GUIDANCE
A risk-based approach supported by guidance
Head of Estates Risk and Environment at Belfast Health and Social Care Trust, George McCracken, Susanne Lee of public microbiology consultancy, Leegionella, Consultant Medical Microbiologist, Dr Michael Weinbren, former Public Health England microbiologist, Dr Jimmy Walker, Consultant Clinical Microbiologist at Frimley Health NHS Foundation Trust, Dr Manjula Meda, and Consultant Medical Microbiologist at NHS Greater Glasgow and Clyde, Dr Teresa Inkster, discuss the role of derogations, and how guidance should be perceived and used to ensure healthcare facilities’ safe design, construction, and commissioning.
Any form of derogation from guidance is perceived by some as incorrect. This article discusses the role of derogations, but perhaps more importantly how guidance should be perceived and utilised in ensuring the safe design, construction, and commissioning, of healthcare facilities. NHS England has recently published a process for managing derogations.1
This
is most welcome to help ensure that derogations are not used as ‘a back door’ for inappropriate decisions, and such a format should provide the necessary transparency. Annex A of the new publication lists derogations in the context of the business case process referred to in the HBNs and HTMs, which are seen as best practice guidance (Table 1).1 To some, any form of derogation is
regarded as inappropriate. This likely stems from the HTM and HBNs being promoted as ‘best practice’. The latter terminology is not only incorrect, but just as derogations for the wrong reason can result in patient harm and increase costs, failure to derogate will also result in avoidable patient harm, in addition to being a wasteful use of health service funds. Derogations which can be evidenced as providing a higher standard should not only be encouraged, but are fundamentally necessary to ensuring patient safety. All guidance has limitations, including:
n It is only as good as the information available at the time of publication. Unless these are ‘live’ documents which are regularly updated in the light of new information, innovations, or incidents (which could affect patient safety), the contents will be outdated. Some HBNs are a decade old – e.g. HBN 00-09. Infection control in the built environment.
n Guidance does not replace the requirement for training – it cannot turn individuals into experts. Thus, architects and design teams need access to expertise to aid them in their decisions.
n Quality of guidance is reflected by the choice of individuals invited to participate in its production, as well as
3.8.9
Does the scheme comply with Health Building Note (HBN) requirements?
HBNs give ‘best practice’ guidance on the design and planning of new healthcare buildings and on the adaptation/ extension of existing facilities. They provide information to support the briefing and design processes for individual projects in the NHS building programme. They should be complied with; however, where they are not, the deviation from guidance should be included in the derogations.
Table 1. Best practice guidance on design and planning and inclusion of deviations from Best Practice.
the dynamics of the group.
n Ambiguity – it is open to different interpretation by different groups and individuals.
n It cannot cover every hazard, hazardous event, or risk; therefore it cannot be relied upon alone to ensure patient safety.
Risk of ‘stifling innovation’ Perceived incorrectly (as ‘best practice’), guidance is also likely to stifle innovation. For example, several augmented care units have been forced to move to ‘water-free patient’, to prevent the spread of water/ wastewater-borne infections which were otherwise intractable. The implementation of water-free patient units, which have been shown to be effective in protecting patients, would be prevented by a culture which sees the HTM and HBN as best practice, and does not allow for change.2 Guidance, combined with compliance,
have formed the backbone of construction (including healthcare) and numerous other industries, despite a long history of failing
‘‘
A key message when issuing
guidance is that if it is to be successful, there needs to be accompanying training, and staff need to be competent
to deliver safe buildings. Compliance is seductive, and for many becomes their target, perhaps based on the philosophy that if followed, then no fault can be attributed to ensuing work. It is not only a lazy, but also a dangerous, approach, incorrectly perceived as removing the need for thought and recognition of risk to patients. The Hackitt report, Building a safer
future, has called for a cultural change within the industry. We believe this cultural change should begin with how guidance is perceived and utilised. A compliant building does not equate to a safe building. For example, in a recently opened new hospital (which is both HBN and HTM-compliant), clinical handwash stations are having to be removed, as the water and drains pose an unacceptable risk to patient care. The risk is not trivial. Grenfell rightly attracted media attention and drove change. In contrast, the number of patients contracting avoidable infections – including fatalities from water/ wastewater systems – significantly exceeds the number of lives lost at Grenfell, yet due to limitations in surveillance, these cases are not traced back to water/wastewater systems. Unless patient safety is placed right at the front and centre of everything we do, such needless folly will continue. Given the slow pace of change and learning around risks associated with water and wastewater systems, combined with further delays in translating into guidance, valid concerns should arise if a new healthcare facility has no derogations from current guidance. Many of the current transmission events leading to infections
October 2023 Health Estate Journal 33
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