Purchaser and provider working together for infection prevention

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Making the NHS sustainable for our communities

Veronica Johnson-Roffey and Kate Prevc outline the benefits of healthcare facilities management companies employing their own infection control nurse to ensure their staff working in hospitals are trained in infection control

Many healthcare providers contract out elements or all of their soft facilities services and the providers are expected to help in fulfilling aspects of the Hygiene Code in relation to infection prevention and control. It is widely accepted that good facility management is hugely important in helping to prevent and control healthcare infections. Services contracted out are classed as hard and soft facilities.

Registered healthcare organisations are required to comply with the Health and Social Care Act 2008 - Code of Practice on the prevention and control of infections and related guidance. The Act outlines 10 criteria which organisations must satisfy the CQC they are meeting to provide safe care. These include having systems to manage and monitor the prevention and control of infections, providing and maintaining a clean environment that facilitates prevention and control of infections, providing suitable information on infections, identifying people who have or are at risk of developing infections in order to treat and reduce risk of spread, systems to ensure that care workers including contractors are aware of and discharge their responsibilities in preventing and controlling infections, have and adhere to appropriate policies and managing occupational health needs of staff in relation to infections,

This article discusses some facets of how University Hospitals Coventry and Warwickshire (UHCW) NHS Trust, one of the most modern healthcare facilities in Europe with 1,250 beds, and ISS Mediclean Limited, one of the largest facility services providers in healthcare, collaborated on a project to support the message that, infection prevention and control (IPC) is everyone’s responsibility. ISS has been providing the soft services facilities to UHCW since it opened in 2006, and the project which involved ISS employing their own dedicated IPC nurse – the first of its kind in ISS nationally - was the idea of the on-site ISS General Manager in 2017 with full support from the UHCW Director of Nursing and their Lead IPC Nurse.

What are soft services in facilities management?

In healthcare these are the services that make the environment safe, secure, efficient and pleasant for patients, staff and visitors. These services include portering, cleaning, catering, security, waste management, car parking, post, switchboard, helpdesk, and linen and laundry services – all provided by ISS in the case of UHCW.

Soft services differ from hard services which are related to the fabric of the building such as heating, plumbing, ventilation, lightning and building maintenance. The purpose of the role is: to ensure Infection Prevention and Control (IPC) was addressed in all aspects of healthcare cleaning and reflected throughout all activity related to the ISS healthcare cleaning provision (and other soft service elements); to ensure infection prevention is taken into account in assessing method statements, cleaning schedules and training activities; and to provide a professional and collaborative link between the soft service provider and the trust’s clinical and IPC teams.

The core responsibilities include: being a core member of the trust’s Infection Prevention and Control Committee; developing, in partnership with the Head of Cleaning and Trust IPC Manager, an annual audit and improvement program which was aligned to the ICNA Audit tool and reflects specific objectives of UHCW Infection Prevention and Control annual program; contributing to the development and implementation of policies, procedures and guidelines; working in partnership with the local Infection Control leads, Matrons and Ward Managers ensuring that the ISS service level inputs are appropriate for the hospital size, activity levels and complexity; ensuring programs of auditing are in place in relation to IPC; ensuring all staff completed mandatory infection prevention and control training and review that training to ensure it was most appropriate and effective; implementing and maintain a continuous hand hygiene surveillance and improvement programme for healthcare cleaning and other soft service elements; supporting Trust IPC team in undertaking Root Cause Analysis (RCA) in cases of infection to identify issues and causes with inclusion of healthcare cleaning staff, especially in relation to changes required in practice as a result of identifying the root cause; providing comment and advice on the purchase/introduction and use of equipment in relation to IPC issues; and promoting effective team working across clinical and soft services staff within the team.

The ISS appointed person being a nurse was clinically accountable to the Trust IPC lead who was instrumental in drawing up the job description and recruiting, but was managed operationally and worked closely with the head of healthcare cleaning, although with regards to regular IPC issues was autonomous.

Facets of the role

Cleaning

Healthcare cleaning is an integral part of IPC so a major part of the role involved working with the healthcare cleaning team. ‘A Matron’s Charter: An Action Plan for Cleaner Hospitals’ and ‘The matron’s handbook’ make it clear that matrons have ultimate responsibility and accountability for standards of environmental cleaning and IPC in their areas.

Therefore, from the outset it was important to quickly establish a relationship with as many of the 34 Trust matrons. This was achieved by meeting with as many matrons as possible individually but mostly by attending the monthly matrons’ meeting chaired by the UHCW IPC Lead. This was an ideal opportunity to meet the matrons, discuss cleaning audit reports and get feedback from them on any cleaning concerns to feed back to the head of healthcare cleaning and support in rectifying these. It was also a good opportunity to feed back to the matrons any concerns from the cleaning teams which impact negatively on effective cleaning such as ward clutter or access to areas and making the healthcare cleaner feel part of the ward team was always encouraged.

The nurse in charge of the shift has direct responsibility for ensuring that cleanliness standards are maintained throughout that shift so if the healthcare cleaner always feels part of the ward team they can be directly approached by the matron, nurse in charge or her staff to rectify any cleaning problems.

Training

If staff are informed they tend to be more compliant and more motivated if they feel their work is important. Training was already high on the agenda of ISS but training was an important part of this project. During the project all newly appointed staff including porters, cleaners, catering, ward hostess, retail, security and support teams had two hour face to face IPC training included in their induction. This was important in reiterating the ISS message to staff that whatever their job in the hospital they had a part to play in preventing infections regardless of whether they were patient facing or not. This was an important message because some staff had never worked in a hospital before and had little knowledge of IPC on any level. Training included the basics of standard precautions and practical session on hand hygiene and use of PPE.

If the ISS nurse was not able to undertake a session a member from the Trust IPC team stood in, this was also a good way to reiterate that ISS are following the same policies as the Trust and for staff to get to know members of the Trust’s IPC team.

One to one hand hygiene sessions were also undertaken with staff on the wards so they didn’t have to be away from their area. This was also a way to show Trust staff that ISS staff such as cleaners and ward hostesses working in their area, were getting hand hygiene training the same as the Trust staff. Audits of hand hygiene practices by the Trust included any ISS staff in the area and any concerns or good practice were fed back to the ISS nurse to follow up on. The ISS healthcare cleaning manager and supervisors were also updated on their IPC and hand hygiene knowledge so they could be an up to date resource for cascade training in their areas.

Audits

In line with the national specifications for cleanliness in the NHS: a framework for setting and measuring performance outcomes (NHS 2007) the healthcare environments should pose minimal risks to patients, staff and visitors. Regular auditing of the healthcare environment helps to ensure that high standards are maintained and give an early warning if standards are failing or where best practice prevails.

The ISS IPC nurse attended environmental cleaning audits with the healthcare cleaning team managers or supervisors and, if appropriate, the matron of the area or Trust IPC nurse. This supported the cleaning team but also gave extra assurance to the matron that we were working together to improve standards but also again point out where maybe practices on the ward could be impacting on effective cleaning.

Historically the trust used two methods of auditing the cleanliness of the environment, the nursing team used the Infection Control Nurses Association (ICNA) Audit Tool for Monitoring Infection Control Standards (2004) and ISS used a Maximiser tool to audit against the contractual specifications for cleanliness requirements. This was at times confusing and staff wanted a single tool that allowed ISS to meet contractual obligations but also include the nursing aspects of environmental infection control management.

Together ISS and the Trust IPC team created a single audit tool that produced a single percentage to reflect the overall cleanliness standard of the environment. This provided a single measure that all staff understood and for upward assurance the trust board could understand what score indicated a well-managed area. The scores could also be broken down into areas of responsibility: ISS, estates and the nursing team. A one day workshop facilitated by a researcher from Imperial College worked with the teams to develop a tool that met a number of requirements, this initially was delayed due to contractual concerns but as the benefit was realised by using it for those area that had increased incidence of Clostridioides Difficile (CDT) it was brought into increased use. Having an IPC lead for ISS during this work was mutually beneficial as there was a unique insight into the issues that both sides encountered.

Infection Control Committee (ICC)

The role required the ISS IPC nurse to be a member of the Trust ICC which was important in supporting the cleaning management who were required to present an environmental cleaning report but also to get updated on other IPC matters useful for self-development. It was also a good way to give assurance that IPC matters were firmly on the ISS agenda.

Outbreaks

The ISS nurse was alerted to any outbreaks in the hospital so she could support relevant ISS teams such as enhanced cleaning and ward hostessing in any actions they had to take to help in controlling the outbreak. It was also a good opportunity to provide some education to staff about the organism causing the outbreak to allay fears. When necessary the ISS nurse also supported the Trust IPC team with e.g. contact tracing activities.

Observation Walks

The IPC Lead for the trust and the ISS IPC nurse would walk as many wards/areas as possible at least once a week and this visibility was very good again for showing that we were working together and it was useful to highlight any IPC problems that needed attention from ISS or the Trust.

The ISS nurse would also do a daily walk around selected wards or depts. with one of the healthcare cleaning managers or supervisor meeting ISS staff and sometimes using it as an opportunity to do ad hoc hand hygiene inspection or to deal with any problems that may impact on IPC. Sometimes this might just be observing staff like porters who are visiting wards or ward hostesses serving drinks and food and making sure they were observing correct practices like hand hygiene and use of PPE where appropriate.

It was also a good opportunity during flu season to encourage staff to have annual flu vaccination and also organising out of hours clinics with occupational health for ISS staff on later shifts to get their vaccine.

Conclusion

We are aware that other similar facilities companies have employed nurses in various roles but to our knowledge none have specifically employed a trained IPC nurse to work with the hospital Trust IPC team in genuine collaboration.

Following the project which lasted 20 months, working part time, ISS, UHCW and the appointed nurse, have agreed it was a success and ISS will look to continuing this at UHCW and replicate in any new larger healthcare contracts. This was a part time post but following feedback from the nurse undertaking the role; it’s recognised that a full time person would be able to expand the role further to add even greater value. The IPC team at UHCW felt the role definitely helped to break down barriers and strengthen IPC links between ISS and UHCW and vice versa. The ISS staff felt it was useful to have their own IPC nurse they could directly refer to and some, especially the cleaners, said it made them realise that their role was important.

The expertise of the Trust’s IPC team to the service provider can sometimes be constrained by time or clinical priority and therefore an initiative such as this helped to ensure that both organisations were aligned in relation to IPC.