Quality Improvement Plans based on the Unannounced Hygiene Audit Report

By the Health Information and Quality Authority (HIQA) at UL Hospitals, Nenagh Hospital on the 17th August 2017

Standard / Findings/ Non Compliance / Action Plans / Action Taken / Lead Responsibility / Target Timeframe / Progress To Date / Review
Environmental and Facilities Management / Insufficient Infection prevention and Control resources on site Monday to Friday
Lack of isolation facilities / There is an IP&C CNM II on site half day alternate weeks.
There is a Group plan for 2018 to increase IP&C resources which will increase onsite presence
New 16 bedded single rooms ward opening 2018 / Barbara Slevin
Cathrina Ryan
Medicine Directorate
Group Building & Maintenance management / First quarter 2018
2018
Environmental and Facilities Management
Infusion room / No clean utility dedicated to Infusion Room. Medicine preparation area not meeting standards / Review of top floor footprint in 2018 to progress dedicated clean utility /
  • Use of disposable IV trays introduced.
  • Disposable tourniquets use is standard.
  • Sharing of medicine vials is not a practice.
  • PPE used at all times in preparing and administering medication.
/ Cathrina Ryan
Mary Clifford
Group Building and maintenance Management.
Estates / 2018
Standard / Findings/ Non Compliance / Action Plans / Action Taken / Lead Responsibility / Target Timeframe / Progress To Date / Review
Environmental and Facilities Management
Infusion room / Worktop on which medication being prepared contained a sink.
Space between patient treatment chairs not meeting standard.
Lack of storage space for patient belongings.
Failure to separate clinical area and clerical work space. / Curtains to be put up around each patient area.
Source small lockers
An alternative office space will be looked at with the redesign of the top floor / Sink removed in December
Patient files removed from patient area with resulting small increase between treatment chairs
De cluttering took place, filing cabinets removed. / Philip Brennan
Mary Clifford
Mary Clifford
Mary Clifford / First quarter 2018
Firstquarter 2018
Third quarter 2018 / Closed
Closed
Standard
PPPGs / Printed copies of policies out of date in some areas /
  • Staff to use QPulse to access all policies.
  • All PPPG Folders to be reviewed and compared with QPulse to ensure all policies present. Paper copies will then be removed.
/ Staff awareness created. / Cathrina Ryan
Cathrina Ryan / First Quarter 2018 / Closed
Hand Hygiene / 80% of staff in date with Hand Hygiene training. / Hand Hygiene trainers have revalidated their training. Schedule of Hand Hygiene developed for 2018. Further hand hygiene training session in October. Current compliance 84%. / Cathrina Ryan / Done
Environmental and Facilities Management
Medical 2 / Some clinical handwash sinks not in line with recommended requirements
Nightingale room containing 10 beds / Risk assessment to be completed and escalated to the Group Building and Maintenance Management
Risk assessment to be completed and escalated to the Group Building and Maintenance Management / Cathrina Ryan
Bridget Kelly
Cathrina Ryan
Bridget Kelly / First quarter 2018
First quarter 2018
Environmental and Facilities Management / No Hygiene Supervisor dedicated to the site
Cleaning resources not yet at optimal level in the hospital /
  • Appointment of Supervisor in 2018.
  • Risk assessment completed and escalated as appropriate.
  • Being progressed through Operational Services Directorate and HR.
  • 4 further hygiene attendants commenced since Sept 2017
/ Operational Services Directorate
Cathrina Ryan
Operational Services Directorate
Cathrina Ryan / 2018
Recruitment should be completed early in 2018
OUTSTANDING ITEMS FOLLOWING HIQA INSPECTION SEPTEMBER 2015
Endoscopy
Standard / Findings/ Non Compliance / Action Plans / Action Taken / Lead Responsibility / Target Timeframe / Progress To Date / Review
Environment and Facilities Management / Inadequate patient Preparation / waiting area / Patients prepped for procedure in post procedure observation area / Patient preparation /waiting area to be included in review of top floor footprint for Endoscopy Unit for JAG accreditation / Philip Brennan / Third Quarter 2018 / Upgrade of MAU commenced on ground floor. Plan to move MAU by first quarter of 2018 which will release more floor space to Endoscopy. / First quarter of 2018
Environment and Facilities Management / No Endoscopy patient discharge lounge / Patients being discharged from bed space
Designation of Endoscopy Discharge Lounge with review of top floor footprint for JAG accreditation / Discharge care and advice being provided in observation bed space
Seating area available / Celia Dwan CNM2
Cathrina Ryan ODON
Philip Brennan Maintenance manager / Ongoing
First quarter of 2018 / Discharge care and advice being provided in observation bed space
Upgrade of MAU to commence on ground floor. Plan to move MAU by first quarter of 2017 which will release more floor space to Endoscopy / Ongoing
First quarter of 2018
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 audit / Completed
Ongoing monitoring and audit / Completed
Ongoing monitoring and audit