Annual Report 2009 -2010 - Belfast Health and Social Care Trust

In addition, 17 complaints were received, investigated and successfully resolved under theProblem Solving stage of the Children (NI) Order 1997 Representation and Complaintsprocedure.The Complaints Review Committee continues to meet on a quarterly basis to review complaintsreceived and to monitor lessons learned and any actions taken.The New Complaints Procedure was launched in April 09 and throughout the year staff within thecomplaints department and service groups have worked hard on its implementation. Awarenesstraining on the new procedure has been provided and remains ongoing across the Trust.Safer patient initiative – highlighting the work of the ward improvement teamReducing Healthcare-Acquired InfectionsIn 2009/10 Belfast Trust has been able to reduce Healthcare-Acquired Infections (HCAIs) in ourhospitals.The total number of Clostridium Difficile infections (C Diff.) in hospitalised patients over 65 yearsof age was 165. The target set by the Department of Health was 242. This is a significantreduction and is an indication of how important this is to us.MRSA bacteraemias are a similar story. Belfast Trust had 63 episodes this year (target 62) whichis a reduction of 46 cases compared with the 2007/08 recorded cases.These results were achieved by a rigorous action plan that incorporated stringent hand hygienemeasures, compliance with high impact interventions around venous cannulas and catheters, anantimicrobial policy, environmental strategies, and regular audits of every clinical area’s practice.This has allowed a Trust-wide view of individual wards performances and constant feedbackloops to drive improvement.Introducing medicines KardexWe have introduced a single Kardex for all hospitals in Belfast. This will bring safety benefits andimprove efficiency. The Kardex is also designed to help doctors and nurses in ensuring patientsget the optimal treatment for preventing blood clots.Key initiatives for the ward improvement team in conjunction with Patient, Client, andSupport Services were:• Development of Trust environmental cleanliness strategy• Adoption of a risk-based approach to developing appropriate cleaning methods andfrequencies for specific functional areas within health and social care facilities andequipment• Monitoring and auditing (both internal and external) is undertaken to ensure the standardsof environmental cleanliness needs are met• As a result of external audits by KPMG and RQIA, action plans have been developed toaddress issues raised by these audits• Training and development in place for multidisciplinary staff in relation to environmentalcleanliness.• Space Utilisation Programme – carried out by a multidisciplinary team to ensure spaceused to full capacity and allow for enhanced cleaning• Belfast Trust De-clutter, Mattress Check and Chlorine Clean Programme carried out on allsites on a three monthly basis.13