Device related Peripheral Vascular NEWS Chart and HIQA Audit results ADON Lead infections are Care bundles & become part of fed back to staff. QIP Cathrina Ryan prevented or Urinary Catheter Care patients routine in place until A/ODON Monthly review via reduced bundles required observations documentation Metrics on Medical streamlined Floor. New audit tool introduced to audit care bundles on Medical floor. Standard 3 Blood Glucose Device All staff reminded for Hospital policy re Cathrina Ryan January 2017 Reaudit March 2017 Ongoing Monitoring Environment and and container being need to make up and circulated. CNMS A/ODON and Audit Facilities brought to clean down individual requested to monitor Relevant CNMS patient’s Management bedside tray when taking a and tutor staff in their patients blood glucose work areas Outstanding Items From HIQA QIP 2014 Action Plans Action Taken Lead Responsibility Progress To Date Review Standard Findings/ Non Compliance Target Timeframe Standard 3 Environment and Sanitary Facilities not Sanitary Facilities Redesign of shift Cathrina Ryan December 2016 Meetings First quarter 2017 Facilities being checked in the check sheet to be patterns and rosters to A/ODON commenced with Management evening checklists redesigned to reflect have availability of Unions and MTAs – Irene O’Connor not being signed off in National Cleaning Hygiene attendants on Facilities for review of rosters evening standard of 3 cleans duty in afternoons / to facilitate extended and 2 check cleans a evenings to carry out day. Final draft of day. checks / cleans rosters circulated to commenced include evening Appropriate schedules cleaning designed and to be distributed WTE Deficit identified– awaiting appointment of same to achieve and maintain hygiene standard. 5 MTAs recruited and 7 further vacancies identified. Recruitment ongoing. Monitoring of patients Monthly sanitary Bridget Kelly CNM2 Monthly and Ongoing Ongoing sanitary facilities facility audits ongoing
Device related infections are prevented or reduced Peripheral Vascular Care bundles & Urinary Catheter Care bundles required NEWS Chart and become part of patients routine observations HIQA Audit results fed back to staff. QIP in place until documentation streamlined ADON Cathrina Ryan A/ODON Lead Monthly review via Metrics on Medical Floor. New audit tool introduced to audit care bundles on Medical floor. 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 January 2017 Reaudit March 2017 Ongoing Monitoring and Audit Outstanding Items From HIQA QIP 2014 Standard Findings/ Non Compliance Action Plans 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 December 2016 Monthly and ongoing Meetings commenced with Unions and MTAs for review of rosters to facilitate extended day. Final draft of rosters circulated to include evening cleaning WTE Deficit identified– awaiting appointment of same to achieve and maintain hygiene standard. 5 MTAs recruited and 7 further vacancies identified. Recruitment ongoing. Ongoing First quarter 2017 Ongoing
hiqa-qip-january-2017.docx