HEALTH SERVICES AND DELIVERY RESEARCH

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1 HEALTH SERVICES AND DELIVERY RESEARCH VOLUME 2 ISSUE 6 MARCH 2014 ISSN Making sense of evidence in management decisions: the roe of research-based knowedge on innovation adoption and impementation in heath care Yiannis Kyratsis, Raheeah Ahmad, Kyriakos Hatzaras, Michiyo Iwami and Aison Homes DOI /hsdr02060

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3 Making sense of evidence in management decisions: the roe of research-based knowedge on innovation adoption and impementation in heath care Yiannis Kyratsis, 1,2,* * Raheeah Ahmad, 1,3 Kyriakos Hatzaras, 1,4 Michiyo Iwami 1 and Aison Homes 1 1 Nationa Centre for Infection Prevention and Management, Imperia Coege London, London, UK 2 Schoo of Heath Sciences, City University London, London, UK 3 Schoo of Life and Medica Sciences, University of Hertfordshire, Hatfied, UK 4 Information Technoogy Services Directorate, King s Coege London, London, UK *Corresponding author Decared competing interests of authors: none The views and opinions expressed by the interviewees, in the verbatim quotations, are those of the interviewees and do not necessariy refect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. Pubished March 2014 DOI: /hsdr02060 This report shoud be referenced as foows: Kyratsis Y, Ahmad R, Hatzaras K, Iwami M, Homes A. Making sense of evidence in management decisions: the roe of research-based knowedge on innovation adoption and impementation in heath care. Heath Serv Deiv Res 2014;2(6).

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5 Heath Services and Deivery Research ISSN (Print) ISSN (Onine) This journa is a member of and subscribes to the principes of the Committee on Pubication Ethics (COPE) ( Editoria contact: nihredit@southampton.ac.uk The fu HS&DR archive is freey avaiabe to view onine at Print-on-demand copies can be purchased from the report pages of the NIHR Journas Library website: Criteria for incusion in the Heath Services and Deivery Research journa Reports are pubished in Heath Services and Deivery Research (HS&DR) if (1) they have resuted from work for the HS&DR programme or programmes which preceded the HS&DR programme, and (2) they are of a sufficienty high scientific quaity as assessed by the reviewers and editors. HS&DR programme The Heath Services and Deivery Research (HS&DR) programme, part of the Nationa Institute for Heath Research (NIHR), was estabished to fund a broad range of research. It combines the strengths and contributions of two previous NIHR research programmes: the Heath Services Research (HSR) programme and the Service Deivery and Organisation (SDO) programme, which were merged in January The HS&DR programme aims to produce rigorous and reevant evidence on the quaity, access and organisation of heath services incuding costs and outcomes, as we as research on impementation. The programme wi enhance the strategic focus on research that matters to the NHS and is keen to support ambitious evauative research to improve heath services. For more information about the HS&DR programme pease visit the website: This report The research reported in this issue of the journa was funded by the HS&DR programme or one of its proceeding programmes as project number 09/1002/38. The contractua start date was in November The fina report began editoria review in November 2012 and was accepted for pubication in Juy The authors have been whoy responsibe for a data coection, anaysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors report and woud ike to thank the reviewers for their constructive comments on the fina report document. However, they do not accept iabiity for damages or osses arising from materia pubished in this report. This report presents independent research funded by the Nationa Institute for Heath Research (NIHR). The views and opinions expressed by authors in this pubication are those of the authors and do not necessariy refect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. If there are verbatim quotations incuded in this pubication the views and opinions expressed by the interviewees are those of the interviewees and do not necessariy refect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. Queen s Printer and Controer of HMSO This work was produced by Kyratsis et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Pubished by the NIHR Journas Library ( produced by Prepress Projects Ltd, Perth, Scotand (

6 Heath Services and Deivery Research Editor-in-Chief Professor Ray Fitzpatrick Professor of Pubic Heath and Primary Care, University of Oxford, UK NIHR Journas Library Editor-in-Chief Professor Tom Waey Director, NIHR Evauation, Trias and Studies and Director of the HTA Programme, UK NIHR Journas Library Editors Professor Ken Stein Chair of HTA Editoria Board and Professor of Pubic Heath, University of Exeter Medica Schoo, UK Professor Andree Le May Chair of NIHR Journas Library Editoria Group (EME, HS&DR, PGfAR, PHR journas) Dr Martin Ashton-Key Consutant in Pubic Heath Medicine/Consutant Advisor, NETSCC, UK Professor Matthias Beck Chair in Pubic Sector Management and Subject Leader (Management Group), Queen s University Management Schoo, Queen s University Befast, UK Professor Aieen Carke Professor of Heath Sciences, Warwick Medica Schoo, University of Warwick, UK Dr Tessa Criy Director, Crysta Bue Consuting Ltd, UK Dr Peter Davidson Director of NETSCC, HTA, UK Ms Tara Lamont Scientific Advisor, NETSCC, UK Professor Eaine McCo Director, Newcaste Cinica Trias Unit, Institute of Heath and Society, Newcaste University, UK Professor Wiiam McGuire Professor of Chid Heath, Hu York Medica Schoo, University of York, UK Professor Geoffrey Meads Honorary Professor, Business Schoo, Winchester University and Medica Schoo, University of Warwick, UK Professor Jane Norman Professor of Materna and Feta Heath, University of Edinburgh, UK Professor John Powe Consutant Cinica Adviser, Nationa Institute for Heath and Care Exceence (NICE), UK Professor James Raftery Professor of Heath Technoogy Assessment, Wessex Institute, Facuty of Medicine, University of Southampton, UK Dr Rob Riemsma Reviews Manager, Keijnen Systematic Reviews Ltd, UK Professor Heen Roberts Professoria Research Associate, University Coege London, UK Professor Heen Snooks Professor of Heath Services Research, Institute of Life Science, Coege of Medicine, Swansea University, UK Pease visit the website for a ist of members of the NIHR Journas Library Board: Editoria contact: nihredit@southampton.ac.uk NIHR Journas Library

7 DOI: /hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Abstract Making sense of evidence in management decisions: the roe of research-based knowedge on innovation adoption and impementation in heath care Yiannis Kyratsis, 1,2 * Raheeah Ahmad, 1,3 Kyriakos Hatzaras, 1,4 Michiyo Iwami 1 and Aison Homes 1 1 Nationa Centre for Infection Prevention and Management, Imperia Coege London, London, UK 2 Schoo of Heath Sciences, City University London, London, UK 3 Schoo of Life and Medica Sciences, University of Hertfordshire, Hatfied, UK 4 Information Technoogy Services Directorate, King s Coege London, London, UK *Corresponding author Background: Athough innovation can improve patient care, impementing new ideas is often chaenging. Previous research found that professiona attitudes, shaped in part by heath poicies and organisationa cutures, contribute to differing perceptions of innovation evidence. However, we sti know itte about how evidence is empiricay accessed and used by organisationa decision-makers when innovations are introduced. Aims and objectives: We aimed to investigate the use of different sources and types of evidence in innovation decisions to answer the foowing questions: how do managers make sense of evidence? What roe does evidence pay in management decision-making when adopting and impementing innovations in heath care? How do wider contextua conditions and intraorganisationa capacity infuence research use and appication by heath-care managers? Methods: Our research design comprised mutipe case studies with mixed methods. We investigated technoogy adoption and impementation in nine acute-care organisations across Engand. We empoyed structured survey questionnaires, in-depth interviews and documentary anaysis. The empirica setting was infection prevention and contro. Phase 1 focused on the espoused use of evidence by 126 non-cinica and cinica hybrid managers. Phase 2 expored the use of evidence by managers in specific technoogy exampes: (1) considered for adoption; (2) successfuy adopted and impemented; and (3) rejected or discontinued. Findings: (1) Access to, and use of, evidence types and sources varied greaty by profession. Cinicians reported a strong preference for science-based, peer-reviewed, pubished evidence. A groups caed upon experientia knowedge and expert opinion. Nurses overa drew upon a wider range of evidence sources and types. Non-cinica managers tended to sequentiay prioritise evidence on cost from nationa-eve sources, and oca impementation trias. (2) A sizeabe proportion of professionas from a groups, incuding experienced staff, reported difficuty in making sense of evidence. Lack of awareness of existing impementation iterature, ack of knowedge on how to transate information into current practice, and ack of time and reevant skis were reported as key reasons for this. (3) Infection outbreaks, financia pressures, performance targets and trusted reationships with suppiers seemed to emphasise a pragmatic and ess rigorous approach in sourcing for evidence. Trust infrastructure redeveopment projects, and a strong emphasis on patient safety and coaboration, appeared to widen scope for evidence use. (4) Evidence was continuousy interpreted and (re)constructed by professiona identity, organisationa roe, Queen s Printer and Controer of HMSO This work was produced by Kyratsis et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. v

8 ABSTRACT team membership, audience and organisationa goas. (5) Doctors and non-cinica managers sourced evidence pausibe to sef. Nursing staff aso sought acceptance of evidence from other groups. (6) We found diverse evidence tempates in use: biomedica-scientific, practice-based, rationa-poicy. These represented shared cognitive modes which defined what constituted acceptabe and credibe evidence in decisions. Nurses drew on a diverse tempates to make sense of evidence and probems; non-cinica managers drew mainy on the practice-based and rationa-poicy tempates; and doctors drew primariy on the biomedica-scientific tempate. Concusions: An evidence-based management approach that infexiby appies the principes of evidence-based medicine, our findings suggest, negects how evidence is actioned in practice and how codified research knowedge inter-reates with other evidence aso vaued by decision-makers. Loca processes and professiona and microsystem considerations payed a significant roe in adoption and impementation. This has substantia impications for the effectiveness of arge-scae projects and systems-wide poicy. Funding: The Nationa Institute for Heath Research Heath Services and Deivery Research programme. vi NIHR Journas Library

9 DOI: /hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Contents List of tabes...xi List of figures...xiii Gossary...xv List of abbreviations.... xvii Pain Engish summary...xix Scientific summary...xxi Chapter 1 Introduction 1 Background 1 Aims and research questions 2 Structure of the report 3 Chapter 2 Reevant iterature and the research context 5 Evidence-based medicine and the spread of innovations 5 Organisationa innovation process and the use of evidence 5 Sensemaking in organisations 6 Gaps in innovation, evidence-based heath care and organisationa sensemaking iteratures 8 Chapter 3 Study design and methods 9 Study design 9 Conceptua framework 11 Data coection strategy and methods 11 Primary data 11 Secondary data 12 Data anaysis 13 Learning from project chaenges 14 Chapter 4 Chaenges in making sense of evidence 15 Ongoing sensemaking: keeping up with the evoving evidence 15 Missing research evidence 16 Making sense of evidence for sef and others 18 Refection on this chapter 20 Chapter 5 Making sense of evidence in the heath-care organisationa and macro context 23 Innovation decisions: evidence sources 23 Innovation decisions: awareness and use of centra evidence sources incuding sources concerning infection prevention and contro 26 Innovation decisions: perceived importance of evidence types 29 Organisationa context: infuences on the use of evidence 32 Macro context infuences on the use of evidence 35 Refection on this chapter 38 Queen s Printer and Controer of HMSO This work was produced by Kyratsis et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. vii

10 CONTENTS Chapter 6 Organisationa context: the macrocases of the eight NHS trusts studied 41 Trust size and financia and human resources 41 Organisationa vaues, vision and aims 41 Trust performance and patient experience 43 Magnitude of shocks, crises and critica events 46 Research activity 51 Innovation activity 54 Communication: interna/externa 58 Summary 59 Chapter 7 Evidence in action: technoogy products overview and typoogy 61 Technoogy products overview 61 Typoogy of technoogies 62 Chapter 8 Evidence in action: product microcases in eight NHS trusts 67 Trust 1 technoogy microcases 67 Microcase 1: Design Bugs Out commode 67 Microcase 2: cine universa sanitising wipes 69 Microcase 3: Bioque vapour hydrogen peroxide Room Bio-Decontamination Service 72 Trust 2 technoogy product microcases 74 Microcase 1: standardisation of disposabe sterie gowns 74 Microcase 2: 3M Cean-Trace NG uminometer 76 Microcase 3: ASP GLOSAIR 400 ahp system 78 Microcase 4: UV LIGHT Technoogies inspection torch 80 Trust 3 technoogy product microcases 82 Microcase 1: Bioque vapour hydrogen peroxide Room Bio-Decontamination Service 82 Microcase 2: cine sporicida wipes 83 Microcase 3: Medixair UV Light Air Steriisation Unit 86 Trust 4 technoogy product microcases 88 Microcase 1: DIFFICIL-S disinfectant iquid detergent 88 Microcase 2: Bioque vapour hydrogen peroxide Room Bio-Decontamination Service and Steris BioGenie 90 Microcase 3: Virusove+ 92 Trust 5 technoogy product microcases 94 Microcase 1: Bioque vapour hydrogen peroxide Room Bio-Decontamination Service 94 Microcase 2: Chor-Cean tabets 96 Microcase 3: 3M CeanTrace and Hygiena SystemSURE II ATP hygiene monitoring system 98 Trust 6 technoogy product microcases 100 Microcase 1: Bioque vapour hydrogen peroxide Room Bio-Decontamination Service 100 Microcase 2: JLA OTEX system 102 Microcase 3: Medixair UV air steriisation units 104 Trust 7 technoogy product microcases 105 Microcase 1: DIFFICIL-S disinfectant iquid detergent 105 Microcase 2: ASP GLOSAIR 400 ahp system 107 Microcase 3: Medixair UV air steriisation units 110 Microcase 4: DaRo UV ight inspection cabinet 112 Trust 9 technoogy product microcases 112 Microcase 1: cine and PDI Sani-Coth CHG 2% acohoic chorhexidine guconate wipes for skin preparation 112 Microcase 2: cine sporicida wipes (red) 114 Microcase 3: JLA OTEX system 115 Microcase 4: Bioque vapour hydrogen peroxide Room Bio-Decontamination Service 118 viii NIHR Journas Library

11 DOI: /hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Chapter 9 Cross-case anaysis 121 Overview of technoogy microcase outcomes across trusts 121 Decision outcome themes 121 Evidence strength on efficacy themes 121 Perceived impact on practice themes 123 Budget impact theme 124 Technoogy product microcase themes 124 The roe of the director of infection prevention and contro 125 Mobiising sources and types of evidence and innovation stakehoders 126 Chapter 10 Synthesis and inferences 129 Refecting on our research questions 129 How do managers (non-cinica and cinica hybrid managers) make sense of evidence? 129 What roe does evidence pay in management decision-making when adopting and impementing innovations in heath care? 130 How do wider contextua conditions and intraorganisationa capacity infuence research use and appication by heath-care managers? 130 Impications for theory 131 Evidence-based heath care and organisationa innovation processes 131 Sensemaking in organisations 134 Strengths and weaknesses/imitations of the study 137 Chapter 11 Impications and suggestions for future research 139 Impications for poicy and practice 139 Reported missing research 140 Suggestions for future research 140 Acknowedgements 143 References 145 Appendix 1 Samping options appraisa (9 May 2011) 153 Appendix 2 Participant information sheet and consent form 157 Appendix 3 Study protoco 163 Appendix 4 Interview schedue phase Appendix 5 Interview schedue phase Appendix 6 Brief technoogy product descriptions 187 Appendix 7 Technoogy products unit cost price ist 191 Queen s Printer and Controer of HMSO This work was produced by Kyratsis et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. ix

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13 DOI: /hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 List of tabes TABLE 1 Characteristics of case study site 10 TABLE 2 Informant sampe for phase 1 13 TABLE 3 Informant sampe for phase 2 13 TABLE 4 Trust size and financia and human resources 42 TABLE 5 Trust performance and patient experience 44 TABLE 6 Magnitude of shocks, crises and critica events 47 TABLE 7 Research activity (reported 2007/08 spring 2011) 52 TABLE 8 Innovation activity (reported 2007/08 spring 2011) 54 TABLE 9 Innovations reported at each trust (reported 2007/08 spring 2011) 56 TABLE 10 Communication (interna and externa) (reported 2007/08 spring 2011) 59 TABLE 11 Overa summary of contextua data reported by the trust (based on secondary source) 60 TABLE 12 Technoogy products seected for review by trusts 62 TABLE 13 Technoogy products expected budgetary impact in trusts 63 TABLE 14 Practice impact of technoogy products 64 TABLE 15 Evidence strength on the efficacy of technoogy products 65 TABLE 16 T1 DBO commode: evidence sources and types 68 TABLE 17 T1 cine universa wipes: evidence sources and types 70 TABLE 18 T1 Bioque VHP RBDS: evidence sources and types 72 TABLE 19 T2 standardisation of disposabe sterie gowns: evidence sources and types 75 TABLE 20 T2 3M Cean-Trace NG uminometer: evidence sources and types 76 TABLE 21 T2 ASP GLOSAIR 400 ahp system: evidence sources and types 79 TABLE 22 T2 UV LIGHT inspection torch: evidence sources and types 81 TABLE 23 T3 Bioque VHP RBDS: evidence sources and types 83 TABLE 24 T3 cine sporicida wipes: evidence sources and types 85 TABLE 25 T3 Medixair UV Light Air Steriisation Units: evidence sources and types 87 Queen s Printer and Controer of HMSO This work was produced by Kyratsis et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xi

14 LIST OF TABLES TABLE 26 T4 DIFFICIL-S disinfectant iquid detergent: evidence sources and types 89 TABLE 27 T4 Bioque VHP RBDS & Steris BioGenie: evidence sources and types 91 TABLE 28 T4 Virusove+: evidence sources and types 93 TABLE 29 T5 Bioque VHP RBDS: evidence sources and types 95 TABLE 30 T5 Chor-Cean tabets: evidence sources and types 97 TABLE 31 T5 3M CeanTrace and Hygiena SystemSURE II ATP hygiene monitoring system: evidence sources and types 99 TABLE 32 T6 Bioque VHP RBDS: evidence sources and types 101 TABLE 33 T6 JLA OTEX system: evidence sources and types 103 TABLE 34 T6 Medixair UV air steriisation units: evidence sources and types 104 TABLE 35 T7 DIFFICIL-S disinfectant iquid detergent: evidence sources and types 106 TABLE 36 T7 ASP GLOSAIR 400 ahp system: evidence sources and types 109 TABLE 37 T7 Medixair UV air steriisation units: evidence sources and types 111 TABLE 38 T9 cine and PDI Sani-Coth CHG 2% acohoic chorhexidine guconate wipes for skin preparation: evidence sources and types 114 TABLE 39 T9 cine sporicida wipes (red): evidence sources and types 115 TABLE 40 T9 JLA OTEX system: evidence sources and types 117 TABLE 41 T9 Bioque VHP RBDS: evidence sources and types 119 TABLE 42 Product attributes and outcomes 122 TABLE 43 The presenter and audience matter 128 TABLE 44 Motivation and span of evidence sourcing 128 xii NIHR Journas Library

15 DOI: /hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 List of figures FIGURE 1 A conceptua framework for the adoption of compex heath innovations 11 FIGURE 2 Evidence sources breakdown by professiona group. (a) Doctors; (b) nurses; (c) non-cinica managers; (d) aied heath professionas; and (e) pharmacists 24 FIGURE 3 Knowedge and use of centra evidence sources breakdown by professiona group. (a) Doctors; (b) nurses; (c) non-cinica managers; (d) aied heath professionas; and (e) pharmacists 26 FIGURE 4 Perceived importance of evidence types breakdown by professiona group. (a) Doctors; (b) nurses; (c) non-cinica managers; (d) aied heath professionas; and (e) pharmacists 29 FIGURE 5 Tota number of innovations reported 2007/08 spring FIGURE 6 Types of innovations reported by each trust 2007/08 spring FIGURE 7 Reationship between number of staff (average 2007/ /11) and number of innovations reported (2007/08 spring 2011) 58 FIGURE 8 T1 DBO commode: professionas engagement and evidence types in decision-making 68 FIGURE 9 T1 cine universa wipes: professionas engagement and evidence types in decision-making 70 FIGURE 10 T1 Bioque VHP RBDS: professionas engagement and evidence types in decision-making 73 FIGURE 11 T2 standardisation of disposabe sterie gowns: professionas engagement and evidence types in decision-making 75 FIGURE 12 T2 3M Cean-Trace NG uminometer: professionas engagement and evidence types in decision-making 77 FIGURE 13 T2 ASP GLOSAIR 400 ahp system: professionas engagement and evidence types in decision-making 79 FIGURE 14 T2 UV LIGHT inspection torch: professionas engagement and evidence types in decision-making 81 FIGURE 15 T3 Bioque VHP RBDS: professionas engagement and evidence types in decision-making. H&S, heath and safety; IC, infection contro 84 FIGURE 16 T3 cine sporicida wipes: professionas engagement and evidence types in decision-making. H&S, heath and safety; IPS, Infection Prevention Society 85 FIGURE 17 T3 Medixair UV Light Air Steriisation Units: professionas engagement and evidence types in decision-making. IC, infection contro 87 Queen s Printer and Controer of HMSO This work was produced by Kyratsis et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xiii

16 LIST OF FIGURES FIGURE 18 T4 DIFFICIL-S disinfectant iquid detergent: professionas engagement and evidence types in decision-making. IPM, infection prevention monitoring 89 FIGURE 19 T4 Bioque VHP RBDS and Steris BioGenie: professionas engagement and evidence types in decision-making 91 FIGURE 20 T4 Virusove+: professionas engagement and evidence types in decision-making IPS, Infection Prevention Society 93 FIGURE 21 T5 Bioque VHP RBDS: professionas engagement and evidence types in decision-making 95 FIGURE 22 T5 Chor-Cean tabets: professionas engagement and evidence types in decision-making 97 FIGURE 23 T5 3M CeanTrace and Hygiena SystemSURE II ATP hygiene monitoring system: professionas engagement and evidence types in decision-making 99 FIGURE 24 T6 Bioque VHP RBDS: professionas engagement and evidence types in decision-making. IC, infection contro 101 FIGURE 25 T6 JLA OTEX system: professionas engagement and evidence types in decision-making 103 FIGURE 26 T6 Medixair UV air steriisation units: professionas engagement and evidence types in decision-making 105 FIGURE 27 T7 DIFFICIL-S disinfectant iquid detergent: professionas engagement and evidence types in decision-making. IC, infection contro 107 FIGURE 28 T7 ASP GLOSAIR 400 ahp system: professionas engagement and evidence types in decision-making. IC, infection contro 109 FIGURE 29 T7 Medixair UV air steriisation units: professionas engagement and evidence types in decision-making 111 FIGURE 30 T9 cine and PDI Sani-Coth CHG 2% acohoic chorhexidine guconate wipes for skin preparation: professionas engagement and evidence types in decision-making 114 FIGURE 31 T9 cine sporicida wipes (red): professionas engagement and evidence types in decision-making. DoN, director of nursing 116 FIGURE 32 T9 JLA OTEX system: professionas engagement and evidence types in decision-making 117 FIGURE 33 T9 Bioque VHP RBDS: professionas engagement and evidence types in decision-making 119 FIGURE 34 Main sources of infuence on sourcing evidence in organisationa decisions 133 xiv NIHR Journas Library

17 DOI: /hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Gossary Academic Heath Sciences Centre (AHSC) A partnership between one or more universities and heath-care providers focusing on research, cinica services, education and training. Biomedica Research Centre (BRC) It was set up by the Nationa Institute for Heath Research in 2007, and based in the most outstanding university teaching NHS trusts across the country. It promotes transationa biomedica research and innovation in the NHS. Currenty there are 11 BRCs (some continued from the period , and some newy estabished since Apri 2012). See URL: Pages/infrastructure_biomedica_research_centres.aspx (accessed 10 October 2012). Biomedica Research Unit (BRU) It was set up by the Nationa Institute for Heath Research in 2008, and based in the UK s eading university teaching NHS trusts. It conducts transationa cinica research, focusing upon seven high-priority areas. Currenty there are 20 BRUs (some continued from the period , and some newy estabished since Apri 2012). See URL: Pages/infrastructure_biomedica_research_units.aspx (accessed 10 October 2012). Care Quaity Commission (CQC) The independent reguator of a heath and socia-care services in Engand. Department of Heath The department of the UK government with responsibiity for government poicy for Engand on heath, socia care and the NHS. Director of infection prevention and contro (DIPC) He or she has authority and is responsibe for the reduction of heath-care-associated infections in a heath-care organisation. This incudes reporting directy to the chief executive and the trust board, producing an annua report on the state of heath-care-associated infections in the organisation, and oca contro and impementation of infection prevention and contro poicies. Evidence-based management (EBMgt) A term adopted from medica science (particuary evidence-based medicine) to describe the practice of management based on empirica evidence. Evidence-based medicine (EBM) A scientific approach that aims at appying the best avaiabe evidence gained from scientific methods to cinica decision-making. Foundation trust (FT) Organisationa type of some hospitas in NHS Engand. Foundation trusts have a significant amount of manageria and financia freedom compared with other NHS hospitas. Heath-care-associated infection (HCAI) An infection caused by any infectious agent associated with a person s medica treatment, or acquired by heath-care workers in the course of their duties. A hospita HCAI is one that is neither present nor incubating on admission to hospita. Heath Protection Agency (HPA) A non-departmenta pubic body set up in 2003 to offer speciaist support and expert advice to oca authorities and the NHS for the protection of the heath and we-being of the popuation of the UK in reation to infectious diseases and environmenta hazards. It became part of Pubic Heath Engand (new executive agency of the Department of Heath) on 1 Apri See URL: www. hpa.org.uk/aboutthehpa/ (accessed 10 October 2012). Heath Protection Agency Rapid Review Pane recommendations (HPA RRP) An independent pane, set up by the Department of Heath in 2004, that offers prompt evauations of new product technoogies to tacke HCAIs. Queen s Printer and Controer of HMSO This work was produced by Kyratsis et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xv

18 GLOSSARY Infection prevention and contro (IPC) In reation to heath care, the term is generay used with reference to preventing patients from acquiring those infections most often associated with the provision of heath care and preventing the transmission of microorganisms from one patient to another (referred to as cross-infection). Nationa Institute for Heath and Care Exceence (formery the Nationa Institute for Heath and Cinica Exceence) (NICE) It was set up as a Specia Heath Authority in 1999, and initiay named the Nationa Institute for Cinica Exceence, to offer guidance on best practice (i.e. current heath technoogies and cinica management of specific conditions) to the NHS. On 1 Apri 2005, it became the Nationa Institute for Heath and Cinica Exceence, and on 1 Apri 2013 NICE became the Nationa Institute for Heath and Care Exceence, at which point it changed its status to a non-departmenta pubic body and began offering guidance to ensure quaity and vaue for money. See URL: (accessed 10 October 2012). Nationa Institute for Heath Research (NIHR) An organisation deveoped with the aim of creating a heath research system through which the NHS can support outstanding individuas, working in word-cass faciities, conducting cutting-edge research focused on the needs of patients and the pubic. Nationa Patient Safety Agency (NPSA) An organisation set up as a Specia Heath Authority to monitor patient safety incidents in the NHS. On 1 June 2012, its key functions were transferred to the NHS Commissioning Board Specia Heath Authority. See URL: (accessed 10 October 2012). NHS The pubicy funded heath-care system in Engand. NHS Institute for Innovation and Improvement A body whose purpose is to support the transformation of the NHS, through innovation, improvement and the adoption of best practice. Private Finance Initiative (PFI) A pubic private partnership that seeks private capita to fund pubic sector infrastructure projects and service deveopments. xvi NIHR Journas Library

19 DOI: /hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 List of abbreviations ahp AHSC ATP BRC BRU CEO CQC DBO DIPC E&F EBM EBMgt FT aerosoised hydrogen peroxide Academic Heath Sciences Centre adenosine triphosphate Biomedica Research Centre Biomedica Research Unit chief executive officer Care Quaity Commission Design Bugs Out director of infection prevention and contro estates and faciities evidence-based medicine evidence-based management foundation trust HPA RRP HS&DR IPC NHS PASA NICE NIHR NPSA PFI RBDS UV Heath Protection Agency Rapid Review Pane Heath Services and Deivery Research infection prevention and contro NHS Purchasing and Suppy Agency Nationa Institute for Heath and Care Exceence Nationa Institute for Heath Research Nationa Patient Safety Agency private finance initiative Room Bio-Decontamination Service utravioet HCAI heath-care-associated infection VHP vapour hydrogen peroxide HPA Heath Protection Agency Queen s Printer and Controer of HMSO This work was produced by Kyratsis et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xvii

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21 DOI: /hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Pain Engish summary Background and methods Innovation can improve patient care, but heath-care managers use of evidence when considering change in hospitas is not we understood. We systematicay ooked at decisions about technoogies avaiabe to hep fight infections in hospitas. We seected nine NHS hospitas across Engand of different size and research experience and, through 191 interviews and 27 different technoogy exampes, aimed to find out which decisions were made, who made these decisions and how the decisions were made. We were especiay interested to earn about which forms of evidence were used by managers and ooked at factors within and outside the hospita that may affect evidence use. Findings and concusion We found that different professiona groups of managers ooked for, and used in decisions, different forms of evidence from each other, incuding research and own experience. For exampe, nurse managers ooked at a wider range of evidence than doctors in management roes. Doctor managers and non-cinica managers were concerned with evidence that heped their own decision-making, whereas nurses were aso concerned with providing evidence to others to aid decision-making. Many factors within and outside the hospita heped or hindered the use of evidence. For exampe, infection outbreaks sometimes highighted the need for evidence but, at the same time, added a time pressure to make decisions quicky. A ot of existing evidence hed centray in the NHS was not used in actua decision-making but, instead, evidence from suppiers and evidence gathered at the hospita eve was used. This study provides a earning opportunity for how poicies intended for system-wide change can be impemented. Queen s Printer and Controer of HMSO This work was produced by Kyratsis et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xix

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23 DOI: /hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Scientific summary Background It is increasingy accepted that patient care can be improved through the impementation of evidence-based innovations and the mobiisation of research findings informing best practice. Successfuy impementing innovations in compex organisations, such as the UK s NHS, is often chaenging, as mutipe contextua dynamics mediate the process. Research studies have expored the chaenges of introducing innovations into heath-care settings and have contributed to a better understanding of why potentiay usefu innovations are not aways impemented in practice, even if backed by strong scientific evidence. Mediating factors incude heath poicy and heath system infuences, organisationa factors, and individua and professiona attitudes, which incude perceptions of decision-makers of innovation evidence. These studies further suggest that the nature and definition of evidence is often ambiguous and contested among diverse professiona groups. This is further exacerbated when mutiprofessiona teams dispersed across hospita departments must deiver on cross-cutting deiverabes such as infection prevention and contro in acute care. Despite substantia research in the fied, there has been imited empirica investigation into how different forms of evidence are accessed, reviewed and used by organisationa decision-makers (in contrast to individuas) during innovation adoption and impementation. These heath-care decision-makers have varying backgrounds and incude cinica hybrid managers (e.g. nurses, doctors, pharmacists by training and profession) and non-cinica staff. We aso know itte about how these managers from a diverse range of professiona backgrounds make sense of evidence coectivey when they come together to take organisationa decisions. We aso have a imited understanding of how this coective sensemaking mediates the uptake of heath innovations. Aims and objectives The study s broad aim was to investigate the use of different sources and types of evidence, incuding research-generated knowedge in heath-care management decisions. A key objective was to expore the process of innovation in heath-care organisations and the construction and use of evidence by decision-makers in this process. The search for, and assessment and use of, evidence by diverse decision-makers at the different stages of the innovation process was expored, ooking at specific technoogy exampes. Our anaysis aso captured the faciitating or constraining infuences on the use of evidence during innovation decision-making at mutipe eves. These were (1) the infuences of wider macro-eve contextua dynamics, (2) the processes by which heath-care managers constructed meaning of avaiabe evidence and how they used such evidence when deciding on adoption or rejection, and (3) impementation of innovative technoogies (the micro eve). The study aimed to address the foowing key research questions: How do managers make sense of evidence? What roe does evidence pay in management decision-making when adopting and impementing innovations in heath care? How do wider contextua conditions and intraorganisationa capacity infuence research use and appication by heath-care managers? Queen s Printer and Controer of HMSO This work was produced by Kyratsis et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxi

24 SCIENTIFIC SUMMARY Methods Our research design comprised mutipe case studies and used mixed methods. We anaysed both contemporary and retrospective exampes of technoogy adoption and impementation processes in acute-care organisations across Engand. We empoyed structured survey questionnaires, in-depth interviews, systematic anaysis of reevant secondary data and fied visits to empirica sites to understand the rationae and chaenges invoved in sourcing and using evidence in reation to innovative technoogies. We aso incorporated active input into the research process from a mutidiscipinary project steering group that heped to construct meaning and interpret research findings. We focused our anaysis on the empirica setting of infection prevention and contro. We anaysed the data using a combination of inductive and deductive reasoning (with the use of a conceptua framework as a sensitising device on key emerging themes). We empoyed theories of organisationa innovation adoption and sensemaking in organisations to interpret the data, informed by our review of the iterature. The research design consisted of two phases. Phase 1 focused on the espoused use of evidence by senior, mid-career and junior managers, as we as diverse cinica hybrid managers. We empoyed structured survey questionnaires (embedded in the interview guide and administered during the face-to-face interviews) invoving 126 informants in nine acute-care organisations (NHS trusts); we aso conducted 126 in-depth semistructured interviews with the same key informants. We purposefuy samped for senior (e.g. medica director, director of nursing, director of research and deveopment), midde and operationa managers and heath professionas (from various backgrounds incuding medicine, nursing, pharmacy) in manageria roes across each trust and, specificay, in infection contro. Phase 2 expored the use of evidence in practice and in context, at the point of decisions, and incuded informants invoved in the adoption decisions and impementation of particuar technoogies in infection prevention and contro. In phase 2 we conducted 65 semistructured interviews across eight NHS trusts. In each trust we samped for three technoogies fufiing the foowing criteria: (1) being considered for adoption at the time of the study, (2) successfuy adopted and impemented, and (3) rejected or discontinued after initia adoption. Using a systematic options appraisa, we bounded the technoogy by infection prevention contro priority area (environmenta hygiene/ceaning/disinfection) and time frame of the organisationa adoption decision (technoogies prior to 2007 were not incuded to avoid reca bias and incompete data owing to staff turnover). Findings In phase 1, a range of sources and types of evidence were reported as being accessed and used by non-cinica staff and cinica hybrid managers. Access to and use of evidence types and sources varied greaty among professiona groups. Evidence types incuded research-generated information on innovation decisions from nationa bodies and agencies, oca tria data, peer exchange or, ess often, input from externa agents such as management consutants. No difference was reported in accessing evidence sources by NHS professionas in hospitas when comparing different organisationa types Academic Heath Sciences Centre, foundation trust or acute trust/district genera hospita. The dominant sources across professionas and the organisationa sampe were The Cochrane Library, the Nationa Institute for Heath and Care Exceence (NICE), Nationa Service Frameworks, NHS Evidence and the former Nationa Patient Safety Agency (NPSA). A regiona network effect was identified for those trusts participating in the Department of Heath Showcase Hospitas Programme and the NHS Institute for Innovation and Improvement, and those ocated in north-west Engand, using evidence from the Nationa Technoogy Adoption Centre and the Department of Heath Smart Soutions Programme. In phase 1, cinica staff reported a strong preference for science-based, peer-reviewed and pubished evidence, athough the extent to which they used such evidence in practice varied, as reported in phase 2. In addition, a groups caed upon experientia knowedge and expert opinion. Nurses overa drew upon a wider range of evidence sources and types. Non-cinica managers tended to sequentiay prioritise evidence on cost produced by nationa-eve sources, and impementation trias and cost xxii NIHR Journas Library

25 DOI: /hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 information from within their own or other hospita organisations, considering the biomedica evidence after this form of evidence. Research evidence identified as missing by respondents in our sampe incuded behavioura studies; impementation research; and organisationa or management research. Pharmacists reported a higher need for behavioura studies, which is in contrast to doctors, who did not perceive these as a priority. This is despite the fact that a significant body of such research evidence exists in heath services research and mainstream management journas. When probed, most respondents were not aware of these journas, and did not report reading them. Respondents highighted that the very nature of evidence around innovations was emergent, iterative and changing. We identified no cear observabe pattern between adoption or impementation outcomes and evidence strength on efficacy or expected budget impact of the studied technoogies when considered in isoation. Low perceived practice impact was more ikey to be inked with successfu adoption and trust-wide impementation. The combination of a three dimensions of evidence better expained outcomes and these were consistenty considered in tandem by decision-makers across a microcases in phase 2. In phase 2, we systematicay mapped 27 innovation journeys of 18 unique environmenta hygiene technoogy products across eight trusts. This reveaed the types and sources of evidence used by diverse stakehoder groups aong the three substages of initiation, adoption decision and impementation. There were significant differences between the types and sources reported in phase 2 and those reported in phase 1. For exampe, sources such as The Cochrane Library, NICE, Nationa Service Frameworks, NHS Evidence and the former NPSA did not feature in those decisions concerning adoption or non-adoption of these technoogy products. Athough in phase 1 a ow importance for industry as a source of evidence was reported, suppier product documentation and demonstrations featured most frequenty in decisions in phase 2. For the particuar organisationa decisions studied (adoption and impementation of innovative technoogies) evidence generated from research did not offer unambiguous or universa prescriptions for action, and even did not aways emerge as the primary evidence source. In most cases, a puraity of types of evidence was used, which were contingent on the oca context, offering a range of potentia sources to guide decision-making. Different types of evidence were interwoven and contributed to oca decision-making discourses. In these discourses research evidence, persona experiences and knowedge, reationships with the suppiers, poitics, resources, nationa performance targets, nationa and organisationa poicies, organisationa and departmenta priorities and cinica pressures (infection outbreaks) were continuousy at pay and have shaped decision-making outcomes. Critica events, externa pressures and the trusts distinct organisationa cutures were widey perceived by respondents to have a significant, but differentia, impact on evidence use during the decision-making process. Infection outbreaks, financia pressures, performance targets and trusted reationships with suppiers seemed to induce an emphasis on what works and a ess rigorous approach to evidence use, eading to the adoption of products with an emergent evidence base on efficacy. On the other hand, trust infrastructure redeveopment projects, a strong emphasis on patient safety and coaboration or teamwork appears to widen scope for evidence access, review and use in decision-making. The different forms of evidence were not simpy accessed and appied at face vaue by the decision-makers. It was necessary to continuousy interpret and (re)construct the evidence in some way, according to one s own professiona identity, organisationa roe, team members and audience, and organisationa objectives. Far from being merey technica or scientific, we found this process to be highy iterative and messy. Many questioned what counted as evidence. Professiona identities impacted upon prospects for meaningfu knowedge exchange and individua knowedge and evidence seection. In these evidence discourses, members of professiona groups viewed and used evidence differenty. For doctors and non-cinica managers, pausibiity to sef of a type of evidence sufficed to bring it into the decision-making process. Nursing staff aso sought pausibiity and acceptance of the evidence from other groups, before formay contributing evidence into decision-making. Queen s Printer and Controer of HMSO This work was produced by Kyratsis et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxiii