“Creating a Centre of Excellence
to Care for Children’s Health”
Hygiene Quality Improvement Plan, 2016 / 2017,
against the Standards for the Prevention and Control of Healthcare Associated Infections.
TEMPLE STREET CHILDREN’S UNIVERSITY HOSPITAL
QUALITY IMPROVEMENT PLAN: 2016 / 2017
Populating Quality Improvement (QIP) Plans
1. This QIP was developed by following the unannounced HIQA Hygiene Inspection carried out on 27 th July 2016 and subsequent
hygiene inspection on 6th September 2016, in relation to Standards 3 and 6 of: The Prevention and Control of Healthcare
Associated Infections, HIQA 2009.
2. Monitoring Process: This Quality Improvement Plan will be monitored quarterly with status report provided to Corporate
Prevention and Control Infection Committee (IPCC), CEO and Quality Standards and Service Planning Manager.
© TSCUH QIP Template
13/07/2017
Page 2 of 8
IMPACT
Negligible (1)
Adverse event leading minor injury not
requiring first aid.
Injury
Minor (2)
Minor injury or illness, first aid
treatment required
<3 days absence
< 3 days extended hospital stay
Emotional Distress
Moderate (3)
Major (4)
Extreme (5)
Significant injury requiring medical
treatment e.g. Fracture and/or
counselling. Agency reportable, e.g.
HSA, Gardaí (violent and aggressive
acts). >3 Days absence
Major injuries/long term incapacity or
disability (loss of limb) requiring
medical treatment and/or counselling
3-8 Days extended hospital Stay
Physical /emotional disability
Incident leading to death or major
permanent incapacity.
Event which impacts on large number of
patients or member of the public
(Emotional / Physical trauma)
Emotional Trauma
Reduced quality of service user
experience related to inadequate
provision of information
Unsatisfactory service user experience
related to less than optimal treatment
and/or inadequate information, not
being to talked to & treated as an
equal; or not being treated with
honesty, dignity & respect - readily
resolvable
Unsatisfactory service user experience
related to less than optimal treatment
resulting in short term effects (less
than 1 week)
Unsatisfactory service user experience
related to poor treatment resulting in
long term effects
Compliance Standards
(Statutory, Clinical,
Professional and
Management)
Minor non compliance with internal
standards. Small number of minor
issues requiring improvement
Single failure to meet internal
standards or follow protocol. Minor
recommendations which can be easily
addressed by local management
Repeated failure to meet HSE internal
standards or follow protocols.
Important recommendations that can
be addressed with an appropriate
management action plan.
Repeated failure to meet external
standards. Failure to meet national
norms and standards / Regulations
(e.g. Mental Health, Child Care Act
etc). Critical report or substantial
number of significant findings and/or
lack of adherence to regulations.
Objectives/Projects
Barely noticeable reduction in scope,
quality or schedule.
Minor reduction in scope, quality or
schedule.
Reduction in scope or quality of
project; project objectives or schedule.
Significant project over – run.
Inability to meet project objectives.
Reputation of the organisation seriously
damaged.
Business Continuity
Interruption in a service which does not
impact on the delivery of service user
care or the ability to continue to
provide service.
Short term disruption to service with
minor impact on service user care.
Some disruption in service with
unacceptable impact on service user
care. Temporary loss of ability to
provide service
Sustained loss of service which has
serious impact on delivery of service
user care resulting in major
contingency plans being involved
Permanent loss of core service or facility.
Disruption to facility leading to significant
‘knock on’ effect
Service User
Experience
Adverse
Publicity/Reputation
Financial Loss
Environment
© TSCUH QIP Template
Rumours, no media coverage. No
public concerns voiced.
Little effect on staff morale.
Local media coverage – short term.
Some public concern.
No review/investigation necessary.
Minor effect on staff morale / public
attitudes. Internal review necessary.
<€1k
€1k – €10k
Nuisance Release.
On site release contained by
organisation.
Local media – adverse publicity.
Significant effect on staff morale &
public perception of the organisation.
Public calls (at local level) for specific
remedial actions. Comprehensive
review/investigation necessary.
National media/ adverse publicity, less
than 3 days. News stories & features in
national papers. Local media – long
term adverse publicity.
Public confidence in the organisation
undermined. HSE use of resources
questioned. Minister may make
comment. Possible questions in Dail.
Public calls (at national level) for
specific remedial actions to be taken
possible HSE review/investigation
Totally unsatisfactory service user
outcome resulting in long term effects, or
extremely poor experience of care
provision
Gross failure to meet external standards
Repeated failure to meet national norms
and standards / regulations.
Severely critical report with possible major
reputational or financial implications.
National/International media/ adverse
publicity, > than 3 days. Editorial follows
days of news stories & features in National
papers. Public confidence in the
organisation undermined. HSE use of
resources questioned. CEO’s performance
questioned. Calls for individual HSE
officials to be sanctioned.
Taoiseach/Minister forced to comment or
intervene. Questions in the Dail. Public
calls (at national level) for specific
remedial actions to be taken. Court action.
Public (independent) Inquiry.
€10k – €100k
€100k – €1m
>€1m
On site release contained by
organisation.
Release affecting minimal off-site area
requiring external assistance (fire
brigade, radiation, protection service
etc.)
Toxic release affecting offsite with
detrimental effect requiring outside
assistance.
13/07/2017
Page 3 of 8
Standards:
QIP status Quarterly Review
Hygiene
National Standards for the Prevention & Control of Healthcare Associated
Infections (HIQA 2009).
No:
1
Standard :
Criteria
Standard 3
Criterion
3.6
Risk
Rating
Description of Improvement – Outcome/Goals
By Whom
(SMART) Specific: Measurable: Achievable: Realistic: Timely
Ensure that environmental hygiene is managed in
line with current national standards and
guidelines for hospital cleaning.
Hygiene
Services Coordinator.
Contracts
Manager
Due Date for
Completion
Q2, 2017
A
Completed
B
On-Going
C
At Risk
D
Deferred
Current Status
QIP Status 2017
Q4 2016
Q1
Status Report Q4, 2016
Regular meetings
conducted with
management from the
Contract Cleaning
Company to review and
assess progress against
the findings of
multidisciplinary hygiene
audits.
Status Report Q1, 2017
Management from the
Contract Cleaning
Company partake in
management hygiene
audits, to ensure a prompt
response and a
preventative action plan to
address cleaning issues, if
identified.
© TSCUH QIP Template
13/07/2017
Page 4 of 8
Q2
Q3
Q4
2
Standard 3
Review the methodology for undertaking
multidisciplinary environmental hygiene audits.
Criterion
Hygiene
Services Coordinator
Q4, 2016
Hygiene
Services Coordinator /
Q4, 2016
Dedicated trained auditors
apply a forensic approach
to completing
unannounced
management hygiene
audits.
3.6
3
Standard 3
Criterion
3.6
© TSCUH QIP Template
Review cleaning checklists to assure that
cleaning staff have been appropriately trained
and supervised.
Contracts
Manager
13/07/2017
Status Report Q4, 2016
Status Report Q4, 2016
Contractor Cleaning
Company (CCC) has
implemented a QIP which
includes a comprehensive
staff re-training
programme. Such training
records are maintained on
the Hospital site.
Additional CCC
Management resources
have been assigned to the
Hospital.
Page 5 of 8
4
Standard 3
Criterion
3.6
Review schedules and frequencies for the
cleaning of patient care equipment to assure that
this equipment is managed to achieve required
standards.
Divisional
Nurse
Manager
Q2, 2017
Status Report Q4, 2016
Pilot study involving a
dedicated resource for the
cleaning of clinical
equipment, completed
December 2016.
Status Report Q1, 2017
Dedicated cleaning
resource allocated to the
cleaning of patient care
equipment continues.
Increased auditing of this
equipment demonstrates
compliance to the Hygiene
Standards.
5
Standard 3
Criterion
Implement a Planned Preventative Maintenance
Programme for the general hospital infrastructure
and its maintenance.
Head of
Facilities
Management
3.1
© TSCUH QIP Template
13/07/2017
Q4, 2016
Status Report Q4, 2016
Computer Maintenance
Management System
developed and
implemented as of 1st
January 2017.
Page 6 of 8
6
Standard 3
Address maintenance requests reported by ward
management staff, in a timely manner.
Criterion
3.1
Develop a system for reporting and recording
maintenance priorities.
Head of
Facilities
Management
Q2, 2017
Status Report Q4, 2016
In progress as per
Computer Maintenance
Management System and
the Technical Services
Department Work Flow
Process.
Status Report Q1, 2017
A Computer Maintenance
Management System has
been set up on a shared
drive. Clinical Nurse
Managers have access to
this shared drive,
facilitating a prompt
response in addressing
maintenance issues
reported.
This initiative is under
continuous review.
© TSCUH QIP Template
13/07/2017
Page 7 of 8
7
Review the existing designated drainage outlet for
dialysis waste fluid within St. Michael's C Ward.
Standard 3
Criterion
Head of
Facilities
Management
Q4, 2017
Status Report Q4, 2016
Following completion of
the new OPD extension, it
is proposed to relocate the
Dirty Utility Room within
St. Michael’s C Ward,
which will facilitate the
drainage outlet for dialysis
waste fluid.
3.1
Status Report Q1, 2017
Risk assesses the existing
designated drainage outlet
for dialysis waste fluid in
St. Michael’s C Ward, to
include proposals for its
potential relocation within
the ward footprint, to
include a designated hand
hygiene sink and drainage
outlet for dialysis fluid.
RISK MATRIX
Almost Certain (5)
Likely (4)
Possible (3)
Unlikely (2)
Negligible
(1)
5
4
3
2
© TSCUH QIP Template
Minor
(2)
10
8
6
4
Moderate
(3)
15
12
9
6
Major
(4)
20
16
12
8
Extreme (5)
25
20
15
10
Rare/Remote (1)
Unlikely (2)
Actual
frequency
Actual
frequency
Occurs
every 5yrs
of more
Probability
1%
Occurs
every 2–5
years
13/07/2017
Possible (3)
Probability
10%
Actual
frequency
Occurs
every 1–2
years
Likely (4)
Almost Certain (5)
Probability
Actual
frequency
Probability
50%
Bimonthly
75%
Actual
frequency
At least
monthly
Page 8 of 8