HIQA to make unannounced inspections

HIQA is now commencing Phase 1 of its programme of monitoring assessments of acute hospitals’ compliance with the National Standards for the Prevention and Control of Healthcare Associated Infection and  initially this will focus on announced and unannounced assessment of acute hospitals’ compliance with the Standards writes Phelim Quinn, HIQA Director of Regulation.

The Health Information and Quality Authority has embarked on a series of monitoring assessments of acute hospitals’ compliance with the National Standards for the Prevention and Control of Healthcare Associated Infections in an effort to help hospitals to reduce and control preventable Healthcare Associated Infections (HCAIs).

Drawing on the themes from HIQA’s National Standards for Safer Better Healthcare, the new monitoring programme will initially access the essential elements of Leadership, Governance and Management, Workforce and Safe Care that an acute hospital or group of hospitals must have in place as the foundation for providing safe quality care in order to manage HCAIs.

Monitoring approach

The Authority published a guide to the methodology and approach to monitoring the National Standards for the Prevention and Control of Healthcare Associated Infections. The monitoring programme will focus on the essential elements necessary to implement four of the practices that international research has shown to contribute significantly to reducing Healthcare Associated Infections and improve patient safety. These are:

1. Hand hygiene compliance.
2. The cleanliness of the environment and equipment.
3. The appropriate use of antimicrobial antibiotics (antimicrobial stewardship).
4. The prevention of Healthcare Associated Infections associated with invasive medical devices such as intravenous lines and urinary catheters.

In order to contribute to reducing HCAIs and drive quality and safety, the Authority will:

• Assess if service providers have the essential elements in place to prevent and control HCAIs.
• Determine if failure to have these essential elements in place poses a serious risk to the health or welfare of patients.
• Look for assurances from hospitals that they are safeguarding service users through the mitigation of serious risks.
• Carry out announced and unannounced on-site assessments of environment, equipment and hand hygiene.
• Provide service providers with the findings of the assessments so they can develop and publish prioritised quality improvement plans (QIPs).
• Inform the public and promote confidence through the publication of reports detailing the Authority’s findings.

Unannounced assessments will consider compliance with environment and facilities hygiene, and hand hygiene standards – primarily through observation.

HIQA is now commencing Phase 1 of the programme, initially focusing on announced and unannounced assessment of acute hospitals’ compliance with the Standards. Phase 2 will start next year and will also include the assessment of compliance with the National Standards by the National Ambulance Service. The assessments will be carried out by authorised persons appointed in accordance with section 70 of the Health Act 2007, for the purposes of monitoring compliance with standards.

Unannounced assessments will consider compliance with environment and facilities hygiene, and hand hygiene standards – primarily through observation. The chief executive or general manager of an acute hospital will be contacted by authorised persons on their arrival on site. HIQA is advising that unannounced monitoring assessments will generally be within core working hours. However, weekend and out-of-hours monitoring assessments may be carried out.

Announced assessments will gather evidence of compliance with the essential elements necessary to implement the aforementioned practices that contribute significantly to reducing HCAIs. The process will involve observation, document review and meetings with relevant staff during the on-site part of the process. Service providers will receive notice of announced monitoring assessments from HIQA. An announced monitoring assessment will include a document and data requirement in advance of the scheduled on-site component. Generally, these assessments will be within core working hours. An office will be required by HIQA in order to accommodate scheduled meetings with relevant staff and on-site documentation review.

The documentation and data requirement will be issued by HIQA under the Health Act 2007, in line with the process detailed in the recently published Guide: Monitoring Programme for National Standards for the Prevention and Control of Healthcare Associated Infections. This requirement has been developed with the understanding that these documents and data should already exist as part of the programme of implementing the Standards.

While the authorised persons will take notes of these meetings, information provided will not be attributed to any individual in the final report.

The authorised persons will schedule two meetings, one with the CEO/general manager, the clinical director and the director of nursing and another with the infection prevention and control team to include the consultant microbiologist at a single-site hospital and at the group-lead-hospital. At group-associate-hospital(s), the authorised persons will meet the designated responsible person for the prevention and control of HCAIs programme. While the authorised persons will take notes of these meetings, information provided will not be attributed to any individual in the final report.

Authorised persons may identify specific issues that they believe may present a risk to the health or welfare of patients (this is applicable to any risk identified, i.e. it may not be related to hygiene or infection prevention and control). Any serious risks to the health or welfare of patients identified during the on-site monitoring assessment which require immediate mitigation, will be brought to the attention of the hospital CEO/general manager to allow them to put in place the actions necessary to mitigate such risk.

Conclusion

The National Standards for the Prevention and Control of Healthcare Associated Infections have been in place since 2009. Given that these Standards are intended to set a direction of improvement in quality and safety for patients, the Authority expects that, at this stage, service providers should have evaluated their compliance with these 2009 Standards, and have moved towards substantial implementation of them. Healthcare Associated Infections are not inevitable consequences of healthcare and are the most frequent adverse event for patients and can result in serious illness, prolonged hospital stays or long-term disability and contribute to unnecessary deaths. They can also lead to an additional financial burden on the healthcare system. HIQA will work with providers on managing these challenges.