for JAG accreditation quarter of 2017 which will release more floor space to Endoscopy Standard 3 Completed Clutter on work Office space adjacent New office space Philip Brennan Completed Completed Environment and Ongoing monitoring surfaces in Procedure to Endoscopy provided to Facilities Ongoing monitoring Ongoing monitoring Facilities and audit room 1 Procedure Room 1 Endoscopy Unit. All and audit and audit Management designated to possible equipment / Celia Dwan CNM2 Endoscopy. paperwork decanted to new office space Standard Findings/ Non Compliance Action Plans Action Taken Lead Responsibility Target Timeframe Progress To Date Review Standard 3 Environment and Failure to remove Re-education of all Education to be Celia Dwan CNM2 First Quarter 2017 Staff have been First quarter 2017 Facilities sterile consumables staff in Department carried out by IP&C Barbara Slevin updated on relevant Management and clean sharps tray ADON Barbara ADON policys and after use Slevin. Education awareness created schedule being around availability of finalised same by Dept manager Standard 3 Isolation Room Door Review practices of Each patient assessed Relevant CNM2 Ongoing Ongoing, assess on a Ongoing, assess on a Environment and open keeping door open in on an individual basis. IPC Education patient by patient patient by patient Facilities isolation cases after Reason for leaving programme basis basis Management appropriate patient door open to be safety assessment i.e. documented and for slips trips and falls reported Standard 6 Clinical Hand Wash Assessment of hand Awaited Philip Brennan February 2016 Awaiting possible Suspended Hand Hygiene sinks in Medical 2 do wash sinks in medical Facilities ward revamp June 2017 not fully conform with 2. Forward business Health Building Note case to Estates re 00-10 Part C feasibility of replacing Standard Findings/ Non Compliance Action Plans Action Taken Lead Responsibility Target Timeframe Progress To Date Review First quarter 2017 Standard 8 Improvement in Care bundles to be Ongoing Audits Relevant CNM2 May 2016 Await Guidance Invasive Medical Documentation for incorporated to continued. Local and Barbara Slevin from Project Group
for JAG accreditation quarter of 2017 which will release more floor space to Endoscopy Standard 3 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 Standard Findings/ Non Compliance Action Plans Action Taken Lead Responsibility Target Timeframe Progress To Date Review Standard 3 Environment and Facilities Management Failure to remove sterile consumables and clean sharps tray after use Re-education of all staff in Department Education to be carried out by IP&C ADON Barbara Slevin. Education schedule being finalised Celia Dwan CNM2 Barbara Slevin ADON First Quarter 2017 Staff have been updated on relevant policys and awareness created around availability of same by Dept manager First quarter 2017 Standard 3 Environment and Facilities Management Isolation Room Door open Review practices of keeping door open in isolation cases after appropriate patient safety assessment i.e. for slips trips and falls Each patient assessed on an individual basis. Reason for leaving door open to be documented and reported Relevant CNM2 Ongoing IPC Education programme Ongoing, assess on a patient by patient basis Ongoing, assess on a patient by patient basis Standard 6 Hand Hygiene Clinical Hand Wash sinks in Medical 2 do not fully conform with Health Building Note 00-10 Part C Assessment of hand wash sinks in medical 2. Forward business case to Estates re feasibility of replacing Awaited Philip Brennan Facilities February 2016 Awaiting possible ward revamp Suspended June 2017 Standard Findings/ Non Compliance Action Plans Action Taken Lead Responsibility Target Timeframe Progress To Date Review Standard 8 Invasive Medical Improvement in Documentation for Care bundles to be incorporated to Ongoing Audits continued. Local and Relevant CNM2 Barbara Slevin May 2016 Await Guidance from Project Group First quarter 2017
hiqa-qip-january-2017.docx