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Changing practice

Developing ward accreditation to improve infection control practice

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A ward accreditation audit scheme cut rates of healthcare associated infection and standardised infection control at a large acute trust



Joanna Coward, MSc, BSc, RN, is nurse specialist patient safety; Diane Palmer, PGCE, BSc, RN, is director of quality and effectiveness; Bernadette Risebury, MBCS, CITP, MBA, is clinical guidelines and policy adviser; Karen Collingwood, RN, Dip Health Education, is clinical effectiveness adviser; all at Newcastle upon Tyne Hospitals Foundation Trust.


Coward J et al (2009) Developing an audit tool to standardise infection control practice. Nursing Times; 105: 45, early online publication.

This article describes the development of a ward accreditation scheme that was set up to tackle healthcare-associated infection in an acute trust. The scheme was used on all inpatient wards, and early reports indicated significant variation in practice. Standardisation of practice and regular audit has resulted in a 35.6% reduction in MRSA over a 12-month period.

Keywords: Audit tool, Standards, Healthcare-associated infection

  • This article has been double-blind peer reviewed

Practice points

  • Leadership is crucial at all levels within the organisation.
  • Setting clear objectives and measurement strategies are essential for performance monitoring.
  • Communication and education are critical elements to the successful implementation of change in an organisation.


Ensuring good-quality care and reducing healthcare-associated infections are high priorities for NHS trusts. Strong leadership, good management systems and solid organisational strategies are crucial in establishing high standards of infection control.

The Newcastle upon Tyne Hospitals Foundation Trust provides a wide range of specialist services to the North East of England and has a capacity of more than 1,600 beds across three major sites.

A ward accreditation scheme was introduced in April 2008 with the purpose of reducing the number of HCAIs within the trust, through the provision of clear, consistent, evidenced-based clinical and environmental standards for all wards and departments.

The scheme is based on:

  • Saving Lives: reducing infection, delivering clean and safe care documentation, and specific care bundles from the seven high-impact interventions (HII) (Department of Health, 2007);
  • epic2: national evidence-based guidelines for preventing HCAIs in NHS hospitals in England (Pratt et al, 2007);
  • Local trust policies.

It was evident from the trust’s root cause analysis data collated in April 2007–March 2008 that patients who developed MRSA bacteraemia had urinary catheters, peripheral cannulas or central lines in place. The care bundles from the seven HIIs covering these three issues were added as specific sections as part of the audit tool for ward accreditation.

The ward accreditation scheme

The ward accreditation audit tool is made up of 12 sections related to areas of practice and one containing staff questions (Box 1). The scheme consists of regular mandatory audits. Accreditation is open to all wards.

Each practice section includes 20–30 questions that are based on infection control, environmental standards and specific HIIs from the Saving Lives documentation (DH, 2007). The staff question section assess knowledge on specific aspects of clinical care. Information from this section is cross-referenced with other sections where appropriate.

The audit tool is completed on a monthly basis as a mandatory requirement of the trust. When a ward has attained a 100% score in each of the 12 practice sections, accreditation can be applied for.

The tool aimed to:

  • Identify levels of compliance with environmental standards that are known to affect HCAI levels. For example, the sluice is clean, the kitchen is tidy and fridge temperature is maintained at 0–5ºC;
  • Identify levels of compliance with standards of clinical practice recognised to reduce HCAI. For example, a peripheral cannula assessment label is inserted in the drug prescription chart for each one inserted, and staff are up to date with their aseptic technique;
  • Identify clinical areas that are not meeting specified standards;
  • Ensure action is targeted where standards are weak;
  • Ensure best practice is highlighted and shared throughout the organisation.

The tool allows individual wards to monitor their own standards and to benchmark themselves against other wards.

Using the tool

The trust has 99 inpatient wards, within 19 clinical directorates. There are three audit tools in use for the wards, depending on the patient population: adults; paediatrics; or a combination of the two.

Each ward sister/charge nurse completes the ward accreditation audit tool every month, which is downloaded from the hospital intranet.

Each of the 12 practice sections contains questions that are relevant to the three groups of patients relating to clinical, hotel services and estates issues as appropriate. These cover, for example:

  • Clinical: care of a central line;
  • Hotel services: supply of cleaning products such as soap, paper towels and hand gel;
  • Estates: maintenance of equipment.

Monthly trust board and individual directorate reports are produced and wards receive feedback each month about their performance. These reports are discussed and monitored at a range of forums in the trust: at communications meetings, the matrons’ forums, the sister/charge nurses’ forum, and clinical standards and practice review meetings. Reports are also published on a quarterly basis.

Scoring system

The clinical governance and risk department analyses the information. Scores are calculated using simple yes, no or not applicable responses, and clinical, hotel services and estates are given a score for each section. There is also an overall total score per section.

A simple traffic light colour-coded scoring system is used to illustrate the total scores. The aim is for 100% compliance. Compliance of 80–99% indicates that work is required and <80% compliance identifies that urgent action is needed. Where a ward is achieving 100% compliance in all sections and the sister/charge nurse is confident in its performance, they are encouraged to apply for accreditation.


The trust’s overall scores demonstrate a month-on-month improvement since the ward accreditation scheme was implemented. Results indicate that, over a 12-month period, the trust average by directorate has improved from 83% to 99.0%. There has also been an improvement in the individual sections with the overall section average score increasing from 78.3% to 99.0% (Table 1).

The tool has been amended following feedback from clinical staff to ensure it reflects standards and practice within the clinical environment.

There has been a significant reduction in the number of HCAIs within the last 12 months since the ward accreditation scheme was introduced.

Fig 1 illustrates the number of MRSA bacteraemias compared with the previous year. A total of 59 MRSA-related bacteraemias were reported during 2007–2008, compared with 38 reported in 2008–2009, indicating a 35.6% reduction.

Monitoring performance

If a ward achieves 100% compliance, the ward sister/charge nurse agrees with the directorate management team that an application for accreditation should be made to the director of nursing and patient services.

An unannounced inspection will be performed by the ward accreditation team made up of senior nurses to validate the award of accreditation. If accreditation is successful, the ward team attends an accreditation ceremony.

‘Light touch’ monitoring will start, where the ward is expected to complete a ward accreditation audit tool every three months as evidence of the achieved standard being maintained. The process is outlined in Fig 2.

Improving low scoring wards

If a ward scores red in one or more sections of the tool, an action plan is agreed and implemented as a matter of urgency to address deficits.

Fig 3 outlines the process. The director of nursing and patient services sends the matron a letter and pro forma to complete within a specified timeframe, as well as an action plan to be returned to the head of nursing who monitors progress.

Benefits to the trust

The ward accreditation scheme is now well embedded within the trust and has resulted in a collaborative ward-to-board approach resulting in standardisation of practice trust-wide. It has developed local ownership, promoted the sharing of ideas and information, and positively reinforced excellence in practice. In addition, it has highlighted areas where improvement was needed.

The implementation of this audit tool has promoted shared governance and encouraged communications within and between directorates.

Future development

It is evident that since its implementation 12 months ago the ward accreditation scheme has led to a month-on-month improvement in practice and an increase in the overall trust average compliance from 83% to 99%.

Following the successful implementation of the ward accreditation scheme, additional audit tools have been developed specifically to monitor standards in theatres and outpatient departments.

The trust has also been approached to develop a tool in partnership with the primary care sector to work with nursing homes to identify and maintain good standards of care.


The introduction of the ward accreditation scheme has been a challenging project for a trust of this size.

It is evident that it has raised standards throughout the trust and reduced HCAI rates.

The development of this quality tool has also enhanced communications and, through standardisation of practice, has established a collaborative ward-to-board approach resulting in a robust critical shared ownership.



  • Patient safety and reducing HCAIs are top priorities for all NHS trusts.
  • Trusts need robust standards in infection control practice.
  • It is important to audit and monitor performance.
  • Tackling HCAIs requires collaborative ward-to-board ownership of the problem.


Box 1. The sections of the ward accreditation tool

  • Staff questions
  • The environment
  • Decontamination and waste management
  • Infection control practice
  • Source isolation practice
  • Management of surgical patients
  • Aseptic technique
  • Urinary catheters
  • Taking bloods
  • Peripheral cannulas
  • Central lines
  • Renal dialysis catheters
  • Ventilators



We would like to thank Sheffield Teaching Hospitals Foundation Trust



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