HSE claims progress on hygiene and infection

  • Niall Hunter, Editor

The doctor in charge of healthcare safety in the HSE has said measurable progress has been made recently in tackling hospital hygiene and infection in Ireland.

While only one Irish hospital received a 'very good' rating and the majority only got 'fair' ratings in the recent HIQA hygiene audit, Dr Kavanagh said the findings in this report showed significant improvements on the previous 2007 audit.

In an interview with irishhealth.com, HSE Director of Healthcare Quality and Safety Dr Paul Kavanagh, also said the extent of healthcare-associated infection in Ireland is not as great as in many other European countries.

He said in terms of tackling poor hygiene and adverse events/medical errors in hospitals, it was more appropriate in Ireland to have a system that encourages compliance with good standards rather than a 'deterrence' model that punishes or sanctions staff.

Q. The HIQA hygiene audit in December, while it showed some improvements on the 2007 audit, still had nine hospitals designated as 'poor'; the majority as only 'fair' , 11 as 'good' and only one as 'very good'. Surely it is still not acceptable that hospitals should still be at that level of hygiene standards?

A. Well, I think crucially the HIQA report in December provided independent validation of the measurable progress across our hospitals. There was significant improvement across the 56 criteria in the hygiene services standards that were measured across all 50 hospitals - so 25% of hospitals scored 'A' for exceptional compliance and the number of 'A' scores actually doubled versus 2007; these scores for extensive compliance were achieved on around 50% of criteria and overall 12 hospitals received a 'very good' or a 'good ' overall award compared to 2007. From the HSE perspective I think there were three strong messages coming through in that report:

First and foremost, the HSE has remained strong in how we deliver hygiene services on the ground. The criteria that related to service delivery scored strong across the board in hospitals, so in other words the delivery of hygiene services in hospitals was essentially good. Those criteria that related to hand hygiene scored particularly well.

The second key message coming through was we particularly improved our performance around corporate management of hygiene services. And that relates to how hospitals lead, plan and monitor their hygiene services.

The third part of the review that was particularly welcome was the patient survey HIQA undertook. They surveyed approximately 500 patients across the system. Patients on the ground found that the hospital environment was clean and they had very positive remarks to make around the area of hand hygiene. They found that staff were cleaning their hands, were happy themselves to encourage staff to clean their hands , they found that signage around hand hygiene was strong in the hospitals and they found that alcohol hand-gel was quite freely available.

So I think the message is that while there is no room for complacency, the report shows there is measurable progress being made and it should be noted that this was an independent HIQA report. 

However, while the HSE's stated aim is to achieve excellence in hygiene, the fact remains that only one hospital was 'very good' and the majority had only a 'fair rating', with nine getting 'poor' ratings.

I think the key issue is we need to put hospitals on the path towards excellence and our strategy is based around this. Having robust hygiene services is a part of our prevention and control strategy for hospital-associated infection and the report from HIQA comes at a time when the rates of of MRSA bloodstream infection in our hospitals has fallen by 25%.  The results around MRSA, taken with the hygiene aspect, show that we have an effective grip on the problems of hospital hygiene and infection.

But the emergence of C.diff is still be a major problem, and there are no comprehensive figures on that yet.

Yes, the issue is around measuring and around figures. What created the platform for us to deliver on improvements such as those around MRSA has been investing in and putting in place robust surveillance systems to monitor MRSA in our hospitals.  C.diff has become a notifiable disease since last May and we are starting to collect data around that. The fundamental platform for getting on top of healthcare-associated infection (HCAI) is having in place a monitoring system. We have it in place in the case of MRSA. I think we need to now commit ourselves to a similar path around C. diff.

How bad are our healthcare-associated infection rates?

It is important to recognise that HCAI is an international problem but by international comparisons the problem of HCAI in Irish hospitals is actually relatively low. Based on a 2006 study that Ireland participated in, the overall HCAI rates in our hospitals were 25% lower than they were in hospitals in neighbouring countries and indeed the prevalence of MRSA was threefold lower. So I think by international comparisons, while we recognise it is challenging, the extent of this problem is not as great as it is in other countries. The overall prevalence of HCAI in Ireland is estimated to be around 5% of admissions, while prevalence in Denmark is around 8%, and 7% in Norway, so I think it is important to see the issue in context.

So is the public and the media over-reacting to the threat from HCAIs?

No, I don't think so. The attention that the public and the media put on this problem is very welcome because it raises the bar for the HSE and it provides an external impetus for us to increase our efforts to tackle the HCAI problem The success in reducing MRSA rates, for example, is not just due to the efforts of staff but is also due to the efforts undertaken by the public in terms of doing things like encouraging health professionals to wash their hands, using antibiotics in a sensible way, observing visiting restrictions etc.

What are the main reasons for people continuing to get HCAIs?

The problem of HCAI is driven by a number of factors in addition to hygiene. Healthcare in 2009 is much more complex and invasive and patients are more likely to have complex medical conditions and more likely to be vulnerable to infection as a result of those conditions. Then, the problem of HCAI is also driven by antibiotic use, high levels of use of these drugs and usage of broad spectrum, 'catch-all' antibiotics. That creates a situation where resistant strains of bugs can emerge. We have at the HSE undertaken initiatives aimed at reducing antibiotic consumption; for example public awareness campaigns in the media.

But whatever about public information campaigns, surely the 'bottom-line' should be that doctors should be educated not to over-prescribe antibiotics. Isn't it ultimately up to the doctor to tell the patient they don't in all cases need an antibiotic?

I think that's a very paternalistic model. I think in 2009 we would see healthcare as not 'done to' patients but delivered in partnership with patients. I think it is about arriving at shared decisions on clinical management. Yes, the doctor writes the prescription, but patients can place demands on their doctor. Certainly you need to reduce the demand for antibiotics on the part of the public through education and we have 'ticked that box'. We need to change prescribing habits in hospitals and we need to change the prescribing behaviours in primary care. The HSE has been working with GPs around developing guidelines and audit tools in this area. This is challenging but I don't think it's impossible.

In terms of accountability in hospitals, what steps does the HSE take to ensure specifically that hospitals are charged with improving hygiene. Are staff given the role of improving hygiene taken to task or sanctioned if they do not achieve specific targets?

The HIQA report showed that corporate management had improved in this area. The chief executive/hospital manager has ultimate responsibility for maintaining good hygiene in hospitals. HIQA has independently validated that we have strengthened that accountability. Hospitals have multidisciplinary hygiene services committees. We are in the process of applying a targeted intervention to those hospitals who haven't made as fast progress around the issue of hygiene as other hospitals. We are now in a position to ensure that the pace of progress across hospitals becomes much faster in those hospitals making slower progress by sharing the exemplary practice from high-performing hospitals. We will require these hospitals to develop quality improvement plans, eg what actions need to be taken; who is responsible for leading that action. By autumn of this year we will have asked them to undertake a self-assessment to provide us with an assurance that they have made improvements in their hygiene.

What if they don't make progress? Can hospitals be penalised by the HSE if they don't reach specific hygiene standards?

The way we have the intervention designed allows us to track their implementation of quality improvement plans to make sure they stay on track. Hospital managers are subject to review of their performance across a number of areas, for example control of issues such as hygiene.

Is there provision to take some form of action against a hospital or its manager if the performance is not up to scratch on hygiene?

I think the principle underpinning this is very much one of trying to drive compliance. There are two basic models in systems of regulating healthcare internationally - those based on compliance and those based on deterrence. What you are alluding to is how do you punish or sanction those who aren't performing well. This underpins the deterrence model. It is much more appropriate to have in place in Ireland a system which encourages compliance. Deterrent systems are generally used more in systems that have private providers.

So this essentially means that nobody will get sacked for not doing their job properly.

Within the human resource framework that would be apply to anybody that is employed in the HSE, if their performance is unsatisfactory then it could lead to a disciplinary action. There are global assessments of hospital managers' performances which take into account a range of areas.

Is it fair to ask patients to ask healthcare staff to wash their hands. Should the hygiene onus not be on the staff?

Delivering healthcare is something that clinical staff do in partnership with patients and their families and encouraging patients to ask doctors to wash their hands is part of that principle of involving patients. Asking patients to ask doctors and other healthcare professionals to wash their hands is not only a practice that is based on best principles on how you should involve patients in contemporary delivery of healthcare but it has also been shown to be an effective intervention.

On patient safety in general, there have been many high profile adverse clinical incidents reported in the health services in recent years. How safe do you think our hospitals are? Also, why do we have so little publicly-available documentation on the level of serious clinical errors and incidents?

Unlike with HCAIs, where we have international studies with comparable data between Ireland other countries, we do not have similar studies in the area of adverse events. We do have international studies measuring the prevalence of adverse events in other countries which give us some indication of what the burden might be in Ireland.  We have no reason to believe the problem is any more or less prevalent than it is in other countries. We just don't at the moment have the comparable data.

The report of the Patient Safety Commission made significant recommendations around developing adverse event reporting systems which would provide us with the sort of monitoring platform that we have used around, for example, MRSA to deliver improvements in that area. In the same way we can use this type of monitoring platform to help deliver improvements in patient safety. In preparation for that, we need to try and build a culture where people will feel happy to report adverse events when they occur.

It is important for us to remember that international experience shows where an error is made it is not usually an issue that people are incompetent in that situation - it is generally to do with systems that reduce the likelihood of somebody making an error being weak. We need to be sure that  the discourse around patient safety happens in a way that we move on from a 'name, blame and shame' situation into a culture where people feel that if something goes wrong they won't be unfairly hounded and chased and blamed. 

That implies that such a system already exists. But in any of the recent adverse event investigations, nobody was 'named, blamed or shamed'. Is that not one of the problems in the system - a problem with accountability?

In most case of medical error, it is exceptional for such an issue to reflect on the competence of an individual. In terms of the underpinning requirements of a safe and high quality system you definitely need to have competent individuals providing care. The question is how do you drive that competence and continually ensure it. What you do not want to do is to wait for something to go wrong, then start scrutinising that person's practice then find out there is a competence problem and then remedy that. What you do is put in place systems of competence assurance and that is what our professional regulators are doing.



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