Quality standard
Quality statement 2: Organisational responsibility
Quality statement 2: Organisational responsibility
Quality statement
Organisations that provide healthcare have a strategy for continuous improvement in infection prevention and control, including accountable leadership, multi-agency working and the use of surveillance systems.
Rationale
It is essential that organisations and agencies work together to coordinate strategies for infection prevention and control across a local area. It is equally important to share information across organisations in order to meet responsibilities for establishing the current position on infection control, monitoring the impact of quality improvement initiatives and ongoing surveillance. Leadership underpins all infection prevention and control, and is vital to ensure that this remains a priority for the organisation as a whole and each person working within it.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
a) Evidence that the organisation includes infection prevention and control within its overall strategy.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from the local organisational strategy.
b) Evidence that the organisation's board is up to date with, and has a working knowledge and understanding of, infection prevention and control.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from minutes of board meetings.
c) Evidence that a lead for infection prevention and control has been assigned and is taking an active role.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from job descriptions.
d) Evidence of support for, and participation in, joint working initiatives beyond mandatory or contractual requirements, to reduce healthcare-associated infections locally.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from joint working agreements.
e) Evidence of an adequately resourced surveillance system with specific, locally defined objectives and priorities for preventing and managing healthcare-associated infections.
Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from audits of healthcare-associated infections.
Outcome
Incidence of healthcare-associated infection.
Data source: 2014/15 NHS Outcomes Framework indicator 5.2 and 2014/15 CCG Outcomes Indicator Set indicators 5.3 and 5.4 measure incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Data are derived from UK Health Security Agency's mandatory reporting of healthcare-associated infections.
What the quality statement means for different audiences
Service providers ensure that a strategy is in place for continuous improvement in infection prevention and control that includes accountable leadership, multi-agency working and surveillance systems.
Healthcare professionals ensure that they implement strategies for continuous improvement in infection prevention and control through accountable leadership, multi-agency working and adhering to the requirements of surveillance systems.
Commissioners ensure that they commission services from organisations that have strategies for continuous improvement in infection prevention and control that include accountable leadership, multi-agency working and surveillance systems.
People receive healthcare from organisations that aim to continually improve their approach to preventing infection (for example, by sharing information with other organisations and monitoring rates of infection).
Source guidance
Healthcare-associated infections: prevention and control. NICE guideline PH36 (2011), quality improvement statements 1, 3 and 6