Summary: Interim Report Recommendations
This Interim Report sets out the initial findings and recommendations developed to date through the NHS Greater Glasgow and Clyde (GGC) Oversight Board's programme of work in response to the infection issues affecting the Queen Elizabeth University Hospital (QEUH) and the Royal Hospital for Children between 2015 and 2019. It summarises the work on investigation, dialogue and improvement from the Oversight Board's establishment in December 2019 to October 2020, and looks ahead to its remaining work and the Final Report, expected in early 2021. It captures progress and early conclusions.
The Oversight Board was put in place by the Director-General of Health and Social Care in the Scottish Government and Chief Executive of NHS Scotland in November 2019. This was done to address critical issues relating to the operation of infection prevention and control, governance, and communication and engagement with respect to the Queen Elizabeth University Hospital and the handling of infection incidents affecting children, young people and their families within the paediatric haemato-oncology service. The Oversight Board was a direct consequence of the escalation of the Health Board to Stage 4 of NHS Scotland's national performance framework.
The Oversight Board consists of a group of experts and key representatives drawn from other Health Boards, the Scottish Government and the affected families themselves. Chaired by Scotland's Chief Nursing Officer, Professor Fiona McQueen, the work of the Board was carried out principally through three Subgroups: Infection Prevention and Control and Governance; Technical Issues; and Communication and Engagement. Overall, the Oversight Board has been focused on assurance of current systems and reviewing the historical issues that gave rise to escalation.
In addition, an independent Case Note Review has been established to examine the individual incidents of infection among the children and young people. This report is being overseen by an Expert Panel that will be reporting in early 2021. Its findings and recommendations will inform the Oversight Board's Final Report.
This is an Interim Report; it does not provide the final summation of the Oversight Board's work, as some key activity – such as the Case Note Review – is continuing. Consequently, this report sets out the Oversight Board's views on several (but not all) of the issues that led to escalation, and the work that remains to be done to provide assurance to Ministers and to the affected families, children and young people. It has also drawn out the wider lessons for national improvement.
Overall, the Oversight Board endorses the changes that have been introduced by NHS GGC in these areas, and welcomes its commitment to improvement. The Interim Report recommendations aim to support that continuing work, and their implementation should be integrated as far as possible into this programme of work. The recommendations are summarised below under the relevant key sets of escalation issues.
Infection Prevention and Control: Processes, Systems and Approach to Improvement
The Interim Report covers the following selected areas of Infection Prevention and Control (IPC):
- the degree to which specific IPC processes in the QEUH have been aligned with national standards and good practice; and
- the extent to which the IPC Team has demonstrated a sustained commitment to improvement in infection management across the Health Board.
It notes the improvement work already undertaken by the Health Board and sets out areas where further action is required to restore assurance.
The Final Report will set out findings and recommendations for the remaining IPC issues, particularly: IPC governance; the responsiveness of the Health Board's IPC to the infection incidents; how staff have worked together in support of IPC; and the way in which leadership has been organised for IPC.
- With the support of ARHAI Scotland and Healthcare Improvement Scotland, NHS GGC should undertake a wide-ranging programme to benchmark key IPC processes. Particular attention should be given to the approach to IPC audits, surveillance and the use of Healthcare Infection Incident Assessment Tools (HIIATs).
- With the support of ARHAI Scotland, NHS GGC should review its local translation of national guidance (especially the National Infection Prevention and Control Manual) and its set of Standard Operating Procedures to avoid any confusion about the clarity and primacy of national standards.
- With the support of Health Facilities Scotland, NHS GGC should undertake a review of current Healthcare Associated Infection Systems for Controlling Risk in the Build Environment (HAI-SCRIBE) practice to ensure conformity with relevant national guidance.
- A NHS GGC-wide improvement collaborative for IPC should be taken forward that prioritises addressing environmental infection risks and ensuring that IPC is less siloed across the Health Board.
- ARHAI Scotland should review the National Infection Prevention and Control Manual in light of the QEUH infection incidents.
- Health Facilities Scotland should lead a programme of work to provide greater consistency and good practice across all Health Boards with respect to the use of HAI-SCRIBE.
- ARHAI Scotland should review the existing national surveillance programme with a view to ensuring there is a sustained programme of quality improvement training for IPC Teams in each Health Board, not least with respect to surveillance and environmental infection issues.
- ARHAI Scotland should lead on work to develop clearer guidance and practice on how HIIAT assessments should be undertaken for the whole of NHS Scotland.
Communication and Engagement
Recommendations are set out below with respect to the overarching question considered by the Oversight Board: is communication and engagement by NHS GGC adequate to address the needs of the children, young people and families with a continuing relationship with the Health Board in the context of the infection incidents? The Oversight Board acknowledged the improvements that have been made to date, but notes that more needs to be done to address the issues that gave rise to escalation.
Further work is being undertaken on other key aspects of engagement with patients and families, particularly processes of review by the Health Board and how they were applied in the instances of these infections. Consequently, issues relating to the organisational duty of candour and review processes such as Significant Adverse Event Reviews will be addressed in the Final Report.
- NHS GGC should pursue more active and open transparency by reviewing how it has engaged with the children, young people and families affected by the incidents, in line with the person-centred principles of its communication strategies. That review should include close involvement of the patients and families themselves.
- NHS GGC should ensure that the recommendations and learning set out in this report should inform an updating of the Healthcare Associated Infection Communications Strategy and an accompanying work programme for the Health Board.
- NHS GGC should make sure that there is a systematic, collaborative and consultative approach in place for taking forward communication and engagement with patients and families. Co-production should be pursued in learning from the experience of these infection incidents.
- NHS GGC should embed the value of early, visible and decisive senior leadership in its communication and engagement efforts and, in so doing, more clearly demonstrate a leadership narrative that reflects this strategic intent.
- NHS GGC should review and take action to ensure that staff can be open about what is happening and discuss patient safety events promptly, fully and compassionately.
- The experience of NHS GGC should inform how all of NHS Scotland can improve communication with patients and families 'outside' hospitals in relation to infection incidents.
- The experience of NHS GGC in systematically eliciting and acting on people's personal preferences, needs and wishes as part of the management of communication in these infection incidents should be shared more widely across NHS Scotland.
- NHS GGC should learn from other Health Boards' good practice in addressing the demand for speedier communication in a quickly-developing and social media context. The issue should be considered further across NHS Scotland as a point of national learning.
- The Scottish Government, with Healthcare Improvement Scotland and ARHAI Scotland, should review the external support for communication to Health Boards facing similar intensive media events.