Meeting staff and patient need

Good infection control practice is an essential aspect of patient care for any healthcare provider yet it is only recently that the public’s attention is being drawn to community healthcare organisations. The Department of Health has for some years now published data on, and set targets for, healthcare associated infections by acute provider and primary care organisation: the latter encompassing the whole health economy rather than relating to specific NHS community provider organisations. However, earlier this year that focus turned to community healthcare for the first time, with the numbers of MRSA bacteraemia and Clostridium difficile infections being published by hospital site on a weekly basis.

Making the right choices
With this data readily available to the public via the Health Protection Agency’s website, current and future patients can see how their local providers are performing and make choices about their healthcare based on that information. Suddenly, infection control has become as crucial to a community healthcare organisation’s image as it is for acute providers.

That’s not to say community healthcare organisations haven’t taken infection control as seriously as their secondary care equivalents: infection prevention and control is a key component of both the quality and patient safety agendas that all providers adhere to. But with the move towards an “any willing provider” model of NHS healthcare driving competition and government proposals to expand patient choice, it is essential for community healthcare providers (and indeed, acute providers too) to not only maintain good records but also improve where possible, to both attract commissioners and patients.

Like many other NHS organisations, community health providers face numerous challenges including shrinking finances, aging estate, and constant change following the recent White Paper (DH 2010a) and the forthcoming integration of community services with other providers (DH2010b) – not to mention the need to meet targets and other regulatory requirements. However, providing services in the community brings with it challenges that differ to those encountered by acute Trusts.

Dispelling old attitudes
Historically infection control had been seen as the role of the infection control nurse and although those days are long gone the focus on infection control targets and legislation (DH 2006, 2009) within secondary care means many community-based staff can’t always see how it applies to community organisations: “Healthcare associated infection? ‘Superbugs’? Well they’re a hospital problem aren’t they?”

This misconception requires essential engagement with community-based staff in infection control by making it meaningful to them – identifying how it impacts them, raising their awareness, working with them and giving them practical realistic advice, involving them in the decisions that are made and that they will be required to carry out.

Understanding service needs
Offering a variety of different services, delivering care in a variety of settings is one of the first challenges for community health. Whilst the diversity of services provide richness to the organisation there is a need to ensure mandatory training is interesting and accessible. A one size fits all approach is not workable: nurturing relationships is essential and this begins at training.

Take Berkshire East Community Health Services as an example. The organisation employs over 1,000 staff, across 40 plus services and departments, based in three unitary authorities. To meet the varied needs of staff, we offer three individual versions of mandatory training: employees are encouraged to attend the one that most fits their developmental needs, which often depends on the service they work in. For example, a smoking cessation adviser does not require the same level of training as a community matron.

Community health services need to consider service location and working hours. Making use of technology is an effective way to make infection control training available to all staff groups, no matter where they are based or what hours they work. Including infection control as an e-learning module has proved particularly useful when training more hard-to-reach staff members such as out-of-hours district nurses or health visitors, who are based in children’s centres. Despite the success of e-learning, sometimes face-to-face communication is needed – after all, not everything can be taught virtually.

When this is the case, geography and hours of services can make attendance difficult. Infection control teams need to recognise this and be flexible. Taking a session out to departments or services on request and not necessarily within the standard nine to five office hours, will be far more productive than stipulating an employee must attend one of the scheduled training sessions, only for them not to attend because of workload pressures.

This understanding is not just limited to training. Infection control teams need to reflect diversity in audit plans. Services have different needs and risks, and the same audits are not suitable for all services; they need to be tailored. For example, antibiotic audits are appropriate in inpatient areas but not in school nursing and health visiting: whereas vaccine handling and transportation is relevant to school nursing and health visiting but not to services that do not administer vaccines. Thus recognising service diversity provides meaning for staff and fosters an inclusive approach.

In patients' homes
Providing care in the community means care being given in schools, community centres and patients’ own homes – in other words, in places where staff have little or no control over the environment.

Forget wipe-able surfaces, laminate floors and the high standard of cleaning hospitals adhere to. The average patient’s home or community centre is not infection control friendly! It’s therefore crucial that community-based staff understand how they can make these environments work for them. All infection control departments within community health services should take an active role in understanding the types of settings their staff are working in, and offer support to community-based teams by accompanying staff on visits to other care settings – including the patient’s home – to give realistic infection control advice.

Working together
As a relatively small organisation, there are many areas of the organisation that are contracted out, including site services. This produces a unique challenge for the organisation – and an opportunity. It’s essential that our cleaning staff understand good principles of infection control and we consider them as part of the wider healthcare team, engaging with them as we do our own staff.

Concerted efforts need to be made to train these members of staff in infection prevention and control: for example undertaking train the trainer sessions on cleaning and decontamination of equipment, as well as ensuring contractor staff are updated with developments in infection control at the same time as your own staff.

Infection control should be considered part of the wider patient environment and an infection control team must work closely with other departments, for example accompanying modern matrons on their rounds to assess environmental issues, patient safety, privacy and dignity (including single sex) and the patient experience as a whole – all of which infection control forms a part of.

Together, modern matrons and infection control specialists need to work closely with services to develop action plans, resolve any identified areas for concern and address issues in such a way that the problem is resolved permanently rather than “just fixed for now”. In a small organisation, resource is a challenge meaning strong relationships and staff understanding must exist so that services feel able to write their own local processes and procedures that they can in turn then monitor themselves.

Communication and engagement
A common thread you may already have noticed in the discussion here is communication. Engaging with staff is what ties this all together and will help a community health service to meet the unique challenges it faces.

Working groups are an excellent way to get different staff groups together, collaborate and take messages back to teams. These groups need to reflect the organisation’s set up. For instance, an infection control working group should consist of representatives from a range of clinical services with different needs, but all with a common purpose and agreed vision: that infection control will become an integrated part of care across the organisation. As well as addressing the basics in this working group (reviewing surveillance data, audit and root cause analysis reports, monitoring action plans policies and patient information, assessing how national initiatives can be implemented), it also needs to act as a forum where staff can confidently share their learning with one another and set a standard for best practice.

A means of achieving this in Berkshire East Community Health Services has been to encourage staff to develop their own infection control work programme that addresses the risks that they have identified (both potential and actual) within their service and demonstrates how they plan to implement initiatives discussed by the group. Not only is this an effective way to get staff to really think about infection control and how it can be uniquely tailored to their service but it also provides an opportunity for shared learning and to inspire others who may be struggling.

Working across departments
Of course it is also essential that infection control works closely with operational and facilities staff in order to address environmental and facilities issues. A facilities services review group can provide an excellent forum for achieving this. Within our own organisation it has been possible to involve staff in the standardisation of cleaning products, soaps, hand gels and similar products, and implement the requirements of the new Healthcare Cleaning Manual (NPSA 2009), through this group.

Furthermore it enables infection control to collaborate with the contracted site services and estates teams so that each can understand the requirements and limits of the other team. Together, the teams have also found creative ways to resolve the challenge of aging and listed buildings. For example, one of our community hospital wards is currently undergoing redesign and refurbishment to meet the needs of those with cognitive disabilities. Certain elements the service would like to include in the design does not meet infection control standards, so there’s a balance that needs to be met: with their expert knowledge the estates team often have a solution, so a compromise can be made that ensures the design remains infection control friendly and still meets the unique requirements of the service. Elsewhere, the teams have worked together with radiator guard manufacturers to improve their design for ease of cleaning to better meet infection control standards.

Managing information
Above I mention the need to take key messages back to services. Champions – or infection control link practitioners – are a simple, yet effective way of achieving this cascade of information and helping to undertake audits and provide simple training to colleagues when something new needs to be rolled out across the organisation. Most importantly, they can help a community healthcare organisation with a small infection control team reach out to loan workers such as district nurses and health visitors.

All the above methods are effective but time-consuming and resource-hungry. Staff newsletters are a great way of communicating en masse but must be engaging, the aim is not to dictate to staff but to interact with them by offering feedback channels such as an agony column where they can ask that silly question they’re too embarrassed to ask face to face and have it answered anonymously; or a quiz or competition to help launch revised policies or a new product.

Making contact with every single member of staff, wherever they may be based, is perhaps the most significant test for an NHS community health provider to meet the challenges of infection control. Indentifying what infection prevention and control means for the different services, working collaboratively and developing innovative ways to resolve issues as they arise, putting processes and monitoring in place and developing the different approaches outlined in this article, will all help to maintain focus and sustainability. Every member of staff represents the organisation’s image: an engaged workforce will reflect positively with patients and commissioners.

References
Department of Health, 2006, ‘The Health Act 2006: Code of Practice for the NHS on the prevention and control of healthcare associated infections’
        
Department of Health, 2009a, ‘The Health and Social Care Act 2008: Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance’
        
Department of Health, 2010a, ‘Equity and Excellence: Liberating the NHS’

Department of Health, 2010b, ‘Transforming Community Services the assurance and approvals process for PCT-provider community services’
        
NPSA, 2009, ‘The Revised Healthcare Cleaning Manual’ www.npsa.nhs.uk/cleaning
        
For more information:
Web: www.berkshire-eastchs.nhs.uk