Standard 3 Environment and Facilities Management Inadequate patient Preparation / waiting area Existing seating area on top floor used for patient waiting Patients prepped for procedure in post procedure observation area Patients being directed to existing seating areas Patient waiting area to be included new plans for remodelled Endoscopy Unit for JAG accreditation Celia Dwan CNM2 Philip Brennan Ongoing First quarter of 2017 Current facilities being used for patient waiting area Upgrade of MAU commenced on ground floor. Plan to move MAU by year end which will release more floor space to Endoscopy. Closed First quarter of 2017 Standard 3 Environment and Facilities Management No Endoscopy patient discharge lounge Patients being discharged from bed space Designation of Endoscopy Discharge Lounge with remodelling of Unit for JAG accreditation Discharge care and advice being provided in observation bed space New Seating area being set up - Celia Dwan CNM2 Philip Brennan Facilities Ongoing First quarter of 2017 Discharge care and advice being provided in observation bed space Upgrade of MAU commenced on ground Plan to move MAU by year end which will release more floor space to Endoscopy Ongoing First quarter of 2017 Standard 3 Environment and Facilities Management No separate cleaners utility room for Endoscopy Unit To provide a cleaning equipment store room specifically for Endoscopy Unit Endoscopy cleaning equipment to be stored in top floor cleaning store room. Celia Dwan CNM2 Hygiene Attendant CLOSED Cleaning Equipment being stored in Top floor equipment room CLOSED Standard 3 Environment and Facilities Management Clutter on work surfaces in Procedure room 1 Office space adjacent to Endoscopy Procedure Room 1 designated to Endoscopy. New office space provided to Endoscopy Unit. All possible equipment / paperwork decanted to new office space Philip Brennan Facilities Celia Dwan CNM2 Completed Ongoing monitoring and Completed Ongoing monitoring and audit Completed Ongoing monitoring and Standard 4 No dedicated Endoscopy Recruitment and Appointment of Staff deficit in Endoscopy risk Irene O’Connor Facilities February 2016 Number of staff required identified. CLOSED
Standard 4 Human Resource Management No Infection Prevention Control Link Nurse in Endoscopy Have IP&C Link nurses working in different departments in Nenagh Hospital IP&C Course information sourced via CNME Information cascaded to all departments Interest sought at ward level Cathrina Ryan A/ODON Relevant CNM2 February 2016 Awaiting Names to be forwarded for appropriate training Endoscopy Nurse completed IP&C Study Day April 2016 April 2016 Closed April 2016 Standard 6 Hand Hygiene Hand Hygiene Audit not carried out in Endoscopy Procedure rooms in 2years Have independent audit carried out Hand Hygiene Audit carried out by Barbara Slevin ADON IP&C UHL November 15 Score – 100% Barbara Slevin ADON IP&C November 2015 Completed Closed Standard 6 Hand Hygiene 2 /10 Hand Hygiene opportunities not Revisit 5 moments of Hand Hygiene with staff Hand Hygiene 5 moments refreshed with staff Celia Dwan CNM2 November 2015 & Ongoing Completed 5 hand Hygiene trainers now on the hospital site and 3 hand Hygiene auditors Ongoing Standard 8 Invasive Medical Device related infections are prevented or reduced Improvement in Documentation for Peripheral Vascular Care bundles & Urinary Catheter Care bundles required Care bundles to be incorporated to NEWS Chart and become part of patients routine observations Ongoing Audits continued. Local and HIQA Audit results fed back to staff. QIP in place until documentation streamlined Relevant CNM2 Barbara Slevin ADON Cathrina Ryan A/ODON May 2016 Await Guidance from Project Group Lead Monthly review via Metrics Ongoing Standard 3 Environment and Facilities Management Blood Glucose Device and container being brought to patient’s bedside All staff reminded for need to make up and clean down individual tray when taking a patients blood glucose Hospital policy re circulated. CNMS requested to monitor and tutor staff in their work areas Cathrina Ryan A/ODON Relevant CNMS February 2016 Compliance appears to be improved Reaudit September 2016 with DiabeticCNS Ongoing Monitoring and Audit Outstanding Items From HIQA QIP 2014
Standard Findings/ Non Compliance Action Action Taken Lead Responsibility Target Timeframe Progress To Date Review Standard 3 Environment and Facilities Management Sanitary Facilities not being checked in the evening – checklists not being signed off in evening Sanitary Facilities check sheet to be redesigned to reflect National Cleaning standard of 3 cleans and 2 check cleans a day. Monitoring of patients sanitary facilities Redesign of shift patterns and rosters to have availability of Hygiene attendants on duty in afternoons / evenings to carry out checks / cleans commenced Appropriate schedules designed and to be distributed Monthly sanitary facility audits Cathrina Ryan A/ODON Irene O’Connor Facilities Bridget Kelly CNM2 February 2016 Monthly and ongoing Meetings commenced with Unions and MTAs for review of rosters to facilitate extended day. WTE Deficit identified– awaiting appointment of same to achieve and maintain hygiene standard. 5 MTAs recruited and 5 further vacancies identified. Interviews April 2016 Ongoing September 2016 Ongoing Standard 4 Human Resource Management Deficits in Hygiene staff WTE identified on Medical 2 ward Recruit and replace deficits in hygiene WTE Placed on Hospital risk register in April 2014 and escalated to Facilities Management Risk submitted to Operations Cathrina Ryan A/ODON Josephine Hynes HR Irene O’Connor Facilities Noreen Spillane COO September 2015 Feb 2016 Ongoing recruitment and training across ULH Group. Awaiting further allocation to Nenagh MARCH 2016 – New staff allocated to hospital. Second hygiene MTA allocated to Med 2 CLOSED