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THE WATT GROUP REPORT
CHAPTER 6 WIDER MANAGEMENT CONSIDERATIONS, INCLUDING COMMUNICATIONS AND OTHER KEY ISSUES
As has already been mentioned in
Chapter 5, the Group considered that management at Executive Director level within the Greater Glasgow NHS system had not been fully engaged in the outbreak until shortly before the issue appeared in the media. A decision had been taken not to issue a press statement (although one had been prepared). The public was not informed of the circumstances and issues surrounding the outbreak until the relatives of one patient took their concerns to the media. An important means of communication and of transmission of a public health message was therefore lost. When the story broke, the Trust's perception of a hostile media became self-fulfilling.
Internally, communication with staff appeared to rely mainly on a verbal briefing system from 3
rd January 2002 and regular ward visits by ICNs from 8
th January onwards. There is some doubt, based on interviews, as to whether all staff would have received a full briefing on the progress of the outbreak or control measures to be implemented. The Group believes that one of the responsibilities of the OCT must be to ensure prompt and clear internal communication with all relevant staff.
The Group found that a series of communications failures had occurred at various stages between the OCT and the Scottish Executive, as well as within the Scottish Executive itself. These can be summarised as follows:
(1) Although the Trust informed the Public Health Department on 3
rd January, there appeared to be a delay in informing senior management of the Greater Glasgow NHS Board.
(2) Delay and lack of clarity within Greater Glasgow NHS Board with no formalised policy for early warning of the Chief Executive and Director of Public Health by Consultants in Public Health Medicine. This resulted in the Chief Executive not being engaged in the outbreak until a week had elapsed.
(3) Failure of the Trust OCT to inform the Scottish Executive although the SCIEH representative on the OCT had informed the Food Standards Agency; eventually information was requested from the Trust by the Scottish Executive when they learned of the press interest (neither SCIEH nor the FSA informed the SEHD).
(4) Greater Glasgow NHS Board did not inform the Scottish Executive about the outbreak until information was requested of them.
(5) The Scottish Executive only learned of the outbreak on 15
th January 2002 when a copy of a press statement from the Trust (prepared in response to media enquiries) was sent to the Press Office at Greater Glasgow NHS Board. This was read over the phone to Press Health at the Scottish Executive. Later that day the Trust informed Press Health directly, because the Trust knew that a Glasgow newspaper would run with the story. Up to that point there had been no direct communication from those involved in the outbreak with the Scottish Executive.
(6) Although the Scottish Executive Press Office informed the Scottish Executive Public Health Division and Performance Management Division, no clear attribution of responsibilities existed.
(7) Initial follow-up action was taken on 15
th January 2002 by the Scottish Executive Public Health Team who made enquiries direct of the Public Health Department at Greater Glasgow NHS Board. Details of the outbreak were then e-mailed from Glasgow to the Public Health Team. However, no further follow-up action occurred by the SEHD until late on 16
th January 2002 and early on 17
th January 2002. The Minister for Health and Community Care was not, therefore, briefed until lunchtime on 17
th January 2002, 9 days after the OCT was convened and just before local and national media released the story.
The common characteristics of these shortcomings were:
(1) A lack of clarity about the circumstances in which details of an outbreak should be communicated to the Scottish Executive.
(2) A similar confusion about which individuals should take the lead for such communication.
(3) No clear internal communications policies within the organisations concerned.
(4) Confusion about which Division/Unit within the Scottish Executive Health Department (SEHD) should take the lead in briefing the Health Minister and take necessary further actions.
(5) A belief that "Press Office to Press Office" communication was a satisfactory and sufficient method of notifying key players about an outbreak of infection.
(6) Reluctance to communicate with the public until forced to do so by external media enquiries, so that media pressures drove events.
Recommendations
The Review Team were concerned about these communications and wider management failures. We recommend the following:
30. That a classification system for infection outbreaks/episodes be drawn up and used by all key players as "common currency" in deciding the actions and communications required in a given infection incident (A framework (Infection Control Risk Matrix) is set out in detail in
Appendix E)
, and that clear policies are developed, using this system, which identify all the key individuals involved in communications about outbreaks of different severity.
31. That in any outbreak that is considered at any stage to be foodborne, the Scottish Executive is informed in addition
to the Food Standards Agency.
32. That Trusts and Boards ensure that there are sufficient resources to appoint adequate levels of communication professionals, but
that "Press Office to Press Office" communication is additional to, not a substitute for, professional communication.
33. (a) That the Chief Executive of a Trust or Health Board (depending on whether the outbreak is primarily in the hospital or community respectively) should assume the unambiguous responsibility for ensuring effective internal and external communications, including the media, appropriate Government
Departments and Agencies.
(b) That within the SEHD consideration should be given to the nomination of an issue manager as soon as a serious outbreak occurs and irrespective of the route through which notification has come. Clear guidelines should also be in place on which Division/Unit within the SEHD should be responsible for actions and briefing associated with an outbreak.
Other Issues
In the course of the Review, the Group considered a series of other key issues that emerged as having wider implications for the control of HAI in Scotland. Recommendations to address these issues are given below.
Infection Control Doctor
The designated Infection Control Doctor (ICD) will be trained in and have a professional interest in infection control and management of HAI. They will have designated sessions for this work and would normally be appointed ICT leader at Trust level. They should agree and implement an infection control programme with all members of the ICT. They will normally chair OCTs at Trust level. They will report and be accountable for infection prevention and management through Trust Clinical Governance and Risk Management Committees. Training and resources will be required to bring this recommendation to fruition.
The Group believes that a more extensive level of ICD service is required if healthcare associated infection is to be kept to a minimum.
Recommendation
34. That resources are in place to ensure that each Trust has a designated and trained ICD, who will normally lead the Trust ICT. This will usually, but not invariably, be a consultant microbiologist who will have designated sessions and a clearly defined job description for this component of their work. In the case of Trusts without laboratory facilities (e.g., Primary Care Trusts) they should formalise arrangements with a suitably trained and appropriately resourced individual.
Infection Control Nursing
Infection control nurses (ICNs) are a key catalyst in preventing and managing infection in hospitals. At present, most Trusts have ICN support available on a 9am to 5pm, 5-day a week, basis that often excludes Public Holidays, as was the case in the Victoria Infirmary. Outwith these hours the ICD provides infection control clinical advice, usually by telephone.
By providing infection control training for all staff at induction and providing a systematic programme for all health care staff at place of work, ICNs can ensure that outbreaks are kept to the minimum. They should have daily contact with wards or other healthcare premises. They should visit each facility at least weekly. They should undertake the education of agency and bank staff as well as medical staff within a coherent programme of training and education. They should undertake, oversee and report on systematic audits of hand washing practice. They should have an on-call rota to advise on infection matters on a 24-hour basis. They will, along with the ICD, be central to management of outbreaks of infection.
Recommendations
35. That resources are in place to ensure that each Trust has sufficient ICN establishment to:
(a) have daily contact with wards or other health care premises;
(b) visit each facility at least weekly;
(c) provide advice to ward and departmental nursing staff on the nursing care of patients who are at risk of , or who have, infection;
(d) be responsible for a systematic competency programme in infection control for all health care workers at their place of work (including medical, agency and bank staff);
(e) undertake systematic hand washing audits, including audits involving night and weekend health care workers; and
(f) provide an on-call service to advise on infection control matters on a 24-hour basis.
36. That there should be a lead Infection Control Nurse (ICN) in each Trust.
Infection Control Champions
The concept of infection control champions
16 announced by the Minister for Health and Community Care on 26 April 2002 is supported by the Group and should be developed.
Recommendation
37. That infection control champions at ward level can complement, but not replace, the roles of the Infection Control Team. They should not be used as substitutes for ICNs but:
(a) They should assist in the delivery of a comprehensive infection control service and be integral members of an enlarged Infection Control Team; and
(b) Have clearly defined roles, dedicated time for infection control duties and be appropriately trained and supervised. The extra responsibilities and training should attract enhancement of salaries.
Role of NHS Boards in Infection Control
NHS Board Infection Control Team (ICT)
The Group believes that NHS Boards should take the lead in the strategic aspects of infection control within their areas, including the formulation of policies.
The Group recommends that each NHS Board should have a standing ICT to co-ordinate the strategic management of all outbreaks where the Major Outbreak Plan is implemented. It will advise the NHS Board and the relevant Trust where infection control resources are needed and where protocols and procedures need to be improved to comply with current standards and requirements.
17,18,19 It will monitor compliance with recommended national guidance at Trust level. It will ensure that clinical governance and risk management committees are made aware of this advice. The NHS Board ICT will provide direct assistance to the Trust ICT when requested to do so.
The NHS Board ICT will have a designated leader, who is trained in infection control and who has the necessary skills to ensure that clinical governance requirements and CSBS standards are met in the prevention and management of infection. The core membership of the Infection Control Team at NHS Board level should include:
Infection Control Doctor;
CPHM (CD/EH);
ICN/Public Health Nurse(s);
Communicable Disease Administrator and Secretarial Support staff.
The Head of Environmental Health should also be a core member of the NHS Board ICT if a food-borne source of infection is suspected. For smaller NHS Boards (e.g., Forth Valley,
Highland, Borders, Dumfries & Galloway, Island Boards) the NHS Board ICT may function as the Trust's ICT also. The core membership is consistent with that set out in the Cairns-Smith Report.
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Recommendation
38. That each Health Board should have an appropriately constituted Standing Infection Control Team (ICT) which:
(a) takes the lead in strategic aspects of infection control in their area;
(b) formulates and agrees infection control policies;
(c) co-ordinates the management of all outbreaks where the Major Outbreak Plan is invoked;
(d) has a designated leader;
(e) links effectively with Risk Management Committees and Clinical Governance Committees; and
(f) provides assistance and advice to Trust ICTs when requested and/or when appropriate.
A review of NHS Board and Trust functions in Scotland may necessitate some changes in infection control organisation and liaison in the future. The infrastructure suggested is, however, consistent with the Clinical Standards Board for Scotland recommendations and more recently the SCIEH commissioned report 'Model of Infection Control and Communicable Disease Control'.
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Trust Infection Control Teams
In larger NHS Boards, Trusts will assemble their own ICTs. Membership will include:
The Trust ICT will be responsible for the prevention and management of healthcare acquired infection within their Trust and will be responsible for ensuring appropriate infection control audits are completed. The Trust ICT will manage outbreaks until the Major Outbreak Plan is invoked or until clear transfer of responsibility is effected to the relevant NHS Board ICT.
This transfer of responsibility should apply to complex or difficult outbreaks where the Major Outbreak Plan is not implemented. It should apply to outbreaks that cross two or more hospitals or Trusts. It should also apply when widespread transmission of infection to and from the community to hospital occurs.
The Trust ICT will appoint a team leader who is trained in and has a professional interest in infection control and who will agree to take responsibility for prevention and management of infection at Trust level. He/she will ensure that clinical governance requirements and Clinical Standards Board Scotland (CSBS) standards are met. The Team Leader would either be the Infection Control Doctor (ICD), or an Infection Control Nurse (ICN).
Comprehensive risk management arrangements will, however, have to be in place to ensure that advice and recommendations are appropriately considered and implemented by the Hospital and Trust management.
Recommendation
39. That large Trusts should have an appropriately constituted Standing Infection Control Team (ICT) which:
(a) prevents and manages healthcare associated infection within their Trust;
(b) implements agreed Board and Trust policies in infection control;
(c) has a designated leader;
(d) links effectively with Risk Management Committees and Clinical Governance Committees; and
(e) liaises closely with, co-operates with, and provides membership for the Health Board ICT.
Consultant in Public Health Medicine with Responsibility for Communicable Diseases [CPHM (CD/EH)]
The CPHM (CD/EH) will become much more closely involved in ICTs at Health Board and at Trust levels. He/she will normally lead the ICT at Board level. CPHMs (CD/EH) should now be trained in the management of HAI and play a much more prominent role in HAI surveillance and management of hospital outbreaks.
Recommendation
40. That CPHMs (CD/EH) should be trained in the management of HAI and play a more prominent role in HAI surveillance and hospital outbreak management. They should normally lead all infection outbreaks within their Board where the Board's Major Outbreak Plan is invoked.
Simulated Outbreaks
At present, although Trusts and Boards hold simulated emergency exercises, these do not include simulated outbreaks of infection. The Group considered that this situation is unsatisfactory.
Recommendation
41. That each Health Board holds regular (possibly every 2 years) simulated outbreak exercises, with adequate debriefing afterward, and that documentation of such exercises be provided to the Clinical Standards Board at the time of their inspections.
Classification of Outbreaks/Episodes and Linkage to Risk Management
At present there is much confusion as to what constitutes an outbreak/episode and when an outbreak/episode is deemed "minor" or "major". There is no consistency of approach so that different health service agencies may operate to different (unwritten) criteria. There is also, in many cases, no linkage of outbreaks to more general risk management structures.
This leads to some of the management and communication problems shown in this outbreak.
Recommendations
42. (a) That all relevant parts of the NHS operate to a consistent set of criteria that is linked to a risk management classification that describes infection outbreaks/episodes.
(b) That the level of outbreak/episode risk category determines both the level of action(s) required and the level of communications.
43. That Trusts link infection control to risk management structures as a matter of urgency.
An Infection Control Outbreak/Episode Risk Matrix is given in
Appendix E. The Group recognises that outbreaks/episodes develop quickly and that situations change from day to day; this should lead to a constant re-appraisal of the risk category of any outbreak/episode with re-assignment to a higher level as soon as deemed appropriate.
Relations with the Media
There is a responsibility for the Scottish Executive and for the NHS to inform and educate the public about all aspects of health care infections. The media has a crucial role in this process. All too often this partnership fails; the media concentrates on raising concerns (and therefore raises public anxiety), there is poor internal communication between and within the organisations responsible for health care provision and externally with a perceived hostile media. The result, as in this case, is that there is both a lack of openness and a lack of context and balance in reporting. The public are made anxious about perceived secrecy relating to
infection incidents without receiving the necessary information to put these in context. Such negative media coverage may lead to:
(a) Important information being withheld from the public; and
(b) A "siege mentality", with lowering of staff morale, recruitment problems and eventually a self-fulfilling prophecy of deteriorating health care.
More involvement of the media in positive aspects of infection issues would allow:
(a) More openness; and
(b) Better public understanding of infection issues (e.g., the limitations of staff screening, the relative risks of HAI as compared to risks of not receiving health care treatment).
Recommendations
44. That at both local and Scottish Executive level more strenuous efforts are made to tap the potential of the media to improve the public understanding of infection control issues. This will require a more open relationship to be developed between the NHS and the media based on mutual trust. There should be presumption of early disclosure to the public and the media of outbreaks of infection.
45. That internal communications within and between the Scottish Executive and NHS organisations are improved and clarified so as to reflect the openness culture and this is emulated in communications with relevant agencies (e.g., The Food Standards Agency, Scottish Water, Scottish Environmental Protection Agency (SEPA).
Resource Issues
There is good evidence that resources put into infection control are cost effective in reducing the costs of HAI.
21,22 At present Trusts, as was the case in this outbreak, often do not have information on the costs of infection nor the costs of infection control.
It is important that infection control commands a much higher order in the resources devoted to it and that Trusts are adequately resourced for this. In the longer term, such resources should be related to the costs of HAI.
To ensure that properly staffed ICTs become a reality will require some resources for ICNs and ICDs. However, it is more important to ensure that there is a culture change within NHS Boards and Trusts to redesign current ways of working towards delivering the NHS Board and Trust agreed infection control programme. Training of staff for these new roles will be a
sine qua non to implement these developments.
Recommendations
46. (a) That NHS Scotland should adopt a programme budgeting approach to Infection Control and that each Trust and each Board be required to provide details of the resources devoted to Infection Control.
(b) That such details are supplied as part of the documentation provided to the Clinical Standards Board for Scotland at the time of individual Trust reviews.
47. That the Scottish Executive should convene a Working Group to develop methods of tracking and calculating the costs of HAI and its control in Scotland.
Health and Safety Executive
Health care associated infection is a patient and staff safety issue. We welcome the increasing profile of the HSE in this area, but would urge that inspections of health care premises are on a consistent basis. The Infection Incident Control Outbreak/Episode Risk Matrix should facilitate such a consistency of approach.
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