Draft v8

DRAFT Hand Hygiene Action Plan - Cardiff and Vale University Health Board
Objective

Aim

Comment

Expected
outcome
UHB Area

To design and
deliver a hand
hygiene
communication
strategy

To systematically
communicate and
promote hand hygiene
awareness throughout
healthcare and
community settings in
Cardiff and the Vale
UHB area.

Hand hygiene is a
fundamental component
of effective infection
control, particularly in
healthcare settings
where it will contribute
to achievement of AQF
targets on HCAI

To improve hand
hygiene in wider
community
settings

To identify opportunities
to improve promotion of
hand hygiene with
partner organisations,
including:
Schools
Health Protection
Team
Environmental Health
Departments
Pharmacies

Hand hygiene
communication
plan

Completion
date

Monitoring

Lead
Manager

June 2011

Monitoring of
agreed actions
in
communication
plan

Director of
Public
Health

Wider Community

School nurses are a

key link with
schools
Healthy Schools
activities stress
importance of hand
washing
Public Health Wales
Health Protection
teams work closely
with Local Authority
Environmental
Health officers to
control spread of
infectious disease
in the community,
including via advice
on hand hygiene

Better hand
hygiene practice in
community settings

Will be
continual as
ongoing

Consultant
in Public
Health

Draft v8

Objective

Aim

Comment

Expected
outcome
Primary Care

All practices to
use the primary
care audit
protocol produced
by the Primary
Care Quality and
Information
Service (Public
Health Wales)

Use of the audit tool

promoted in all general
practices.

Promotion has taken

place via the nominated
infection control lead in
each practice. First
round of audit uptake
completed.

Improvement in
number of
practices using
audit protocol

Further promotion of the

audit will take place and
uptake re-audited

Re-audit

Snr Nurse Primary care

to link with locality leads
to promote the initiative
To re identify infection
control leads/hand
hygiene leads within
General Practice.
To recirculate hand
hygiene audit tool and
summary report to
mangers and practice
nurses via email
To identify to each
organisation that the
Hand hygiene module
can now be accessed
as an individual module
and forms the basis of
training needed to lead
on hand hygiene in the
practice

Completion
date

Monitoring

Lead
Manager

Baseline audit
completed.

Senior
Nurse for
Primary
Care

Repeat audit to
be conducted
annually.
September
2011
June 2011

All organisations to
re-identify lead

June 2011

June 2011

February
2011
June 2011

Draft v8

All practices to
utilise the Welsh
Healthcare
Associated
Infection
Programme hand
hygiene elearning tool

To pilot the use of the elearning tool by Infection

Control link practitioners
(Champions) within
each GP practice as a
means of disseminating
good hand hygiene
practice

To offer training in hand

hygiene and the use of
the light box to
individual organisations
in order that they
undertake the hand
hygiene audit.
Uptake will be audited
and feedback obtained
to determine whether it
is a useful tool. If the
pilot is successful, use
will be promoted more
widely through the
organisation.

ongoing

Improved hand
hygiene practice.

Identify pilot practices

by contacting all
organisations, asking
them to take part.
Alternatively identify
named organisations in
house and follow
through with a short
meeting, access to the
hand hygiene module
and access to the light
box.

To implement
bare below the
elbows (NHS
Wales dress
code)

To publicise and promote

bare below elbows
message for all clinical
staff and in all clinical
area

Snr Nurse for primary

care to distribute
relevant information in a
timely manner
To promote through the
e-learning tool,
educational sessions
and audit form

Pilot audit end

Jan 2011

Audit of use of
e-learning tool

Senior
Nurse for
Primary
Care

Audit of
compliance

Medical
Director

June 2011

ongoing

All staff in clinical

areas to be bare
below the elbows

Ongoing

Draft v8

Independent Sector Providers (Nursing Homes/ HM Prison)

Comment
Expected
Completion
outcome
date

Objective

Aim

All providers to
use the primary
care audit
protocol produced
by the Primary
Care Quality and
Information
Service (Public
Health Wales)

Use of the audit tool

promoted in all nursing
homes and in HM Prison
Cardiff.

Promotion has taken

place via the nominated
infection control lead in
each nursing home.
First round of audit
uptake completed.

Improvement in
number of
practices using
audit protocol

Further promotion of the

audit will take place and
uptake re-audited

Re-audit

Snr Nurse Primary care

to link with locality leads
to promote the initiative
To re identify infection
control leads/hand
hygiene leads within
nursing homes and
HMP Cardiff

Monitoring

Lead
Manager

Baseline audit
completed.

Senior
Nurse for
Primary
Care

Repeat audit to
be conducted
annually.
September
2011
June 2011

All organisations to
re-identify lead

June 2011

To recirculate hand
hygiene audit tool and
summary report to
mangers and practice
nurses via email

June 2011

To identify to each
organisation that the
Hand hygiene module
can now be accessed
as an individual module
and forms the basis of
training needed to lead
on hand hygiene in the
practice

February
2011
June 2011

Draft v8

To offer training in hand

hygiene and the use of
the light box to
individual organisations
in order that they
undertake the hand
hygiene audit.
All practices to
utilise the Welsh
Healthcare
Associated
Infection
Programme hand
hygiene elearning tool

To pilot the use of the elearning tool by Infection

Control link practitioners
(Champions) within
each nursing home as a
means of disseminating
good hand hygiene
practice

Uptake will be audited

and feedback obtained
to determine whether it
is a useful tool. If the
pilot is successful, use
will be promoted more
widely.
Identify pilot
organisations by
contacting all and
asking them to take
part. Alternatively
identify named
organisations in house
and follow through with
a short meeting, access
to the hand hygiene
module and access to
the light box.
Snr Nurse for primary
care to distribute
relevant information in a
timely manner

ongoing

Improved hand
hygiene practice.

Pilot audit end

Jan 2011

Audit of use of
e-learning tool

Senior
Nurse for
Primary
Care

June 2011

ongoing

Draft v8

To explore the
role of nurse
assessor teams in
supporting
infection control in
the independent
sector

To identify a formal
mechanism to support
continuing improvement
in infection prevention
and control practices

The regular oversight

role of these teams
could be used to
promote good hand
hygiene practices

Role of nurse
assessors in
promoting IPC
clearly defined

August 2011

Senior
Nurse for
Primary
Care

Draft v8

Objective

Aim

To improve
arrangements for
infection
prevention and
control link nurses
All lead staff to
utilise the Welsh
Healthcare
Associated
Infection
Programme hand
hygiene elearning tool

To develop a clear
system for improving
infection prevention and
control practice across
the service
Education and training
programmes are in place
and improved use of the
IPC e-learning package
is supported.

Comment

Expected
outcome
Community Nursing

All Community Nurses

undertake a Mandatory
Training
Refresher
programme
annually,
recorded and reported
through the Electronic
Staff Record System.

Completion
date

Monitoring

Lead
Manager

Link nurses to be
re-identified

August 2011

List to be
updated
annually

Improved hand
hygiene practice

September
2011

Audit of use of
e-learning tool

Practice
Educator
for
Community
Nursing
Practice
Educator
for
Community
Nursing

Draft v8

To promote
appropriate hand
hygiene in
community setting

Audit tool to be
developed to monitor
compliance with IPC
agenda.

To implement
bare below the
elbows (NHS
Wales dress
code) for all
clinical staff

To publicise and promote

bare below elbows
message for all clinical
staff and in all clinical
area

The High Five

Campaign (as part of
1000 Lives), was
developed with an
acute care setting
focus, but was launched
in the community on 12
May 2010. The initiative
is directed at ensuring
hand hygiene
compliance amongst
Community Nurses and
raises the profile of
infection control.
Recommended hand
and general purpose
wipes are provided for
use by all community
nursing staff. Timely
feedback of HCAI and
other surveillance data
will also be provided to
staff.

Use of audit tool

leading will lead to
improved hand
hygiene
compliance

Ongoing

Report of audit
results

Practice
Educator
for
Community
Nursing

All staff involved in

clinical activity to be
bare below the
elbows

Ongoing

Audit of
compliance

Medical
Director

Draft v8

Objective

Aim

Comment

Expected
outcome
Hospital Care

Completion
date

Monitoring

Lead
Manager

To promote the
use of the
Lewisham hand
hygiene audit tool

Monthly audits to be
completed by each
ward/department.

Monthly hand hygiene

audits will be available
through the Ward
Dashboard.

Hand Hygiene
compliance will
increase

Ongoing

Via Div Quality

and Safety
meetings and
IPC group

Lead
Nurse
Patient
Experience

To conduct IPC
validation audits

IPC undertake validation

audits
within clinical areas on
as set out in the IPC
Annual
Programme. 10 areas
are audited each month.

Exception report will be

produced bi-monthly to
highlight the progress.

Compliance audits
will demonstrate
ward audits
accurate

Ongoing

Via IPC group

Reports also
sent to Div
Nurses

Lead
Nurse
Patient
Experience

To improve use of
hand washing
facilities.

Replacing all dispensers

for alcohol gel and soap

The soap and alcohol

supplier undertook
a survey of the
requirement across the
UHB
in Oct/Nov 2010. The
new design, which
include a drip tray, will
protect from accidental
splashing into eyes and
personal clothing, as well
as protecting the walls
and floors from
damage. Monitoring of
such facilities and
user-friendliness will be
undertaken
periodically by the
supplier.

Protection of users
and the
walls/flooring

June 2011

IPC Senior
Nurse will
monitor
implementation

Lead
Nurse
Patient
Experience

Draft v8

Dissemination of
Hand Hygiene
education

Hand hygiene is
promoted at every
opportunity during an IPC
teaching session

To promote use of
the Welsh
Healthcare
Associated
Infection
Programme hand
hygiene elearning tool

To implement
bare below the
elbows (NHS
Wales dress
code)

To propose to the
December IPC group
meeting that a pilot is
conducted of the use of
the WHAIP e-learning
tool by Infection Control
link practitioners
(Champions) as a
means of disseminating
good hand hygiene
practice
To publicise and promote
bare below elbows
message for all clinical
staff and in all clinical
areas

Hand Hygiene is
consolidated for all
staff who should be
complying as well as
promoting amongst
other colleagues
auditing.
All staff should also
be able to give
appropriate public
health advice to
inpatients and their
relatives

Uptake will be audited

and feedback obtained
to determine whether it
is a useful tool. If the
pilot is successful, use
will be promoted more
widely through the
organisation.

Compliance with
hand hygiene
policy increases

Current and
Ongoing

Lead
Nurse
Patient
Experience

Link Practitioners
will undertake
standalone module
during Link Pract
study day

September
2011

Database will
demonstrate
completion of
tool by
practitioners

Lead
Nurse
Patient
Experience

All staff in clinical

areas to be bare
below the elbows

Ongoing

Audit of
compliance

Medical
Director

10