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Measuring against Standards toachieve goals

Joy Markey

National Decontamination Programme Lead

Quality & Patient Safety Directorate

Health Service Executive

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Learning objectives

By the end of this presentation delegates will beprovided with the information to:

Identify relevant (suitable Standard for

decontamination services Identify & develop a process of self assessment

Develop and define Performance indicatorsbased on gaps from self assessment

Evaluate Decontamination service provision inyour Department to demonstrate that service issafe and Standardised

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Healthcare Challenges

HEALTHCARE

ENVIRONMENT

HEALTHCARE SYSTEM CHALLENGES

Healthcare systems reform

Increased need to deliver Evidence

Need to meet Standard requirements/Legislation

ECONOMIC CHALLENGES

Cost containment

pressures

Use of Healthcare

Technology

Assessment

TRANSACTIONAL CHALLENGES

Influence of non-clinical decision-makers

Increasing use of procurement organisations (Tenders

and frameworks)

DEMAND SIDE

CHALLENGES

Desire for patient

education / increasedpatient awareness

Growth of private

sector

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Challenges for the Healthcare

professional/Service providers Provide evidence of reduction rate in patient

transmissible healthcare acquired infection

Reprocess medical devices fit for purpose whilst

ensuring a lean approach to providedecontamination services

Reduce the failure/ non compliance ratereprocessing Reusable invasive medical devices(RIMD)

Ensure that equipment purchased will meetStandard requirements and is considered to bevalue for money

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Who influences whom

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10/18/11 6

We are what we repeatedly do.

Excellence, therefore, is not an act

but a habit.

Aristotle

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Quality and Decontamination Unit

Management

Responsibility for leading on:

Quality improvement plan

Risk management

Reprocessing RIMD fit for purpose

Management of adverse incidents

Audit

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Learning

Build on what Decontamination Units/

services have in place

What is working well?

What have we learned?

What can we do better?

Relatively easy to write standards How do we meet them?

If we are not meeting them, what can we do to

improve?

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Learning

Ensure Decontamination Committee/HospitalSenior Management structures are in placeto support implementation of standards

Need to feed into overall governancestructure and follow lines of accountability

Quality improvement planning Identify areas for improvement (gap analysis)

Linked to risk assessment for non conformance Identify priorities (Areas for improvement)

Greater buy-in from staff if they have beenincluded in the self-assessment process

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Learning

Information to support monitoring Real-time information

Linked to other information sources

Support drilling-down into the service as close tothe front-line as possible

Avoid cut and paste

Duplication across multiple sets of standards Duplication in self-assessment

Duplication in QIPs

Not getting overall picture

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Direction

Review current decontamination standards and

guidance against local operational procedures for

decontamination the gaps are clear

Areas/practices forimprovement are identified

Areas/practices forimmediate action are identified

Best Supported by an IT system, which will assist to

evaluate and manage decontamination unit

performance against standards

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Considerations

Build on existing capacity/information

previously gathered

Reduce the burden of compliance develop a

systematic approach to ensure a quality

service

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Governance, Leadership &

Management

1. Clear accountability arrangements

2. Formalised governance arrangements

3.

Statement of purpose4. Clear objectives and plans

5. Effective management arrangements

6. Culture of quality & safety

7. Systematic monitoring arrangements

8. Formalised agreements9. Compliant with relevant legislation

10.Act on standards, alerts, recommendations, guidance,

etc.

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HSE Decontamination of RIMD

4 standards

1. Suitability of decontamination facilities

2. Decontamination equipment

3. Decontamination process

4. Procedures relating to transmissible

spongiform encephalopathies (TSEs)

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Assess local

decontamination

practices PPPGs

against Standard

statement

Develop Quality

Improvement Plans

Create/identify

Performance

indicators

Ensure eveidence is

available to support

meeting the

requirements of

Standards

Asses to develop goals

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Self-assessment

A process whereby the service provider(Decontamination Unit management)

measures performance against Standards

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Self-assessment process

Leadership by Hospital Senior Management

team/Board

Leadership by Senior Clinician/Clinical

Director

Involvement of staff

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Self-assessment team

Senior Management representative

Senior Medical Representative

Senior Nursing representative

Senior Health professional

Quality/Risk Manager

Links with HR/Finance/ICT/Estates, etc.

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Hospitalmanager/CEO begins

SA process

Chair clinicalgovernance

committee delegatesSA of specialised

standards

Each committeereviews standards &assigns responsibilityfor scoring standards

Delegate appraisal ofEOCs

Assign standardscores & monitoring

frequencies

Identify notablepractice & areas forimprovement (list

QIPs)

Sign-off at committeelevel & present to

management team

Delegates to

Clinical

governance

or

appropriate

committee

Identify

standards

where info

may need to

be

aggregated

from

wards/depart

ments/

services, etc.

Self-

assessment

(SA) process

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Some tips

Keep it simple

Identify a committee already in place who can

take this on

Be as honest as you can be

This is about establishing a baseline ajourney of continuous quality improvement toachieve goals

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Next steps

Identify a system (excel/web based)

Assign responsibility for standards/scoring

Ensure access to standards Self-assess

Evaluate

Develop next steps with defined timelines for

completion

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Questions

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References

HSE Standards and Recommended

Practices for Decontamination of RIMD

version 2.1

Health information and Quality Authority

Standards for Safer Better healthcare