DRAFT Internal Document not for circulation
DRAFT Project Management Plan
TITLE:
Revision of HIQA’s PCHCAI
monitoring programme
DIRECTORATE(S): Regulation, Healthcare
AUTHOR: Aileen O’ Brien
TITLE: Inspector
DATE: February 2016
SPONSORED BY: Joan Heffernan
TITLE: Inspector Manager
DATE:
February 2016
Project Plan
Revision of the PCHCAI monitoring programme
Revision No: Page 2 of 14
TITLE: Revision of the PCHCAI monitoring programme
Project Plan
Document History
DOCUMENT LOCATION:
REVISION NO:
REVISION HISTORY:
Date:
Previous
Revision No:
Summary of Change:
APPROVALS:
Date Title Name Signed
18.11.16
Inspector
Manager
Joan Heffernan
Regulatory
Head
Deputy
Director
Sean Egan
Director Mary Dunnion
DISTRIBUTION LIST:
{Name} {Title / Directorate}
Project Plan
Revision of the PCHCAI monitoring programme
Revision No: Page 3 of 14
1. Project purpose
The Authority’s business plan for 2017 (objective 4.23) includes the revision and
implementation of an updated programme of monitoring of acute hospital’s adherence to
the National Standards for the Prevention and Control of Healthcare Associated Infection.
Implementation of the National Standards for the Prevention and Control of Healthcare
Associated Infection has been monitored by HIQA since these standards were published in
2009.
The purpose of this project is to adapt a proportionate risk-based approach to such
monitoring and to develop a Monitoring Approach Plan to support this revised monitoring
programme for the prevention and control of Healthcare Associated Infections.
The revised monitoring programme will comprise of three phases:
Phase 1:
Completition of a self assessment tool on Infection Prevention and Control
programmes across all 49 public acute hospitals in Ireland.
The self assessment tool (SAT) will be based on the 2015 Centers for Disease Control and
Prevention ‘Infection Control Assessment Tool for Acute Hospitals’ and has been adapted
for the Irish context.The self-assessment tool will be aligned to the 2009 National
standards for the Prevention and Control of Healthcare Associated Infections and will also
be cognisent of the revised draft National Standards for the Prevention and Control of
Healthcare Associated infections, currently with the Minister for Health awaiting approval.
This SAT will enable providers to self assess their performance with regards to prevention
and control of healthcare associated infections and to take a proactive approach to
improvement and implementation of measures to prevent and control Healthcare
Associated Infections.
Phase 2:
Unannounced monitoring inspections in acute hospitals focusing on one or more of
the following patient care pathways:
- Clostridium difficile infection
- Invasive Medical Device use
- Safe injection practice
- Resisitant bacteria
- Aspergillosis
Project Plan
Revision of the PCHCAI monitoring programme
Revision No: Page 4 of 14
Phase 3:
Unannounced monitoring inspections in acute hospitals focusing on the
decontamination and management of reusable invasive medical devices.
2. Project aim
The aim of this project is: to revise HIQA’s monitoring programme against the National
Standards for the Prevention and Control of Healthcare Associated Infections The revised
programme will be aligned with the current 2009 PCHCAI standards and willb e cognisent
of the revised draft PCHCAI standards.
3. Project objectives
The objectives of this project are to develop a specific monitoring approach plan (MAP)
1
that delivers the following:
PCHCAI self assessment with input from some external stakeholders March 2017
External stakeholder engagement about the revised monitoring programme
March/April 2017
Completition and return of SAT by all 49 acute hospitals by early May 2017
PCHCAI unannounced inspections ocusing on patient pathways commenced mid May
2017
External expert advisory group consultation in relation to monitoring of reusable
invasive medical device decontamination May and September 2017
RIMD unannounced inspections Q1 2018
4. Scope
(a) In scope
Below is an outline of what is noted to be in of scope of this project;
• Phase 1 – completition of a self assessment tool by all 49 acute hospitals.
• Phase 2 - Unannounced inspections of acute hospitals with lines of enquiry
reflecting patient care pathways for the following:
- Clostridium difficile infection
- Invasive Medical Device use
- Safe injection practice
- Resisitant bacteria
- Aspergillosis
1 MAPs are developed in line with the Standard Operating Procedure – developing a MAP
Project Plan
Revision of the PCHCAI monitoring programme
Revision No: Page 5 of 14
Phase 3 - Unannounced monitoring inspections in acute hospitals focusing
on the decontamination and management of reusable invasive medical
devices.
• Training of staff to allow for revised inspections to commence.
(b) Out of scope
Below is an outline of what is noted to be out of scope of this project;
• Literature review – as this is a revision of an ongoing programme
• Monitoring programme focusing on healthcare outside of acute
hospital care.
Deliverables
The key deliverables of this project are:
• A Monitoring Approach Plan (phase 1 to phase 3) in line with the
Authority’s Monitoring Approach Policy to include the following
components for each pahse:
° Prevention and control of Healthcare Associated Infection self
assessment tool for completion by 49 acute hospitals
° Lines of enquiry for phase 1 and phase 3
° Assessment Framework
° Judgement Framework
° Unannounced monitoring event – information gathering tools
° Guide for providers
° Schedule of activity
° Manpower planning
• Advice and critique from external advisors in relation to the content of
the PCHCAI self assement tool.
• Advise from an expternal advisory group to support the development of
phase 3 – RIMD inspections.
Project Plan
Revision of the PCHCAI monitoring programme
Revision No: Page 6 of 14
5. Work breakdown structure
The workbreakdown structure follows the phases outlined in the methodology section
above.
Phase 1 - Actions completed to date – to be updated at team meetings
SELF ASESSMENT COMPONENT
WBS
No
Tasks
Timeframe
Responsible
Complete
1
Draft PCHCAI self-assessment tool
Feb 2017
AOB
2
Present proposal for review monitoring approach
plan to the Director of Regulation
10/02/17
AOB/Team
3
Seek expert input from the HCAI/AMR Clinical
Advisory Group chaired by Dr Niamh O’ Sullivan
in relation to PCHCAI content
17/03/17
JH/AOB
4
Review feedback from HCAI/AMR Clinical
Advisory Group
06/03/17
SE
8
Draft instructions for hospitals around
completing the SATs
06/03/17
AOB/SG
9
Draft email/letter to accompany SAT
14/03/17
SE
5
Amend SAT as agreed by Team
20/03/17
AOB/SG
6
Convert SAT from Word to iPDF
20/03/17
SG/AOB
7
Test the iPDF
20/03 to
23/03
SG/AOB
10
Send out SAT to 49 hospitals
05/04/17
AOB/JH/AR
11
Review and risk rate each completed SAT
03/05 to
12/05
AOB/NFK/
JH
13
Escalate any risks identified in line with AMA
ASAP
following
receipt
SE
14
Present findings of SAT to HOP
15/05/17
SE
Project Plan
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PHASE 2 - Actions completed to this point – to be updated at team meetings
INTERNAL DOCUMENT REVIEW
WBS
No
Tasks
Timeframe
(Completion
Date)
Responsible
Complete
1
Lines of Enquiry for Phase 1 paient care
pathway unannounced inspections
20/03/17
AOB/NFK
2
Sign off of Lines of Enquiry by HOP
23/03/17
SE
3
Assessment Framework
12/04/17
AOB
4
Judgement Framework
12/04/17
AOB
5
Care pathway assessment tool CDI
20/03/17
AOB
6
Care pathway assessment tool Aspergillosis
20/03/17
AOB
7
Care pathway assessment tool Indwelling
Invasive Device
20/03/17
AOB
8
Care pathway assessment tool Resistant
Bacteria
20/03/17
AOB
9
Care pathway assessment tool Aspergillosis
20/03/17
AOB
10
Sign off Assessment Frameworks and inspection
tools by HOP
13/04/17
SE
XXXX
Sign off Judgement Framework
11
PCHCAI reference list for reports/documents –
formatted in line with HIQA house style
08/05/17
AOB
12
Monitoring guide for phase 2 inspections
18/04/17
AOB/NFK
13
Unannounced inspection report template
08/05/17
AOB
14
Unannounced inspection report FA letter
08/05/17
AOB
15
Unannounced inspection report FA Template
08/05/17
AOB
16
Unannounced inspection report publication
notice
08/05/17
AOB
17
Pre onsite inspection template
08/05/17
AOB/SG
18
Sign off Monitoring guide by HOP
03/05/17
SE
19
Training day for inspection team
10/05/17
AOB/JH
20
Publish Monitoring Guide
15/05/17
AOB/JH
21
Commende inspections for phase 2
22/05/17
AOB/JH
Project Plan
Revision of the PCHCAI monitoring programme
Revision No: Page 8 of 14
PHASE 3 - Actions completed to this point – to be updated at team meetings
INTERNAL DOCUMENT REVIEW
WBS
No
Tasks
Timeframe
Responsible
Complete
1
Lines of Enquiry for Phase 1 paient care pathway
unannounced inspections
03/04/17
NFK
2
Sign off of Lines of Enquirey by HOP
10/04/17
SE
3
Assessment Framework
17/04/17
NFK
4
Judgement Framework
17/04/17
NFK
5
RIMDS Decontamination Assessment Tool
17/04/17
NFK
6
Sign off Assessment and Judgement Frameworks
by HOP
19/04/17
SE
7
PCHCAI reference list for reports/documents –
formatted in line with HIQA house style
25/04/17
NFK
8
Unannounced inspection report template
25/04/17
NFK
9
Unannounced inspection report FA letter
25/04/17
NFK
10
Unannounced inspection report FA Template
25/04/17
NFK
11
Unannounced inspection report publication notice
25/04/17
NFK
12
Pre onsite inspection template
25/04/17
NFK
13
EAG meeting
17/05/17
NFK/JH/SE
14
Amend LOE’s, inspection tool and staff training
programme following EAG feedback.
20/10/17
NFK/JH
15
Sign off Monitoring guide for phase 2 inspections
by HOP
27/10/17
SE
16
Amend inspection tools and training programme
for staff
10/11/17
NFK/SB
17
Inspection training for team
06/12/17
NFK/AOB
18
Publish monitoring guide
12/12/17
NFK/JH
Project Plan
Revision of the PCHCAI monitoring programme
Revision No: Page 9 of 14
PHASE 3 - Actions completed to this point – to be updated at team meetings
Esternal Advisory Group Meetings - RIMD
WBS
No
Tasks
Timeframe
Responsible
Complete
1
Draft EAG membership with reasons for
inclusion/exclusion and sign off by HOP
15/03/17
NFK/AOB
2
Sign off the following for EAG by HOP
• Terms of Reference
• membership for EAG
•
letter of invite to nominate rep to EAG
23/03/17
NFK
3
Prepare EAG documents as follows:
- Letter requesting nominee
- Conflict of Interest form for attendee
- Copy of agreed TORs
- Letter of invite to attend EAG
25/03/17
NFK
4
Book meeting room for EAG and confirm dates for
two meetings (May and Sept)
25/03/17
NFK
5
Send letter to request nominee for EAG
10/04/17
NFK
6
Send letter of invitation to attend EAG with
conflict of interest and confidentiality form,
nominee confirmation letter and directions to
Smithfiled.
03/05/17
NFK
Expert Advisory Group Meeting
7
Agree agenda and format of first EAG meeting
25/04/17
NFK
8
Develop slides and content of first meeting:
• Introductions
• Approval of TOR
• Next steps timelines and agree final
meeting date
• Explanation of HIQA role, PCHCAI
programme to date and plan for RIMD
phase of monitoring.
• Anonymised results of SAT for RIMD
questions.
25/04/17
NFK
9
First EAG meeting:
- signed attendance form
- Conflict of interest forms submitted
- TOR approval
- Date of 2
nd
and final meeting agreed for Sept
17/05/17
NFK/JH
Project Plan
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Revision No: Page 10 of 14
10
Circulate minutes post meeting post sign off by
HOP
26/05/17
NFK/JH/SE
11
Prep work for final EAG meeting - slides,
information for EAG.
29/08/17
NFK/JH
12
Final EAG meeting.
13/09/17
NFK/JH
13
Ciruclate mintues and thank you letter – signed
off by HOP.
27/09/17
NFK
Actions completed to this point – Month YEAR
PREPARATION FOR INSPECTION
WBS
No
Tasks
Timeframe
Responsible
1
Complete
2
Review of SATs
3
Inspection schedule
4
Prepare onsite documentation
5
Review preonsite process
6
Review business intelligence requirements
7
Data capture post inspection/methodology
Actions completed to this point – Month YEAR
WBS
No
Tasks
Timeframe
Responsible
Complete
Prepare a ‘dummy’ report
Standardise formatting/messenging across the
first four inspection reports
Assumptions
To manage the project effectively and efficiently, the assumptions listed below, with
regards to resources and timelines have been considered in the development of this
Project Plan. The quality of the project and the delivery of the outcomes will not be limited
by these elements.
Project Plan
Revision of the PCHCAI monitoring programme
Revision No: Page 11 of 14
• The project remains as a priority within HIQA/Directorate
• That the resources required from within HIQA (personnel) as identified in this
Project Plan are made available
• That external experts are identified and amenable to consultation.
(f) Constraints
The below constraints have been considered in the development of the Project Plan. The
quality of the project and the delivery of the outcomes will not be limited by these
elements.
• The short duration of this project imposes an obvious time constraint to deliver the
outcomes within this time.
• Stakeholders (internal and external) actively support and participate in this project.
(g) Dependencies
The below interfaces/dependencies have been considered in the development of this
Project Plan.
• External Advisory group have availability as per project phase requirement
• Other current ongoing Healthcare Regulation Programmes of Work
• This project will require support from internal Directorates including:
6. Project schedule
(a) Key milestones (to complete on agreement of phase options)
Milestone
Deadline
Distribute SAT to all 49 hospitals
05 April 2017
Stakeholder engagment
27 March - 06 April 2017
Publication of monitoring guide
15 May 2017
Inspection team training
10 May 2017
Commence unannounced
inspections – phase 1
22 May 2017
Publication of reports
1
st
EAG meeting - RIMD
17 May 2017
Final EAG meeting - RIMD
13 September 2017
Publication of monitoring guide -
RIMD
13 September 2017
Inspection team training
06 December 2017
Commence unannounced
Project Plan
Revision of the PCHCAI monitoring programme
Revision No: Page 12 of 14
inspections – phase 1
09 January 2017
Publication of report
7. Budget
This project will be completed within existing PCHCAI resources and require no additional
resources.
Include all estimated costs excluding VAT. If detailed estimates are not available please
generate a rough order of magnitude estimate based on similar projects conducted in-
house or by similar organisations. Internal staffing costs are not required here (however
should be noted in section 7) unless they require incremental backfill by an external
resource. Ensure that all costs are reviewed to provide best value for money and most
cost effectiveness.
Staff
VAT
Total
Training
Travel and Subsistence
Hardware and Software (Technology)
Laptop/Server
SPSS
Meetings/Workshops
Hire of external room
Publications
Nil
Total
8.
9. Risk management plan
The identified risks for this project include:
i.
Tight timelines of the project.
A RAID Log will be completed.xls
10. Quality management plan
Below is an outline of quality assurance steps in place for the development of the self
assessment tool and guidance
• Shared workspace structure/Storage of evidence.
A shared workspace on sharepoint already exists to act as a depository for the
Project Plan
Revision of the PCHCAI monitoring programme
Revision No: Page 13 of 14
storage of all literature gathered during this project. The workspace will support
clear accessibility and efficient use of this literature. Access to the shared
workspace is limited to PCHCAI team members only.
• QA points are detailed as per Work Breakdown Structure
• Declaration of Interest/Confidentiality
Expert advisors are required to return a Declaration of Interest/Confidentiality prior
to their involvement.
11. Communications management plan
Correspondence/Communications:
All email communication will function through the use of the existing designated email
address qualityandsafet[email protected].
All written correspondence in relation to PCHCAI self assessment tool is to be recorded on
sharepoint in the correspondence library.
Internal communications:
Event
Description
Purpose
Method
Frequency
Meetings
Project Team
Meetings
This meeting will
involve all team
members to
discuss the work in
progress/ recently
completed work
and work that will
be performed in
the future
To keep the team
informed of the
project status
and ensure that
issues, risks or
changes are
raised
accordingly
Verbal
Weekly
Milestone
Review
Meetings
Formal Meetings
held at the end of
each phase to
identify the overall
status of the
project, the quality
of the deliverables
outstanding risk,
issues or changes
To control the
process of the
project through
each phase in the
project lifecycle,
thereby
enhancing its
likelihood of
success
Verbal
At the end
of each
milestone
Reports
Project Plan
Revision of the PCHCAI monitoring programme
Revision No: Page 14 of 14
Status
Reports
Frequently report
providing the
status of the
schedule, risks and
changes
To keep team
members
informed of the
status of the
project
Status Report
Monthly
Project
Close-out
Report
To formally finish
the project and
discuss lessons
learnt
Meeting and
Report
When
project
finished
Media:
All media communication will be handled through the Communications Representative for
this project. Any queries received from the media must be passed directly to the Head of
Communications or the nominated representative.
12. Project controls
Once the Project Plan has been approved any changes to scope, timeline, process and
methodology need to be formally approved by the Project Sponsor. Any proposed changes
will be assessed for the impact of the required change to all aspects of the project and its
context. Changes if approved will be incorporated into Project Plan.
All change proposals / approvals need to be minuted and recorded as part of project
documentation.
See Project Document History for summary details of changes made to project plan during
project lifecycle.
13. Project organisation structure/roles and responsibilities
Role and
Responsibilities
Duration and Effort
Suggested Resource
Name(s) if any
Project Sponsor
Project Duration
Joan Heffernan
Project Team
Project Duration
Aileen O’ Brien
Noreen Flannelly-
Kinsella
Antoinette Russell
Shane Grogan
Siobhan Bourke
