.pdf

Public Health England (2013) Acute trust toolkit for the early detection, management and control of carbapenemase-producing Enterobacteriaceae www.gov.uk/government/publications/carbapenemase-producing-enterobacteriaceae-early-detection-management-and-control-toolkit-for-acute-trusts

Public Health England (2013) Antimicrobial prescribing and stewardship competencies www.gov.uk/government/uploads/system/uploads/attachment_data/file/253094/ARHAIprescrcompetencies__2_.pdf



http://www.england.nhs.uk/wp-content/uploads/2014/06/cquin-add-mh-guid.pdf

http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf









http://www.nice.org.uk/guidance/sc1




http://sepsisappg.com/wp-content/uploads/2014/02/FINAL_Sepsis_Report_web.pdf

http://www.gov.uk/government/publications/carbapenemase-producing-enterobacteriaceae-early-detection-management-and-control-toolkit-for-acute-trusts




Further reading

Infection Prevention Society Quality Improvement tools www.ips.uk.net/professional-practice/quality-improvement-tools/#.VqZReOiLSUl [accessed 25 November 2015]

NHS England, Sign up to safety www.england.nhs.uk/signuptosafety/ [accessed 25 November 2015]

NHS England resources for Clinical Commissioning Groups (CCGs) www.england.nhs.uk/resources/resources-for-ccgs/

NHS England (2014) Guidance on the reporting and monitoring arrangements and post infection review process for MRSA bloodstream infections from April 2014 (version 2)

Loveday HP, Wilson JA and Pratt RJ et al (2014) Epic 3: National Evidence-based Guidelines for prevention healthcare associated infections in NHS hospitals in England. Journal of Hospital Infection 86S1 s1-70 Available at www.his.org.uk/files/3113/8693/4808/epic3_National_Evidence-Based_Guidelines_for_Preventing_HCAI_in_NHSE.pdf [accessed 16 July 2014]

Public Health England (2013) Immunisation against infectious disease (Green book) www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book

RCN (2009) Measuring for quality in health and social care: An RCN position statement. London: RCN

RCN (2011) RCN link nurse framework www2.rcn.org.uk/__data/assets/pdf_file/0006/481515/004310.pdf

RCN (2014) Antimicrobial resistance. RCN position on the nursing contribution. London: RCN

RCN (2015) Infection prevention and control within health and social care: commissioning, performance management and regulation arrangement (England). London: RCN

Scottish Intercollegiate Guidelines Network (2012) SIGN 88. Management of suspected bacterial urinary tract infection in adults. A national clinical guideline. Edinburgh: SIGN.


http://www.ips.uk.net/professional-practice/quality-improvement-tools/#.VqZReOiLSUl

http://www.england.nhs.uk/signuptosafety/

http://www.england.nhs.uk/resources/resources-for-ccgs/

http://www.his.org.uk/files/3113/8693/4808/epic3_National_Evidence-Based_Guidelines_for_Preventing_HCAI_in_NHSE.pdf



The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies

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Second edition: January 2016 Review date: January 2018

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