Queen Elizabeth University Hospital/NHS Greater Glasgow and Clyde Oversight Board: interim report

This interim report sets out the initial findings and recommendations developed to date through the NHS Greater Glasgow and Clyde Oversight Board’s programme of work in response to the infection issues affecting the Queen Elizabeth University Hospital and the Royal Hospital for Children.

Annex B: Peer Review Terms of Reference

Purpose and Governance

The Infection Prevention and Control Governance (IPCG) Subgroup of the NHS GGC Scottish Government Oversight Board has examined an array of documentation from NHS GGC which outlines the form and function of governance regarding IPC. The purpose of the Peer Review is to understand how these systems are operationalised at all levels of the organisation.

The Peer Review group will report to the IPCG Subgroup which itself reports directly into the Oversight Board, Chaired by the Chief Nursing Officer, Professor Fiona McQueen.


The Peer Review will take a values-based approach in line with the National Performance Framework (NPF) and the values of NHS Scotland (NHS Scotland).

The focus of the Peer Review is to gain an understanding of how IPC systems and processes are embedded and also establish how the governance framework which supports these systems and processes is operationalised.

It is important to state that ensuring that IPC systems and processes are embedded and governed is not the sole responsibility of the IPC Team. It requires support and collaboration at all levels of the organisation; across specialties, teams and directorates both at Board and also at national level. Therefore, the Peer Review plans to liaise with many other disciplines where patient safety associated with IPC is key. This liaison will include directors and managers, facilities and estates, senior charge nurses as well as local IPC teams.


The Peer Review objectives are to:

  • review how the IPC governance framework provided and described by NHS GGC at the IPCG Subgroup is operationalised across the system; and
  • determine how national policy has been implemented within NHS GGC; identifying areas where this has carried out in line with national requirements as well as areas where this could be improved.

Having reviewed the documentation provided by NHS GGC, the Peer Review has identified five areas of focus:

  • implementation of HAI-SCRIBE;
  • implementation of the National IPC Manual;
  • audit and surveillance;
  • outbreak and incident investigation (including escalation/de-escalation); and
  • water safety.

In Scope

In order to meet these objectives, and with the support of NHS GGC Programme Management Office, the Peer Review team will retrospectively review the relevant (and perhaps supplementary) documentation with the objective of developing a question set. The Peer Review will also review how IPC intelligence and lessons learned are communicated and shared across disciplines, including within the IPC Team.

The Peer Review Team will then meet informally with various stakeholders as described above to gain a deeper understanding of how these systems and processes operate and how key information and lessons learned are communicated locally. This will allow the Team to develop a set of recommendations based on their expert knowledge and skills in the IPC Team and Facilities and Estates.

Out of Scope

As stated in the Terms of Reference for the IPCG Subgroup, the Peer Review Team will not undertake a review of the roles and responsibilities of individual staff members within NHS GGC. However, the Peer Review will review how IPC key information and lessons learned are shared across disciplines, including within the IPC Team.


The Peer Review Team will report to the IPCG Subgroup, which is chaired by Diane Murray.


A report and recommendations will be developed by the Peer Review Team and submitted through the IPCG Subgroup to the Oversight Board.

Peer Review Team Members

Frances Lafferty, Senior IPC Nurse, NHS Ayrshire and Arran, Implementation of HAI-SCRIBE

Lesley Shepherd, Professional Nurse Advisor, HCAI/AMR, Scottish Government, Audit Surveillance National IPC Manual


Email: philip.raines@gov.scot

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