Professional Documents
Culture Documents
Hand Hygiene Action Plan - Final Draft For IPCG
Hand Hygiene Action Plan - Final Draft For IPCG
DRAFT Hand Hygiene Action Plan - Cardiff and Vale University Health Board
Objective
Aim
Comment
Expected
outcome
UHB Area
To design and
deliver a hand
hygiene
communication
strategy
To systematically
communicate and
promote hand hygiene
awareness throughout
healthcare and
community settings in
Cardiff and the Vale
UHB area.
Hand hygiene is a
fundamental component
of effective infection
control, particularly in
healthcare settings
where it will contribute
to achievement of AQF
targets on HCAI
To improve hand
hygiene in wider
community
settings
To identify opportunities
to improve promotion of
hand hygiene with
partner organisations,
including:
Schools
Health Protection
Team
Environmental Health
Departments
Pharmacies
Hand hygiene
communication
plan
Completion
date
Monitoring
Lead
Manager
June 2011
Monitoring of
agreed actions
in
communication
plan
Director of
Public
Health
Wider Community
Better hand
hygiene practice in
community settings
Will be
continual as
ongoing
Consultant
in Public
Health
Draft v8
Objective
Aim
Comment
Expected
outcome
Primary Care
All practices to
use the primary
care audit
protocol produced
by the Primary
Care Quality and
Information
Service (Public
Health Wales)
Improvement in
number of
practices using
audit protocol
Re-audit
Completion
date
Monitoring
Lead
Manager
Baseline audit
completed.
Senior
Nurse for
Primary
Care
Repeat audit to
be conducted
annually.
September
2011
June 2011
All organisations to
re-identify lead
June 2011
June 2011
February
2011
June 2011
Draft v8
All practices to
utilise the Welsh
Healthcare
Associated
Infection
Programme hand
hygiene elearning tool
ongoing
Improved hand
hygiene practice.
To implement
bare below the
elbows (NHS
Wales dress
code)
Audit of use of
e-learning tool
Senior
Nurse for
Primary
Care
Audit of
compliance
Medical
Director
June 2011
ongoing
Ongoing
Draft v8
Objective
Aim
All providers to
use the primary
care audit
protocol produced
by the Primary
Care Quality and
Information
Service (Public
Health Wales)
Improvement in
number of
practices using
audit protocol
Re-audit
Monitoring
Lead
Manager
Baseline audit
completed.
Senior
Nurse for
Primary
Care
Repeat audit to
be conducted
annually.
September
2011
June 2011
All organisations to
re-identify lead
June 2011
To recirculate hand
hygiene audit tool and
summary report to
mangers and practice
nurses via email
June 2011
To identify to each
organisation that the
Hand hygiene module
can now be accessed
as an individual module
and forms the basis of
training needed to lead
on hand hygiene in the
practice
February
2011
June 2011
Draft v8
ongoing
Improved hand
hygiene practice.
Audit of use of
e-learning tool
Senior
Nurse for
Primary
Care
June 2011
ongoing
Draft v8
To explore the
role of nurse
assessor teams in
supporting
infection control in
the independent
sector
To identify a formal
mechanism to support
continuing improvement
in infection prevention
and control practices
Role of nurse
assessors in
promoting IPC
clearly defined
August 2011
Senior
Nurse for
Primary
Care
Draft v8
Objective
Aim
To improve
arrangements for
infection
prevention and
control link nurses
All lead staff to
utilise the Welsh
Healthcare
Associated
Infection
Programme hand
hygiene elearning tool
To develop a clear
system for improving
infection prevention and
control practice across
the service
Education and training
programmes are in place
and improved use of the
IPC e-learning package
is supported.
Comment
Expected
outcome
Community Nursing
Completion
date
Monitoring
Lead
Manager
Link nurses to be
re-identified
August 2011
List to be
updated
annually
Improved hand
hygiene practice
September
2011
Audit of use of
e-learning tool
Practice
Educator
for
Community
Nursing
Practice
Educator
for
Community
Nursing
Draft v8
To promote
appropriate hand
hygiene in
community setting
Audit tool to be
developed to monitor
compliance with IPC
agenda.
To implement
bare below the
elbows (NHS
Wales dress
code) for all
clinical staff
Ongoing
Report of audit
results
Practice
Educator
for
Community
Nursing
Ongoing
Audit of
compliance
Medical
Director
Draft v8
Objective
Aim
Comment
Expected
outcome
Hospital Care
Completion
date
Monitoring
Lead
Manager
To promote the
use of the
Lewisham hand
hygiene audit tool
Monthly audits to be
completed by each
ward/department.
Hand Hygiene
compliance will
increase
Ongoing
Lead
Nurse
Patient
Experience
To conduct IPC
validation audits
Compliance audits
will demonstrate
ward audits
accurate
Ongoing
Lead
Nurse
Patient
Experience
To improve use of
hand washing
facilities.
Protection of users
and the
walls/flooring
June 2011
IPC Senior
Nurse will
monitor
implementation
Lead
Nurse
Patient
Experience
Draft v8
Dissemination of
Hand Hygiene
education
Hand hygiene is
promoted at every
opportunity during an IPC
teaching session
To promote use of
the Welsh
Healthcare
Associated
Infection
Programme hand
hygiene elearning tool
To implement
bare below the
elbows (NHS
Wales dress
code)
To propose to the
December IPC group
meeting that a pilot is
conducted of the use of
the WHAIP e-learning
tool by Infection Control
link practitioners
(Champions) as a
means of disseminating
good hand hygiene
practice
To publicise and promote
bare below elbows
message for all clinical
staff and in all clinical
areas
Hand Hygiene is
consolidated for all
staff who should be
complying as well as
promoting amongst
other colleagues
auditing.
All staff should also
be able to give
appropriate public
health advice to
inpatients and their
relatives
Compliance with
hand hygiene
policy increases
Current and
Ongoing
Lead
Nurse
Patient
Experience
Link Practitioners
will undertake
standalone module
during Link Pract
study day
September
2011
Database will
demonstrate
completion of
tool by
practitioners
Lead
Nurse
Patient
Experience
Ongoing
Audit of
compliance
Medical
Director
10