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"Do you really need to audit the cleanliness of your commodes every week? It’s not unknown for staff in health and care settings to do just that – even in the midst of a pandemic. It’s on the audit questionnaire, so we’ve got to do it.”
Linda Dempster, IPC Consultant
Over the past 18 months, government ministers, scientists and healthcare experts have grappled to find the most efficient and effective ways of managing the spread of Covid-19. As knowledge grew and the scientific evidence developed, guidance, more guidance, and yet more guidance was published – usually on a Friday afternoon, putting paid to any notion of weekend ‘breaks’.
Nowhere, perhaps, was this more keenly felt than in Infection Prevention & Control (IPC) teams in healthcare settings and local authorities. Suddenly, IPC had taken on a renewed importance for care providers and public health teams seeking to minimise the risk of infection across hospitals, surgeries, care homes, schools, businesses – anywhere there was a risk of rapid spread, and potential mutation.
And what has this got to do with commodes?
It’s pretty obvious that a dirty or damaged commode is an infection risk. But when your staff and wards are overwhelmed by rising numbers of seriously ill patients, and stretched to the limit managing extra workloads because their colleagues are also ill, is a weekly audit of commodes a sensible use of time?
A good audit is an essential tool in the fight to achieve the highest possible standards of patient care. It’s also valuable in meeting the assurance requirements of management, commissioners and regulators. But the trick to turning a good regular audit into a truly transformational tool is to STOP asking the questions you’ve always asked.
No, I don’t really want you to stop auditing. Of course I don’t – it’s my bread and butter. It is also the most fundamental source of vital information for your organisation and a driver for improvement. But what I do want you to do is to step back, and reconsider what it is you are auditing and why. What the pandemic has shown is that regimented auditing is not the most efficient way to drive improvements, when what you need is change - NOW.
From our knowledge of Tendable users, we know that an average regular IPC audit involves 120 questions (about 23% of which cover cleanliness, tidiness and locating items), and takes a minimum of 45 - 90 minutes per month. Multiply that by the number of clinical and other areas being subjected to regular audits, and you can see that IPC can consume a huge amount of clinical time. (In addition, with so much information you might end up not seeing the wood for the trees.)
Audits which have become an ever-growing list of rigid, regular checks are not sustainable, take up valuable time, and won’t help the organisation to improve if what’s audited is never reviewed. This is even more the case in times of severe pressure. With winter on its way, and the system already under so much pressure that a lot of winter capacity within acute hospitals has already been opened to help manage the return to ‘business as usual’, now is a valuable opportunity to undertake that review.
How audit behaviours changed during the pandemic?
In the face of a shortage of people, time and energy to carry out regular audits, what happened to auditing when the pandemic struck?
Many regular audits were put on hold during Covid peaks, but IPC audits were strengthened as the government issued its rapidly changing guidance (sometimes on what felt like a daily basis), and suddenly providers were having to submit not monthly organisation reports, but daily reports direct to NHS England. (Tendable saw a 75% drop in regular audits across our customer base in April 2020.)
The chart shows the typical auditing history across the Tendable customer base. Monthly rates of auditing were historically very consistent, but the pressure at the beginning of the pandemic and again in early 2021 show regular audits being dropped in favour of only targeted audits.
Recognising the pressures on audits, and the need to audit what really mattered, Tendable also implemented a short, sharp Covid audit which tackled the key IPC issues of PPE availability, its correct use, and enabling and following social distancing.
The pandemic helped many Tendable customers recognise that the need was to audit on the basis of ‘what makes a difference now’, and to audit where the real risks were. That holds good for audits at any time, not only in a pandemic.
Managing audit fatigue as winter pressures grow
Covid has not gone away, and other common infections including C.Diff, MSRA, influenza and norovirus, are on their way back. Reduced immunity from common respiratory illnesses is also impacting on demand, particularly Respiratory Syncytial Virus (RSV). So, while Covid may no longer be the central focus, IPC audits are as important as ever, and staffing capacity pressures are not going to be reduced any time soon.
Keeping staff motivated and engaged with audits is critical, remembering that audits are there to drive improvements and transform services. During the pandemic, audit-led improvements supported the major reduction in numbers of hospital-acquired infections. As Jay Turner-Gardner said of Wirral University Teaching Hospital NHS FT, “Last year we had no respiratory illnesses, and no norovirus. That was unheard of before the pandemic.”
So, as infections return alongside Covid, it is crucial that staff recognise the importance of the audit work and learn from Covid-19.
Winter’s coming – here’s how to health check your IPC audit:
Don’t duplicate checks: almost a quarter of all questions asked on a typical IPC audit are around cleanliness/tidiness or the location of inappropriate items. These questions are often covered in audits undertaken by other departments, including the national cleaning standards audits, and health and safety audits, not to mention general quality walkabouts. Leverage those instead.
Focus on questions that really matter. It can be reassuring to have a tick list of questions against every topic, but no one has time for that. Instead focus on specific areas of concern: things you need to keep an eye on or areas where you can make a significant impact on patient care.
Validate the audit questions with staff. There is an art to choosing which questions to ask and which questions to leave out of an audit. Following these steps should help:
Involve staff at all levels, especially front line – they will have significant combined experience. Tap into their experience-led intuition for just knowing when things are right
Continually test and refine audits – check out how long they take to do in practice, or whether the questions need to be asked so frequently (if you have no possibility to address any issues before the next audit date, review the frequency).
Keep your questions relevant and up to date. Review questions at least annually. New guidance is always being produced, which means that the things you should focus on may change. Challenge questions to check that they are still relevant when guidance changes. Also with new staff in roles, you will have the opportunity to engage with clinicians who can bring a fresh pair of eyes.
Avoid audit fatigue. It will increase if you continually ask the same questions every week or even every month – and what you don’t want is for staff to lose the motivation to audit well. A great audit should be valued by staff as it is an essential tool to help them focus on what is important, so if compliance drops, it might be time to check in with staff to understand why this is not prioritised.
Get your governance right. You might ask ‘what would the Regulator say if we change our audit questions and process?’. If you have fully risk-assessed your decision-making and have robust governance in place for agreeing those decisions, you can demonstrate the decision you made was the right one for patients and for staff.
Over the past five years, we have seen audits transition from being an assurance tool to a key element of an improvement methodology. Used well, it will connect, engage and empower your staff to own the quality in their area.