HEALTH SERVICES AND DELIVERY RESEARCH

HEALTH SERVICES AND DELIVERY RESEARCH VOLUME 2 ISSUE 6 MARCH 2014 ISSN 2050-4349 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 10.3310/hsdr02060

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: 10.3310/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).

Heath Services and Deivery Research ISSN 2050-4349 (Print) ISSN 2050-4357 (Onine) This journa is a member of and subscribes to the principes of the Committee on Pubication Ethics (COPE) (www.pubicationethics.org/). Editoria contact: nihredit@southampton.ac.uk The fu HS&DR archive is freey avaiabe to view onine at www.journasibrary.nihr.ac.uk/hsdr. Print-on-demand copies can be purchased from the report pages of the NIHR Journas Library website: www.journasibrary.nihr.ac.uk 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 2012. 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: www.netscc.ac.uk/hsdr/ 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 2010. The fina report began editoria review in November 2012 and was accepted for pubication in Juy 2013. 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 2014. 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 (www.journasibrary.nihr.ac.uk), produced by Prepress Projects Ltd, Perth, Scotand (www.prepress-projects.co.uk).

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: www.journasibrary.nihr.ac.uk/about/editors Editoria contact: nihredit@southampton.ac.uk NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 2014. 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

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 www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 2014. 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

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 www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 1 171 Appendix 5 Interview schedue phase 2 181 Appendix 6 Brief technoogy product descriptions 187 Appendix 7 Technoogy products unit cost price ist 191 Queen s Printer and Controer of HMSO 2014. 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

DOI: 10.3310/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 2014. 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

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 www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 2011 57 FIGURE 6 Types of innovations reported by each trust 2007/08 spring 2011 57 FIGURE 7 Reationship between number of staff (average 2007/08 2010/11) 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 2014. 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

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 www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 2007 12, and some newy estabished since Apri 2012). See URL: www.nihr.ac.uk/infrastructure/ 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 2008 12, and some newy estabished since Apri 2012). See URL: www.nihr.ac.uk/infrastructure/ 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 2013. 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 2014. 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

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: www.nice.org.uk/aboutnice/about_nice.jsp; www.nao.org.uk/wp-content/upoads/2000/02/9900230.pdf (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: http://npsa.nhs.uk/ (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 www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 2014. 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

DOI: 10.3310/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 2014. 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

DOI: 10.3310/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 2014. 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

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 www.journasibrary.nihr.ac.uk

DOI: 10.3310/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 2014. 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

SCIENTIFIC SUMMARY A difficuty is reported in making sense of evidence by a sizeabe proportion of members of a professiona groups in our sampe, which aso incudes senior and experienced professionas. Overa, we found diverse evidence tempates in circuation and in use, namey biomedica-scientific, practice-based experientia and rationa-poicy, which defined what constitutes acceptabe and credibe evidence in the decision-making process. Informants variaby drew on those tempates to make sense of the evidence and of the probem under consideration. Concusions In our empirica cases, we observed that organisationa contexts, poicy mandates and professiona identities mediated the use of evidence in the adoption and impementation of the specific heath technoogy products examined. In particuar, evidence sources and types appeared to be variaby prioritised and used by decision-makers depending on their professiona background. Doctors and nurses prioritised evidence on the cinica efficacy and effectiveness of innovations. Non-cinica managers and nurses reied more on their own, or peer, experientia knowedge in contrast to doctors, who showed preference for more systematic forms of knowedge. Non-cinica managers and nurses considered evidence on ease of use, incuding oca trias of innovative products and technoogies, as highy important. In addition, the various professiona groups drew variaby on co-existing evidence tempates to hep them to make sense of the evidence base. Nurses drew on a diverse tempates and aimed for evidence pausibiity to sef and others and were the ony professiona group who expicity tried to make the case to other stakehoders. Non-cinica managers aso drew on a diverse tempates but aimed primariy for evidence pausibiity to sef. In contrast, doctors drew primariy on the biomedica-scientific tempate and were excusivey concerned with evidence pausibiity to sef. These observations have obvious impications for decision-making, especiay who to invove, the breadth of the evidence base needed to be considered, the confuence of different tempates for making sense of the evidence and how consensus in a mutiprofessiona context can be achieved. 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, systematised knowedge generated from research inter-reates with other forms of evidence that are aso vaued by decision-makers. Experience, persona knowedge and expertise, perspectives and preferences of stakehoders, poicy mandates and endorsement, and evidence from the oca context a may contribute as credibe and reevant evidence sources. The NHS and other heath systems have expicit poicy goas to promote the uptake of innovations and systematise new practices across heath-care organisations. Our findings suggest that oca processes and professiona and microsystem considerations pay a significant roe in adoption and impementation. On the basis of this, and significant other research, this poicy goa of systematisation appears to be infeasibe, because of the idiosyncrasies of situated circumstances and cutures. This has substantia impications for the effectiveness of arge-scae projects and systems-wide poicy. Funding Funding for this study was provided by the Heath Services and Deivery Research programme of the Nationa Institute for Heath Research. xxiv NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Chapter 1 Introduction Background The emergence and increasing popuarity of evidence-based medicine (EBM) since the 1990s 1 has provided support for ideas advocating the use of research evidence to improve manageria practice and decision-making in heath care. 2,3 It is argued that heath poicy and management, athough admittedy different from cinica practice in significant ways, are agging behind cinica practice in addressing the probems of overuse, underuse and misuse of evidence reated to management practice and that this has a significant impact on the quaity of care and patient outcomes. 2 Under this perspective, heath service deivery and organisation, as we as decision-making, coud be improved by appying robust and reevant research findings and other forms of knowedge reating to good practice. More recenty, discourse espousing the principes of evidence-based management (EBMgt) and the idea of using research evidence to support manageria decisions aso emerged in mainstream management and organisation studies iterature. 4,5 Foowing a simiar strand of argument, poicy-making circes in the UK have been increasingy advocating the merits of using research evidence to inform cinica and manageria practice. This poicy discourse has particuary emphasised the need to spread best practices and impement innovations within the NHS to hep enhance heath-care quaity and productivity. 6 In recent years, the Department of Heath has issued a number of poicy reports and has set up agencies with the aim of promoting evidence-based practice and innovation. The Cooksey report on UK heath research funding 7 identified a gap in transating innovative ideas and products into practice. The Report of the High Leve Group on Cinica Effectiveness, estabished by the Chief Medica Officer, reviewed areas of significant variation in impementing evidence-based practice. Among a number of recommendations on enhancing the effectiveness and efficiency of cinica care, the report emphasised the need for increased understanding of the mechanisms that encourage the adoption of new interventions. 8 The Report of the Cinica Effectiveness Research Agenda Group highighted the need to deveop the capacity of NHS staff to use impementation (and cinica) research in daiy practice and the need for greater understanding of the processes by which managers and others access and appy impementation and cinica research when making decisions. 9 A number of agencies were aso created, with the NHS Institute for Innovation and Improvement and the NHS Technoogy Adoption Centre being prime exampes. Foowing the Cooksey report, 7 Academic Heath Sciences Centres (AHSCs) and Biomedica Research Centres and Units (BRCs and BRUs) were estabished to faciitate the transation of research knowedge into cinica practice. The Nationa Institute for Heath and Care Exceence (NICE) was set up, and in recent years it has become invoved in heath technoogy evauations. With the pubication of the atest report, Innovation, Heath and Weath, 10 further organisationa changes are being envisaged as the NHS seeks to provide more effective support for innovation and adoption. However, the adoption of new ideas and technoogies is regarded as a chaenging issue. On the one hand, there is a need to ensure that, once identified, effective new technoogies are adopted and disseminated across the NHS, as the poicy goas above suggest. The assumption is that reevant and robust evidence of efficacy and cost-effectiveness produced centray (i.e. via the NICE or the NHS Technoogy Adoption Centre) wi faciitate such dissemination efforts. On the other hand, much recent research suggests that the way in which evidence comes into pay during the adoption and system-wide diffusion is a far more situated and context-mediated process. 11,12 Understanding of the actua practice of how evidence is used in organisationa decisions within the mutiprofessiona setting of NHS is imited. Queen s Printer and Controer of HMSO 2014. 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. 1

INTRODUCTION We know even ess when this process invoves non-cinica decisions. This is where our study aims to make a significant contribution to the NHS and to patient benefit. We empiricay focus on infection prevention and contro (IPC) in NHS acute care. In this fied, reevant NHS poicy reports 6,13 and egisation 14 have highighted that countermeasures of known effectiveness have not been universay impemented. In addition, the NHS has commissioned arge projects in recent years to identify new technoogies and products which work best. One exampe in the fied of heath-care-associated infections (HCAIs) is the Department of Heath s Showcase Hospitas programme, which aimed to evauate technoogies in use across a number of NHS hospitas in Engand and diffuse such earning among heath-care practitioners. Targets for HCAIs are high on the UK Government s agenda with performance being monitored carefuy by reguatory agencies, such as the Care Quaity Commission (CQC), with powers to issue warnings and penaty notices to pubic and private providers. High media attention combined with high pubic and patient interest in recent years has demanded transparency of investment and resutant benefit to patients and the NHS. This accountabiity to the pubic is faciitated by forma channes, such as the patient environment action teams, who assist inspections of NHS sites, as we as the third sector. The compexity of interorganisationa contextua infuences and the mutiprofessiona, cross-cutting nature of IPC make our seected empirica setting an information-rich case for investigating the adoption of innovative technoogies and the use of evidence in this process. In summary, despite the interest in EBM in recent decades, which has ed to considerabe empirica research on the use of cinica evidence by heath professionas, there has so far been imited empirica work in heath care in reation to the use (or non-use) of management research or other forms of knowedge in decision-making and the adoption of innovations. Aims and research questions The main aim of the project is to investigate the use of research-based knowedge in heath-care management decisions. A key objective is to expore the construction of what is regarded as evidence by heath-care managers when they make organisationa decisions. We incude genera managers (non-cinica staff) and cinica hybrid managers (cinicians in a manageria roe) to investigate how heath-care managers draw upon and make sense of different types and sources of evidence when they make decisions about innovations. Emphasis is aso paced on the faciitating or constraining infuences of contextua factors on heath-care managers decision-making processes. The research is empiricay set within the context of management decisions reating to HCAIs. In particuar, we expored how heath-care managers adopt, and impement, innovative technoogies to combat HCAIs in NHS acute trusts. The study design incorporates mutipe eves of anaysis: (1) it expores the infuences of wider macro -eve contextua dynamics on managers decision-making, (2) it expores decision-making processes at the meso organisationa eve, and (3) it anayses at a micro eve the processes by which heath-care managers construct meaning of avaiabe evidence and how they might use such evidence when deciding on the adoption or rejection of innovations. The study aimed to address the foowing key research questions: How do managers (non-cinica and cinica hybrid 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? 2 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Structure of the report The report is organised as foows. In Chapter 2 we outine a summary of the reevant iterature and the research context inked to the aims of this study. Chapter 3 presents our methodoogy, incuding the study s research design and methods. Overa, Chapters 4 to 9 outine our empirica findings and centre on our research questions, namey: How do managers (with cinica and non-cinica backgrounds) make sense of evidence? What roe does evidence pay in management decision-making when adopting and impementing innovations in heath care? Chapter 4 presents findings and emergent themes on the chaenges to making sense of evidence reported by heath-care managers (incuding both non-cinica and cinica hybrid managers). The chapter sketches out the background for the more detaied exporation of empirica processes presented in ater chapters and draws on quaitative interview data from phase 1. Chapters 4 and 5 (drawing mainy on phase 1 data) refect on what decision-makers say they usuay do and Chapter 8 (drawing primariy on phase 2 data) investigates in detai what they actuay did in specific empirica cases of innovation adoption and impementation, thus addressing: How do wider contextua conditions and intraorganisationa capacity infuence research use and appication by heath-care managers? Chapter 5 expores the sensemaking process for individua professionas in context (organisationa and macro), using data from the interviews and the structured questionnaires. In this part of the report we review how decision-makers at different eves of the hierarchy within the organisation report on access and use of various sources and types of evidence reated to innovation decisions. We aso outine key contextua infuences at organisationa and macro eves with a focus on IPC and the NHS. Chapters 6 to 8 ook at evidence in action (how evidence payed out in specific empirica cases). In detai, Chapters 6 and 7 set the background for the in-depth exporation of the innovation products journeys. Chapter 6 draws principay on secondary data sources to present an overview of the eight macrocases (the acute-care NHS trusts incuded in phase 2). Important characteristics of the trusts, such as size, performance, crises and critica events during the period of the study, the research and innovation activity, communication and espoused vaues, are presented in a comparative fashion. The aim is to sensitise subsequent anaysis and inform the reader of the potentia impact of oca and historica contexts on the socia and organisationa processes investigated. Chapter 7 outines the 27 adoption and impementation journeys of the technoogy products, as seected by the trusts (microcases), using interview data from phase 2 and compementary secondary data on supporting evidence for efficacy and cost. In this chapter we aso provide a typoogy of the 27 technoogies, distinguishing among three important dimensions: (1) the strength of the evidence on efficacy, (2) perceived impact on practice, and (3) expected impact on budget. Chapter 8 reports on the 27 microcases in depth. We ook at each technoogy product journey in detai aong the three key stages of the innovation process, namey initiation, adoption decision and impementation. We present the interpay among stakehoders invoved at each stage, associated evidence types and sources, and how these were inked to organisationa adoption and impementation outcomes. This is the ongest chapter of the report, and the chapter in which the 27 microcases are presented in detai. We purposey foowed the same format across cases to faciitate anaysis. The detaied evidence Queen s Printer and Controer of HMSO 2014. 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. 3

INTRODUCTION presented in this chapter enabes the reader to verify the vaidity of the inferences made in the foowing chapters. Chapter 9 outines key themes from the cross-case anaysis (ooking at reevant patterns across the macrocases eight trusts and microcases 27 technoogy product journeys). In Chapters 10 and 11 we refect on what we have earnt and synthesise the reevant findings as to how the coective sensemaking process took pace within the mutiprofessiona empirica setting of our investigation. The report concudes with a discussion on potentia impications for poicy and practice and suggestions for future research. 4 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Chapter 2 Reevant iterature and the research context Evidence-based medicine and the spread of innovations The spread and adoption of innovations re-emerged as an important theme in heath care with the rise of the EBM movement in the 1990s. 1,15 A centra argument in this iterature is that cinica practice shoud be based on rigorous and systematic evidence rather than individua opinion. The EBM movement is evident in a number of heath systems, especiay in Canada, in the USA and in the UK NHS, with expicit interest in understanding the diffusion of evidence-based innovations. 16 18 One of the centra questions in organisationa innovation diffusion iterature that aigns with the aims of this study is as foows: Why do innovations not readiy spread, even if backed by strong (scientificay generated) evidence? There has now emerged considerabe empirica evidence that argues that the adoption of heath technoogies and innovations, even if supported by sound research evidence on effectiveness, is a far more dynamic and compex process than previousy suggested. 19 22 The cassic innovation diffusion mode of change, which has been particuary infuentia in UK heath poicy, suggests that the adoption of innovative ideas, practices or products is conditioned by the interaction among the attributes of the innovation, the characteristics of the adopter and the environment. 23 However, this eary innovation diffusion work was criticised for adopting a simpistic rationa view of change that ignores the compexities of the change process: aso focusing on individuas rather than organisations. Later work by Rogers 24 party addressed the criticism by expicity considering the adoption process within organisations. Recent studies have departed from the inear mode of innovation diffusion 23 to offer more dynamic and interactive conceptuaisations 25,26 and respond to a need for context-sensitive, contingent approaches. 19,27 Buiding on this atter iterature stream, it is suggested that innovation adoption is a process which is highy dependent on the interactions among the innovation, oca actors and contextua factors. 11,27 31 These factors incude the interaction among the attributes of the innovation, the organisationa context and eadership; 32 an organisationa cuture encouraging invovement, experimentation and earning; micropoitica factors; support by peer and expert opinion eadership; 23,30,33 socia networks; 23,34 structura organisationa characteristics; 35 organisationa capacity for absorbing new knowedge; 36 and the existence of a receptive context for change. 37 Organisationa innovation process and the use of evidence The innovation process in organisations is compex and invoves severa stages. Damanpour and Schneider 38 suggest that the process can be divided into three broad phases of pre adoption, adoption decision and post adoption, aso referred to in the iterature as initiation, adoption (decision) and impementation. 24 In this report, we use the atter terminoogy, which is aso more commony appied in the iterature. Different concerns are centra at the different phases, from an initia focus on innovation awareness and information seeking, through innovation use and appication to manage a task or sove a probem, to consequences, and issues of sustainabiity. Adoption is often viewed as a process in which organisationa members examine the potentia benefits and costs or potentia negative consequences of an innovation on the basis of reevant knowedge. 24 Potentia adopters move from ignorance, through awareness, attitude formation, evauation, and on to adoption: the decision to make fu use of the innovation as the best course of action avaiabe. However, organisations shoud not be thought of as merey rationa decision-making entities and innovation as an ordered sequentia process. Rather, the adoption process shoud be recognised as compex, iterative and organic. 19,26 Queen s Printer and Controer of HMSO 2014. 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. 5

RELEVANT LITERATURE AND THE RESEARCH CONTEXT A key eement in the organisationa decision-making process that underpins innovation and technoogy adoption is the avaiabiity of supporting evidence of effectiveness. Despite the chaenges above, there has been impetus for the deveopment of EBMgt in heath care to improve manageria decision-making through the use of the best avaiabe scientific evidence. 2,39 The integration of EBMgt with EBM is advocated to enhance the performance of heath-care organisations. 3 However, within a heath-care setting the evauation of a technoogy can take a number of forms and incude technica, economic and socia assessments. Adoption decisions invove a number of stakehoders and thus it is important that the evidence used to support adoption is not just sufficient but aso reevant and addresses the concerns of a parties. The earier innovation evauation stages are concerned with technica assessments of efficiency 40 as we as efficacy and safety in heath-care interventions 41 whereas the focus in the ater stages incudes considerations of ease of use and socia acceptance. 42 It, thus, marks a move away from scientific assessment to consideration of the compete vaue system for technoogy factors reating to types of evidence supporting adoption and contextua factors that might hep or hinder impementation. Impementation incudes oca trias and evauation. The approach taken to impementation needs to vary according to the type and scae of the technoogy being adopted and the eve and type of consequentia changes it brings about. 43 For exampe, some technoogies can be procured and put into service, whereas others require strategies such as piots and phased ro outs. Impementation is inked to triaing and experimentation. For more compex technoogies, and for those that require or ead to wider changes, such as changes in practice of heath-care staff and changes to a process invoving severa stakehoders or cutting across departments, or even organisations, or need to be roed out across many ocations, impementation may be more chaenging. 27 The end point for successfu impementation wi normay be the point at which the technoogy has become integrated into everyday practice. A different insight on innovation adoption is avaiabe in a recent scoping review by Ferie et a. 44 and Criy et a., 45 which conceptuay synthesised issues of knowedge mobiisation in the NHS and, in particuar, the perceived gaps in the process of transating knowedge from bench to bedside. The change towards EBMgt raises key questions such as what evidence is considered as credibe (and by whom)?. And what is regarded as a egitimate epistemoogica basis for vaidating evidence (what is viewed as egitimate knowedge)? For exampe, shoud the evidence base for impementing an innovation into a specific context be excusivey focused on scientific reproducibiity? Or aternativey, shoud the basis of innovation evidence take into account broader forms of evidence and wider concepts of what constitutes reevant and acceptabe forms of knowedge? Sensemaking in organisations When making decisions, managers need to justify these to themseves and to organisationa members. The sensemaking ens aows these two processes to be examined in context. 46,47 Sensemaking theory is a socia psychoogica approach that emphasises cognitions. Sensemaking is about reaity as an ongoing accompishment that emerges from efforts to create order and make retrospective sense of what occurs (p. 635). 48 According to this perspective, vaues, beiefs, cuture and anguage are important concepts. Centra to this approach is enactment: the important roe that peope pay in creating the environments that impose on them. The impications of a sensemaking ens in the evauation of critica events is the difference between action as an individua making bad choices and action as a resut of an individua in a set of circumstances at a given time. 49 The event is therefore reframed where context and individua action overap (p. 410). 47 Thus, this perspective provides an anaytica ens that heps understand actions in context. The sensemaking perspective asks: how does a manager define his or her roe? How is this shaped by the organisationa cuture, by peers, by professionas, by patients? Does his or her educationa and professiona background draw him or her to a particuar paradigm of what constitutes evidence? This perspective is 6 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 aso interested in drawing out differences according to who the decision-maker is, and how individuas infuence the sensemaking of others. The sensemaking ens has been usefu because of the nature of heath care, with mutiprofessiona work in compex settings where organisationa earning is important. 50 As Fitzgerad and Dopson 51 observe, a cinica team is one exampe of an enactment of negotiated order, in which team members earn to work with each other through repeated interpersona encounters around joint tasks. Those members with a higher degree of power are abe to infuence ways in which work roes are enacted. 51 This interpay between professionas is described we through nurses accounts in the management of hospitaised babies. 47 The nurse makes her case to the attendant physician that a baby requires immediate attention: the first nurse transates her concerns for the second more powerfu nurse, who then rearticuates the case using terms reevant to the Attending [physician] (p. 413). 47 Weick and Sutciffe, 52 in their reanaysis of the inquiry into deaths at the Bristo Roya Infirmary in the UK, found an environment in which they coud further demonstrate how sma actions can enact a socia structure that keeps the organisation entrapped in cyces of behavior that precude improvement (p. 74); 52 that is, easy expanations of an unusua situation shoud be chaenged this did not happen in Bristo. In the study of patient safety, sensemaking provides a powerfu ens, as the most fundamenta eve of data about patient safety is in the ived experience of staff as they strugge to function within an imperfect system (p. 1556). 53 Greenhagh and coresearchers 54 suggest coective sensemaking (deveoping shared meaning) as one narrative approach to understanding issues of organisationa innovation processes. For proposed changes to be accepted and assimiated by providers and service users, the change must make sense in a way that reates to previous understanding and experience (p. 447). 55 Our research questions aimed to expore sensemaking in the oca and wider contexts; that is, the heath-care organisation and the NHS environment. 56 In addition, we expicity set out to expore how individua and coective sensemaking pays out which is particuary pertinent when making decisions about innovation adoption and impementation. This ens aows one to focus on an individua s sensemaking processes and how these iterativey update ways of approaching decision-making and use of evidence. This aso aows refection on how this process differs in everyday, more passive situations compared with those of heightened activity owing to the need for decision-making, either because of funding deadines or because of externa infuences reevant to the empirica setting (in this case, infection outbreaks or poor performance in the infection rates). In the atter, sensemaking is usefuy appied aong Weick s seven dimensions (grounded in identity construction; retrospective; enactive of sensibe environments; socia; ongoing; focused on and extracted by cues; driven by pausibiity rather than accuracy), and emergent from this framework an appreciation of how sense for sef and sense for others pays out. Here the concept of making sense for others or sensegiving is usefu. Sensegiving is concerned with the process of attempting to infuence the sensemaking and meaning construction of others towards a preferred organisationa reaity (p. 442). 57 The concept first emerged as an expanatory concept in the study of strategic change at an American university. 57 In this ethnographic study, the researchers observed the chief executive officer (CEO) adopt a sensegiving mode whereby his actions and cues were used to make sense for others [organisationa members]. This concept reates to previous iterature in the study of organisationa member behaviour, namey impression management 58,59 and sef-monitoring. 60 (The theory of sef-monitoring 60 proposes that individuas reguate their own behaviour in order to convey aignment with a preferred behaviour in any given context or situation. High sef-monitors monitor and modify their behaviour to fit different situations; ow sef-monitors are more consistent in behaviour across situations.) Sensegiving describes the more purposefu and expicit action rather than impicit cues. The sense-giver wi aso make sense of organisationa member behaviour and in turn modify sensegiving. The socia production of reaity for onesef is a very tacit process which shapes decision-making and infuences non-deiberate decisions. Sensemaking as justification to sef and the resuting decision is Queen s Printer and Controer of HMSO 2014. 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. 7

RELEVANT LITERATURE AND THE RESEARCH CONTEXT infuenced by other factors such as egitimacy and pausibiity to others, that is, the pubicy accountabe decision. This ens pays particuar attention to the socia construction and coproduction of evidence through the interaction of a range of diverse professiona and manageria groups. We engage with this body of iterature summarised above, which has been usefu in expaining organisationa response to critica events in the heath-care setting, 47,52 as we as to strategic change. 61,62 Gaps in innovation, evidence-based heath care and organisationa sensemaking iteratures In summary, we note four key gaps in the reevant iterature streams on innovation, evidence use and sensemaking in organisations which triggered our empirica exporation in this study. First, with this study we address a significant gap in evidence-based heath-care impementation iterature. Namey, we respond to the ca for more sustained interpretive work that expores the roe and motives of actors and the infuence of the organisationa context and the socia construction of evidence. 63 Second, despite the progress that has been achieved in our understanding of innovation diffusion and adoption processes, a consistent issue raised in high-quaity reviews of genera innovation diffusion iterature 26,64 66 and a review of reated iterature in heath care 19 is that empirica research has generay been imited to a singe eve of anaysis individua, organisationa or interorganisationa thus faiing to provide a hoistic expanation of the infuence of inter-reated factors on innovation adoption and diffusion. Our study aimed to address the aforementioned criticism by exporing the innovation adoption process and by refecting on infuences at various embedded eves of anaysis: namey, micro (individua), meso (organisationa) and macro (interorganisationa) eves. Third, there are few empirica cases exporing issues of heath management decision-making that focus on non-cinica decisions and particuary innovation, which is characterised by inherenty high uncertainty and ambiguity. Moreover, itte primary research exists that inks the use of evidence to adoption decision-making and impementation within service organisations. We currenty have a imited understanding of how puraist evidence bases (and the associated diverse epistemoogica bases) might be reconcied or not in practice. The construction of shared meanings, or coective sensemaking, 46 is key for understanding how new types of evidence may be successfuy embedded in certain contexts, or even be rejected under conditions of innovation uncertainty and ambiguity. Fourth, in sensemaking theory there is ess emphasis on empirica studies that dea with the day-to-day processes of sensemaking, rather than crises and critica events, and on the sensemaking that occurs among many and diverse organisationa stakehoders as they address a range of issues. 46,62 By appying this theoretica ens to the investigation of manageria decision-making on the adoption and impementation of innovative technoogies, we aim to empiricay contribute to the fied. 8 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Chapter 3 Study design and methods This study uses a comparative and processua case study design, that is, the study of organisationa processes over time in mutipe cases. Specificay, the research focuses on nine case sites purposey seected for comprising diverse organisationa types, each with a potentiay dissimiar eve of engagement with research organisations and interna capacity for knowedge production and utiisation. The research aso comprises 27 embedded microcases of specific technoogy products used to investigate the innovation processes over time and the use of evidence in these processes. This chapter provides the rationae for this research design and then considers the operationa methods appied. Study design We empoyed a comparative case study approach with mixed methods. The empoyed study design aimed to deveop theory inductivey from mutipe in-depth case studies combining an inductive search for emerging themes with deductive reason. 67,68 Comparative case studies offer the opportunity for a deeper insight to generate new conceptua and theoretica propositions or extend existing knowedge through comparing, inking and integrating different cases. The main aim of this study has been to produce new understanding of the access and use of research-based and other forms of knowedge by heath-care managers in organisationa decisions. This can be achieved through detaied descriptions and a rich understanding of contexts across the empirica sites. As our study objectives concerned interpretive how and why questions, our overarching design drew primariy on quaitative methodoogy. 68 To retain the richness of unique cases and enhance the generaisabiity and appicabiity of findings, individua case studies were foowed by cross-case anaysis. Our study comprised nine macrocases of acute-care organisations, and, for eight of them, we further investigated 27 embedded microcases of technoogy product journeys, which we foowed across the stages of the innovation process. The seection of cases invoved theoretica, rather than random, samping. 69 Nine acute NHS trusts were seected across three broad geographic regions in Engand: (1) London, (2) northern and centra Engand, and (3) southern Engand. The nine research case studies were conducted concurrenty. By focusing across different ocaities, we samped for diversity and aimed to expore the infuence of any oca network effects if present, for instance, by comparing London-based institutions to non-london-based institutions, bearing in mind the fact that London is a major cosmopoitan city which has many heath-care institutions, universities and research centres and in which a pethora of socia and professiona events take pace on a reguar basis. We anticipated that this potentia regiona effect might exert infuence on the behaviour and perceptions of academics, heath professionas and managers. In our sampe of cases, we samped for diverse organisationa types, incuding exampes of research-engaged heath-care organisations, such as AHSCs, university/teaching hospitas and ordinary heath-care service providers, such as district genera hospitas (Tabe 1). To better deineate the impact of contextua factors in research use and the appication of various forms of evidence by heath-care managers on the same innovation, we incuded mutipe showcase hospitas as seected by the Department of Heath to evauate the in-use vaue of HCAI technoogies. The study was conducted in two phases, ooking in detai at processes in context. In phase 1 we first systematicay examined espoused use of evidence by potentia decision-makers in the studied organisations; then, in phase 2 we systematicay anaysed the use of evidence in practice at the point of decisions in reation to specific technoogy products. Phase 1 expored perceptions of senior and operationa managers and heath professionas of different backgrounds in manageria roes across each trust and, specificay, in IPC. Phase 2 expored those organisationa members invoved in the adoption decisions and impementation of particuar technoogies in IPC. Eight of the nine trusts in our initia sampe participated in phase 2; trust 8 decided to withdraw from the study. This was a resut of chaenges Queen s Printer and Controer of HMSO 2014. 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. 9

STUDY DESIGN AND METHODS TABLE 1 Characteristics of case study site Trust PFI Foundation AHSC UH/ TH SH BRC 2007 12 BRC 2012 17 BRU 2008 12 BRU 2012 17 DGH T1 In the process T2 In the process T3 In the process T4 In the process T5 T6 In the process T7 T9 DGH, district genera hospita; PFI, private finance initiative; SH, showcase hospitas (programme); TH, teaching hospita; UH, university hospita;, appicabe to the trust;, not appicabe to the trust. Source: trusts annua reports and financia accounts. faced by the trust in service deivery during the study period. Two infection outbreaks impacted significanty on the avaiabiity of staff to participate in our study. A robust, systematic and participatory options appraisa (see Appendix 1) was carried out to inform the samping strategy of phase 2. This invoved input from steering group members, expert advice by Professor Sue Dopson, and input from peers within the research team and from NHS coeagues working in IPC. One particuar IPC priority area, namey environmenta hygiene/ceaning/disinfection, was finay seected. Other IPC areas considered but not samped incuded hand hygiene, diagnostics, antibiotic prescribing, catheter-reated care, training and education, medica devices/equipment hygiene, information technoogy surveiance systems and patient hygiene. Interview respondents at each trust during phase 1 were asked to seect three environmenta hygiene innovations/technoogies considered by the trust from 2007 onwards (2007 12) as foows: (a) A technoogy that has been seected but not impemented yet. (b) A technoogy that has been seected and successfuy impemented. (c) A technoogy that has been rejected. The initia seection of a technoogy may finay ead to adoption or rejection of organisationa decisions. Foowing earier work, 22,41 by successfu adoption we refer to the organisationa executive decision to introduce and make fu use of a technoogy, which resuts in procurement. By successfu impementation we refer to the actua introduction of the new technoogy in the organisation, meaning that the technoogy is put into use and operationaised; the extensiveness of impementation may vary from trust-wide use to use in seected wards. The rationae for the seection of environmenta hygiene as the IPC area of focus for our empirica investigation in phase 2 and the defined time period of 2007 12 are detaied beow. First, the seected time frame (dimension A in Appendix 1) captures the period when major poicy initiatives in IPC were impemented or aready in pace, for exampe, The Heath Act 2006: Code of Practice for the Prevention and Contro of Heathcare Associated Infections (known as the hygiene code ); 70 the introduction of the evidence-based EPIC-2 guideines; 71 the mandatory reporting of methiciin-resistant Staphyococcus aureus (MRSA) bacteraemia and Costridium difficie infections (Apri 2001 and January 2004, respectivey); the Saving Lives programme 2007; 72 and the Cean Safe Care programme aunched in 2008. 6 We seected environmenta hygiene technoogies because they represented 50% of seection decisions according to a recent study of innovation adoption in IPC in 10 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Engand. 43,73 In addition, environmenta hygiene is a cross-cutting intervention for various HCAIs. Such interventions range from an inexpensive poster and basic ceaning products to expensive cutting-edge technoogies incuding hydrogen peroxide robots. This is a growing area in industry and has gathered particuar attention in recent years through reguations, such as the Department of Heath s Deep Cean Programme. More importanty, a wide range of stakehoders coud be invoved to debate the evidence in this area in contrast to a highy speciaised or technica fied, such as diagnostics. Conceptua framework Our approach draws primariy on innovation diffusion theory of change. 24 We specificay focus on four factors (Figure 1) that heath-care researchers 11,21,22,27,31 broady agree infuence the adoption decision and subsequent impementation of heath innovations: (1) the perceived attributes of the innovative technoogies, (2) the characteristics of adopters, incuding both individua heath-care managers and their organisations, (3) contextua factors that incude the reevant sector (NHS) and wider societa, poitica, economic and institutiona (symboic, ideationa and materia) environments, and (4) the communication process. Data coection strategy and methods We empoyed a two-phased approach to the fied work. Phase 1 focused upon senior (director eve, incuding trust directors of medicine and nursing), midde-eve and operationa managers invoved in organisationa decision-making. We focused on a specific type of organisationa decision, the adoption of innovative interventions, which entais uncertainty and the risk of newness, and thus offers great potentia for sourcing evidence from the decision-makers. Technoogy products for phase 2 research were then samped, which examined in detai the stakehoders invoved in specific cases of evidence use in practice. Primary data In phase 1 the unit of anaysis was the individua manager (non-cinica and cinica hybrid managers) and the eve of anaysis was each of the nine trusts (macrocases). For phase 1 we used a combination of semistructured interviews with structured questionnaires embedded in the interview schedues (see Appendix 4). We empoyed a mutieve sampe of key informants. Informants incuded senior, midde and operationa managers and representatives from different professiona groups, incuding doctors, infection contro speciaists, cinica microbioogists, nurses, pharmacists, aied heath professionas and non-cinica managers with diverse professiona backgrounds (i.e. in engineering, science, accounting or finance). The categories of evidence used in these questionnaires were informed by a previous study on HCAI technoogy adoption funded by the Department of Heath which invoved 121 interviews with NHS staff from 12 NHS trusts across Engand. 22,43 The categories were further refined and vaidated foowing expert advice from poicy-makers in the Heath Protection Agency (HPA) and the Department of Heath, Macro context Innovation Communication Adopter Individua Organisation Heath system FIGURE 1 A conceptua framework for the adoption of compex heath innovations. Queen s Printer and Controer of HMSO 2014. 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. 11

STUDY DESIGN AND METHODS as we as heath professionas in IPC with non-cinica, nursing and medica backgrounds. We further vaidated and finaised the categories in consutation with the members of our project steering group. The primary focus of phase 2 was the mobiisation and use of evidence in the decision-making for specific technoogy products in context and in reation to the task of soving an identified probem in IPC. The unit of anaysis was the group of stakehoders invoved through the innovation journey for each of the seected technoogy products and the eve of anaysis was each of the eight trusts that participated in phase 2 (macrocases) and each of the 27 embedded technoogy journeys (microcases). The ongitudina, rea-time design of the study was intended to give a better understanding than short-term and snap-shot methods. As we as these measures of methodoogica rigour through the study design and methods of anaysis, we used measures of acceptabiity and reevance of the research as defined by key stakehoders, namey professiona, manageria and patient groups (e.g. patient environment action teams, the two patient advisors who were members of the project s steering group). For both phases we aso ooked at the wider context through the systematic coection of secondary data (discussed in more detaied beow). For exampe, we considered for each macrocase the profie of the popuation, the institutiona conditions (e.g. egisation and reguatory frameworks, the infuence of professiona associations, socia norms), intraorganisationa factors, incuding practices and organisationa cuture, and trusts history and tradition. For the microcases we additionay considered the capacity and previous experience reating to the technoogy under consideration and simiar innovations. The research was conducted over a period of 2 years, between November 2010 and October 2012. After ethica approvas were obtained, fied work and data coection began in Apri 2011, and was competed in Juy 2012. The recruitment of respondents foowed cosey the pan outined in Appendix 3, the study protoco. YK or KH invited potentia participants via e-mai to take part in the study and these e-mais were accompanied by a participant information sheet (see Appendix 2). Our predefined roes detaied in the study protoco, suggestions by oca study eads and snowbaing shaped the actua respondents sampe. In addition, for phase 2 the fina sampe of respondents was determined by participation of staff in the adoption and/or impementation of the seected technoogy products studied in each of the eight trusts. Very high respondent recruitment was achieved (> 90% acceptance of invitations with the exception of T8, as outined above). We used semistructured interview schedues for both phases of the research (see Appendices 4 and 5). Prior to the fied visits, interviewers famiiarised themseves with contextua information on each trust and information about IPC-reated innovations. This enhanced their knowedge on oca contexts and enabed them to ask reevant questions to expore areas of further interest. On average, each interview asted 60 90 minutes. Face- to-face interviews were conducted at trust sites, and we obtained prior consent to audio record interviews (see Appendix 3). The tota number of interviews was 191, incuding 126 for phase 1 (with a 126 informants aso having competed the embedded structured questionnaires) and 65 semistructured interviews for phase 2. The detaied breakdown per trust and professiona background of informant is summarised in Tabes 2 (phase 1) and 3 (phase 2). Secondary data We systematicay coected data from secondary sources (both trust specific and goba) for each case study site to obtain a detaied contextua description for each trust. The trust-specific sources incuded the foowing: trusts annua reports and financia accounts (2007/08; 2008/09; 2009/10; 2010/11; 2011/12 where avaiabe and appicabe), trusts quaity accounts (2009/10; 2010/11; 2011/12), reports by the director of IPC (DIPC) (where avaiabe), trust board meeting minutes (where avaiabe), staff magazines, and newsetters and/or buetins that were pubished up to spring 2011. We aso coected pubications from governmenta or reguatory agencies, incuding the CQC (previousy the Heathcare Commission), the Audit Commission, the Monitor and the Network of Pubic Heath Observatories, to highight wider 12 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 TABLE 2 Informant sampe for phase 1 Number of respondents per trust Type of informant T1 T2 T3 T4 T5 T6 T7 T8 T9 Tota Doctor 5 2 3 2 3 2 4 1 2 24 Nurse 10 9 8 5 5 8 6 1 9 61 Non-cinica manager 3 4 4 3 4 3 3 0 1 25 Aied heath professiona 1 0 1 1 2 0 1 0 0 6 Pharmacist 1 1 1 2 1 1 1 1 1 10 Tota 20 16 17 13 15 14 15 3 13 126 TABLE 3 Informant sampe for phase 2 Number of respondents per trust Type of informant T1 T2 T3 T4 T5 T6 T7 T9 Tota Doctor 1 1 Nurse 7 4 5 3 (6) 7 4 7 7 44 (47) Non-cinica manager 3 4 3 1 1 1 2 15 Aied heath professiona 1 1 Pharmacist 1 1 Tota 10 8 8 5 (8) 7 6 8 10 62 (65) contextua factors that might infuence the innovation decision-making processes at the trusts. We systematicay reviewed a tota of > 800 documents derived from the aforementioned sources. The trust-specific secondary data sources suppemented and/or trianguated other data sources, incuding goba secondary data sources and our primary data originating from interviews with trust managers. Data anaysis Data anaysis comprised six interinked and, to some extent, overapping stages: (1) transcribing of quaitative data; (2) initia open coding of interview data focusing around the research questions; (3) systematic coding of interview data; (4) ceaning, error checking, creation of descriptive summaries and tabuation of the questionnaire data; (5) individua case study anayses; and (6) cross-case anaysis. Soon after the competion of interviews, the content of audio recordings was verbatim transcribed by professiona transcribers an independent professiona and an agency. The inguistic accuracy of texts was checked by the interviewers themseves, and, whenever transcribers fet unsure, the researchers who conducted the interviews confirmed the accuracy of the text and revised it accordingy by paying cose attention to the raw interview data. Interviewees vaidated most transcripts (the option was offered to obtain a copy their transcribed interview). Upon competion of transcription, three researchers thoroughy read through the fu transcribed texts severa times to enabe understanding of the meaning of the data in their entirety. 74 The reviewing of data prior to coding heped us identify emergent themes without osing the connections between concepts and the context associated with these concepts. The quaitative data anaysis computer software package Queen s Printer and Controer of HMSO 2014. 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. 13

STUDY DESIGN AND METHODS NVivo 9 (QSR Internationa, Cambridge, MA) was used to systematicay code the coected data and assist anaysis. In ine with recommendations by quaitative methodoogists, we used mutipe coders (MI, RA, KH, YK) to enhance inter-rater reiabiity of the quaitative study. 74,75 Our quaitative anaysis foowed an integrated approach. 76 We empoyed an inductive approach to open up new ines of enquiry and then agreed a framework for data anaysis based on these findings together with our conceptua framework (deineating factors that infuence the adoption process of compex heath innovations, see aso Figure 1). The deveopment of the code structure was finaised when the point of theoretica saturation was reached in each of the empirica cases. 69,77 Secondary data were used as compementary to the preiminary interpretation (based on interview data) of each case study and for trianguation, through cross-checking the vaidity of caims in interview accounts. Fied notes taken by the interviewers during the visits to the trusts were shared with the other members of the research team during anaysis of the interview and documentary data. The fied notes provided a feeing for each trust, aowed for a better understanding of the trust context and incuded expanatory information about the technoogies in use. In particuar, the fied notes heped sensitise and accimatise the researchers not famiiar with the microcases. Anaysis within cases was foowed by a cross-case anaysis of emergent themes. The cross-case anaysis commenced with a systematic examination of the data based on our research questions. We compared the data on these questions across the macrocases and across the microcases (technoogy product journeys). Individua case study reports with common formats were produced for each of the eight trusts that participated in phase 2. Summary tabes were used to simutaneousy compare severa categories and dimensions of the content and context of change impied by the adoption and impementation of the innovative technoogies across the nine trusts. The above strategies heped us to reduce the voume of primary data. The fina interpretation was conducted through comparison and integration of seemingy common or contradictory themes, categories, patterns and cases. Learning from project chaenges The context of the NHS poses chaenges to access to participants. In the fied of IPC, this is further exacerbated because critica events can pose high demands on IPC teams and senior management within trusts. We empoyed a mutifaceted approach to gaining access, buiding on our previous reationship with five of the trusts in the first instance. We found that the nature of the research questions prompted genuine interest and, therefore, engagement in the research. We were abe to access a higher than initiay anticipated number of respondents. Nonetheess, these very pressures resuted in incompete participation in the study for one of the trusts, T8. The initia deays in gaining ethics approva and then oca access did make data coection chaenging. Interna contingency and a highy fexibe approach by the research team was empoyed to maximise interview opportunities at each research site visit. We found that the guidance from our expert steering committee and, notaby, our patient advisors heped with every stage of the research process, enhancing the quaity of the research. Perspectives from heath poicy, quantitative methods and accounting, organisationa management, service users, and IPC and service managers were present and debated. The mutidiscipinary make up of this group refected we the stakehoders we were studying and aowed a refexive approach to data anaysis and wi inform dissemination activities beyond the project. 14 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Chapter 4 Chaenges in making sense of evidence In this chapter we summarise some key themes from the quaitative study, which drew on primary data coected through interviews in phase 1. These themes were deemed hepfu in providing a conceptua understanding of the main chaenges to making sense of evidence reported by the informants. The emergent issues discussed in this chapter hep pace individua sensemaking of evidence by heath-care managers in the context of the hospita and wider NHS environment. Ongoing sensemaking: keeping up with the evoving evidence The very nature of evidence as emergent, iterative and changing featured in the majority of interviews with respondents, particuary as the context of this research was innovation. The accuracy of evidence therefore had a tempora dimension, irrespective of the source of the evidence, or the audience making sense of the evidence. The need for up-to-date evidence, which sometimes needed to be generated ocay, was an important theme in respondents accounts: We-written trias that have been peer reviewed and written up in trusted journas. But I am aso now od enough to see that some of the things that we took as facts, 10 years ago, have aready been proved incorrect. T5M4 doctor This evoving andscape of evidence posed a chaenge, therefore, for individuas and groups when making decisions about adoption and methods of impementation. Further chaenges to making sense of evidence reported by the respondents ranged from the individua s interna capacity to process the scientific data presented to externa factors, such as the ack of evidence in the specific areas of innovation and IPC. The ack of high-quaity evidence was reported by the majority of respondents, athough this definition of quaity varied across the professiona groups and is discussed ater when we ook at the importance attributed to various sources and types of evidence (see Chapter 5): As a doctor I go to the medica iterature, didn t find a ot. So my nurses came back with a ot of nursing iterature evidence. Which I fet was of poorer quaity evidence, but there was a arge voume of it, so it was put into the mix somewhere. T3M3 doctor In terms of the individua s interna capacity, respondents across the professiona groups cited difficuties in understanding the evidence presented in pubished papers and reports. Specificay, 75% of medica hybrid managers and 77% of nursing hybrid managers said that they sometimes found the content of presented evidence difficut to understand. Simiary, the majority in each of these groups found it difficut to reate evidence to practice : 63% of doctors and 72% of nurses. The non-cinica managers reported a different experience 60% stated that they sometimes found the content of presented evidence difficut to understand, but ony 40% had difficuty in reating this to practice. There was consistency among the groups in agreeing that different professiona groups have access to different sources of evidence because of different needs for evidence. This access and need for different types of evidence was deemed to have direct impications for practice: If everybody isn t ooking at the same piece of information it can affect how you make the decision because we can a be coming at it from different points of view. I can say generay speaking within this organisation when we are ooking to do anything we get the reevant peope round the tabe. It s not that IPC woud make a decision that woud impact on the provider without invoving, they woud invove our actua service provider and we wi be invoved as we. And I do think we do that we reay. T2M2 non-cinica manager Queen s Printer and Controer of HMSO 2014. 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. 15

CHALLENGES IN MAKING SENSE OF EVIDENCE Missing research evidence Looking in greater detai at the gap in evidence or missing evidence as identified by the respondents, there is more consensus than variation on this issue across professiona groups and across the trusts. Chaenges arising from the ack of reevant evidence as we as incompete evidence were mentioned by the majority of respondents. For exampe, a aboratory-based/microbioogy study may be avaiabe for a given product but no studies reating to cost. Impementation studies may be avaiabe, but may ony report a ward-based sma study, which may not be reevant to the hospita-wide context. A ack of product trias was described, the products being either untested in the rea-word setting or untested in the ocay reevant setting. Particuary among doctors, basing decisions within the context of incompete evidence was reported as not just a chaenge but undesirabe: There s damn a evidence most of the time. So we re very used to doing what seems sensibe from first principes, which may not actuay be, so often we do things without a forma eve of evidence basicay. T9M2 doctor It s difficut because some of the things we do I must admit they are based on very itte evidence. T1M17 doctor It [personaised care pans for rena patients] was a good idea but it wasn t triaed anywhere, there was no sort of piot study to demonstrate how much time it was going to take to fi these things out, whether they woud actuay be usefu, did the patients think they were usefu, did the doctors think it was usefu. T5M5 doctor These findings have an important impication as to what managers currenty perceive as incompete evidence in research when making decisions on innovation adoption, and what future research shoud focus on to meet such oca needs. Types or topics of research studies perceived as missing by the respondents did vary across the respondents and across the trusts, but views converged for three types of research study, which were identified as missing in the foowing order: behavioura studies, impementation research and organisationa studies or management research. Approximatey one-third of respondents in trusts T1, T3, T6 and T9 fet a need for behavioura studies to assist decision-making, impementation and evauation. Specificay, interest in behavioura studies was driven by the need to overcome non-compiant behaviour; insights into bringing about change in the way peope work; earning from training and deveopment mechanisms; and better communication. More importanty, the respondents identified a need for better understanding of decision-making across the different eves of hospita staff, from senior management to front-ine staff: I think that there is quite a ot of management research that is missing. Party because managers don t tend to do a great dea of research in this organisation. Then again a the behavioura work that is done is inked to nursing or medica, I think this is the first research that I have seen that is inked to managers as we. I woud ike to see a ot more research based around behaviours and how managers and cinica staff coud work much better together, to deiver a heath service, because I see modes out there where they work so we and yet somehow the NHS cannot get it right across the whoe trust. T1M1 non-cinica manager 16 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Yeah not enough is done around the whoe decision architecture and infuencing behaviours in the cinica areas. How do we improve behaviours? Not just in the cinica areas, manageria areas, but how do we improve the way we work which is not around new technoogies but how can we stop wasting huge amounts of time repeating the same things over and over again. T1M10 doctor The missing evidence highighted by respondents is interinked and demonstrated a need by the hospita managers not ony for appied, meaningfu evidence use in adoption decision-making itsef, but aso more operationa and manageria research. This ranged from effective management to psycho-socia research about behaviour change and receptive organisationa cuture. The foowing respondent highighted a shift in evidence needs highighting what is most usefu to managers: My research brain has gone exponentia in the ast year or two. I think there needs to be far more focus on the behavioura and cutura aspects of innovation spread as we as just the subject matter. Because the understanding how to chaenge the behaviours and how to deveop the peope who are invoved in the organisations is far more important than the actua evidence that drives it. Increasingy I m convinced more and more. T3M4 doctor [...] where we ve got the catheter project, the CAUTI project we re doing, where we ve got John who s our cinica academic, we re ooking at doing some sort of research around peope s decision making as to why they re putting catheters in. [...] Why do peope make those decisions to do that or why do peope make decisions to move away from the guideine that s there [...] There s a ot, from an infection prevention point of view there s a ot of scientific type stuff we coud do but that is quite difficut aready because we don t want to inject peope with, but [...] I find that behaviour reay interesting as to why peope do make the decisions they do. T9M1 nurse I work with a pubic heath doctor and he was reay interested in impementing change, change methodoogy. And I think as much importance of thinking about that as thinking about the evidence. If the evidence stacks up, or evidence doesn t stack up particuary we. You coud have good evidence and poor impementation and no effect. Poor evidence not even particuary good but with reay good impementation wi make it improve but amost, I think there is something there. What I woud say [is] that even if I d ike to assimiate stuff, actuay it s not what other peope want to do, you don t have the time to do it. Lots of peope who are over-committed and busy and sometime go, I m sure there is something better uness you te me what you want to do. T9M8 doctor This type of management iterature was not accessibe to the respondents argey because of the sources used by these professionas, and aso because of the time constraints faced by these professionas, who were not abe to branch out to wider iterature streams. Of the professionas groups, pharmacists appeared to be more aware of the discrepancy between recommended practice (through nationa or oca guideines and protocos) and non-adherence or deviation of behaviour than the other professionas in our study sampe. Approximatey two-thirds of respondents, despite the sma sampe size, commented on the importance of behavioura studies and the ack of such studies. One-quarter of nurses and non-cinica managers identified the importance of studies to address non-adherence to guideines, whereas this view was ess prevaent in accounts from medica managers and missing in accounts from managers with an aied heath professiona background. Medica managers were the outiers in terms of being ess concerned about understanding behavioura change in greater depth. Queen s Printer and Controer of HMSO 2014. 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. 17

CHALLENGES IN MAKING SENSE OF EVIDENCE Making sense of evidence for sef and others Sourcing practice-based evidence was mentioned as being important across professiona groups. The practice of earning from other trusts and peers featured across respondents accounts. This was because of the ocay reevant information in practice-based evidence but aso because of the exchange of information which is possibe through such means: A microbioogist in another hospita or someone who has used something in practice and any research or studies they have done, that is usuay the most usefu. I guess because you are taking to them you can ask questions and get feedback straight away, so you know where you are with it. So that s a reay good source. T7M3 doctor Upon direct questioning, respondents reported a hierarchy of evidence, but this was articuated more as processua rather than as an objective vertica hierarchy, or means to excude certain forms of evidence. Athough the first port of ca may be scientific randomised controed trias (when avaiabe), this was assessed in tandem with experientia evidence: We used that, iterature searches for that [Gentamicin (antibiotic) as first ine for the treatment of urinary tract infections]. But we aso used experience of other hospitas, our own experiences, we drew on that. So actuay it was probaby a decision which was much more of a pragmatic decision rather than a pure academic-based decision. T3M17 pharmacist The approach described by the majority of respondents was an iterative process of trianguating different types of evidence. There were few reports of an evidence dichotomy within professiona groups, but rather a more compex picture of synthesis across the professiona groups. Paradoxicay, many respondents did view other professiona groups as having a more dichotomous approach to evidence, as iustrated by this view of non-cinica managers: [...] if they re an accountant it wi be purey based on cost effectiveness without ooking at the wider picture of your added vaue this technique may bring. T1M19 doctor This view was reciprocated by non-cinica managers: Party because peope spend more time critiquing the research paper than ooking at how we can impement it, or not impement it or how we can try it ourseves. That s how we get stuck sometimes, peope spending too much time focusing on their research, was it true was it evidence-based, did it have faws? T1M1 non-cinica manager A contested ground emerged, with each professiona group caiming a more rounded view of evidence and perceiving other groups as taking a one-dimensiona approach. The quest for evidence of doctors was driven primariy by pausibiity and accuracy to sef. The evidence sought was argey of a biomedica nature. Doctors appreciated that the cost-effectiveness of interventions was important but, as shown above, described non-cinica managers approach as too focused on the business case. Athough both the nursing group and the non-cinica managers group reported a reativey baanced mutidimensiona view to evidence, the motivation for sourcing a diverse evidence base was different for these two groups. Non-cinica managers took a mutidimensiona view to satisfy the major objective in their 18 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 organisationa roe, that is, to improve performance and outcomes. Nurses were driven primariy by the need to make the case for others and appreciated that different professionas had different evidence needs: Most of things I do are evidence-based. I woud be ooking for things such as standard of construction, standard of vaidation with processing that sort of thing. I can t honesty say that I can think of an instance that I did something where I didn t actuay have the evidence. T2M12 non-cinica manager Non-cinica managers were simiar to doctors in that the way they made sense of evidence was driven primariy by pausibiity and accuracy to sef, athough their sensemaking was based on different views of evidence. That is, what came to count as evidence for doctors and non-cinica managers was different, but what counted most was that they themseves were satisfied with the evidence. The nursing group differed markedy in this respect from the doctors and non-cinica managers. The nursing hybrid managers focused on the pursuit of evidence for pausibiity and accuracy for sef and others. For the nurses, what counted as evidence to others mattered equay and sometimes more than their own satisfaction with evidence. This shaped the types and sources of evidence used by nurses. In the nursing group, we found there was a high awareness of different types of evidence being reevant to different organisationa members. They appreciated the evidence needs of those working both at the front-ine and at more strategic eves, and the needs across professiona groups. Nurses were aso the ony group to make expicit reference to the perceptions of patients. Pausibiity to others thus featured highy in accounts by nurses. Nurses made purposefu attempts to frame evidence using anguage which was meaningfu and taiored to the audience. Nurses aso were aware of their own professiona roe and identity and how they were perceived by others that is, being refective on their own credibiity as sources of evidence. This non-cinica manager articuated this varying credibiity of the presenter of evidence: Athough it gas me to say it but I think the medica coeagues within the team are better at accessing [evidence] and they may come to a meeting and say I have had a ook at the evidence. I don t think it coud necessariy have been a systematic review of the evidence. Stating quite confidenty a particuar position and that coud be quite infuentia so that is something they are more ikey to do than nursing members of the team. T7M13 non-cinica manager Nurses therefore approached sourcing evidence in a systematic and comprehensive way in order to find evidence that was meaningfu and accurate for themseves as we as for significant others. There was a convergence towards synthesising diverse forms of evidence, but, utimatey, evidence synthesis was grounded in the biomedica paradigm. This was party a resut of their own training but aso refected a need to resonate with doctors, who were consistenty identified as infuentia stakehoders in organisationa decision-making: You wi see it in very speciaist nurses that they wi do scoping exercises around what the evidence is, systematic review around evidence of impementing a certain thing and cinica evidence to support it. I think the reason why nurses do that is because they know that the doctors, that are going to try and infuence [the decision], wi ask them for that evidence, so they aready do it. T1M2 nurse I think it is the avaiabiity of good quaity evidence and research something that wi convince the senior members and the medica staff that this is a good quaity piece of research, peer reviewed etc. T6M5 senior nurse Queen s Printer and Controer of HMSO 2014. 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. 19

CHALLENGES IN MAKING SENSE OF EVIDENCE I can remember quite ceary presenting to our anaesthetist body, some 200 odd anaesthetists on one of the cinica audit days, on a topic, [...] around ine care, and the changes we had made in the organisation. And there was one consutant, a specific consutant who d been a probem a the way through, he d not engaged we. We gave the presentation, we demonstrated what we d achieved in the organisation since we d introduced our changes in practice, and he actuay turned round in front of the other 200, and he said I change my opinion, he says, I accept what you ve been championing. And to be honest that was one of the most powerfu moments in my career, to get that individua to, in front of 200 of his coeagues, to turn round and say I ve seen the ight. [...] And sort of do, do the St Pau s Damascus moment, it was just, it was tremendous, [...] It was strongy presented with good, we used, took an epidemioogica approach to demonstrate that the changes we had made had had a significant impact. T8M1 nurse Nurses were aware of the use of evidence for different agendas, but overa perceived that evidence was used primariy for the benefit of patients in the context of financia constraints. This, in turn, ed to the need for combining different types of evidence (i.e. cinica effectiveness, cost, usabiity) to satisfy the perceptions and priorities of key organisationa stakehoders from doctors to managers. Doctors and non-cinica managers were both mindfu of issues of cost-effectiveness, particuary given that our sampe in phase 1 comprises senior managers. The findings from the quaitative interviews are vaidated by quantitative anaysis. The quantitative anaysis shows that nurses were aware of, and utiise more widey, the fu range of centray avaiabe evidence sources when compared with the other professiona groups (see Chapter 5). In addition, nurses were more formay engaged across the phases of the innovation process, whereas doctors were more formay invoved in the ater phases of technoogy adoption decisions and post-impementation evauation. The nursing group was, across the trusts, more formay tasked with making the case to diverse groups. Across respondent groups, pausibiity to sef was cosey inked with perceived accuracy of the evidence. This was infuenced by socia and persona identities situated within a wider organisationa context. For exampe, financia considerations were evident in the sensemaking of the majority of respondents. The infuences of the oca and macro context of financia parsimony added to the chaenges of making sense of evidence: Financia viabiity [...] that has rapidy changed, we have to justify everything that is new in terms of spending. T1M2 nurse Refection on this chapter In summary, a respondents reported that they experienced chaenges in making sense of evidence. Key issues that contributed to this were reported as a ack of capacity or skis to process presented evidence, a ack of time to thoroughy search for and review the evidence base, unawareness of appropriate iterature on management and impementation research and poor perceived quaity of avaiabe evidence. Professiona background and training couped with differentia access to different evidence reinforced some of the divergence in the type of evidence accessed. Pursuit of evidence to satisfy onesef or others was found to guide action and expained some of the compexity in the process of decision-making. Looking across the professiona groups, what counted as evidence for doctors and non-cinica managers was different, but what counted most was that they themseves (doctors 20 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 and non-cinica managers) were satisfied with the evidence. For the nurses, what counted as evidence to others mattered equay and sometimes more than their own satisfaction with evidence. This shaped the types and sources of evidence used by nurses. As regards perceived missing evidence, three research study types were identified by respondents: behavioura studies, impementation research, and organisationa and management research. Pharmacists were particuary mindfu of the need to understand behavioura change within organisations, particuary in reation to non-compiance with guideines. Queen s Printer and Controer of HMSO 2014. 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. 21

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Chapter 5 Making sense of evidence in the heath-care organisationa and macro context In this chapter we summarise findings on how non-cinica and cinica hybrid managers from various professiona backgrounds reported on how they make sense of evidence within the heath-care context. We review how they access and use different sources and types of evidence reated to innovation decisions and outine key contextua infuences at organisationa and macro eves within IPC and the NHS. This chapter draws on data from, first, the structured questionnaires embedded in the phase 1 interview schedue and, subsequenty, from the semistructured interviews themseves. We outine the espoused use of evidence by the decision-makers. First, we ook at the reported use of more genera sources of evidence (such as peer-reviewed journas, professiona networks, peers, the industry) to inform the decision-making of different professionas. Second, we outine the reported awareness and use of centra evidence sources incuding sources directy inked to IPC. Third, we outine responses on the use of different types of evidence (such as systematic reviews, guideines, economic cost anayses and expert opinion). In the fina sections, we deineate important infuences on the use of evidence by heath-care decision-makers from the organisationa context (main eve of anaysis) and the wider context. In the proceeding chapters we find out how this espoused use is actioned. Innovation decisions: evidence sources Figure 2 presents the use of more genera sources of evidence, such as peer-reviewed journas, professiona networks, peers and the industry, in decision-making by different professionas. Few non-cinica managers sourced peer-reviewed journas, either management or cinica. This group ceary veered towards centraised and standardised sources of evidence (Department of Heath agencies), interna updates and aso ocay derived evidence from other heath-care organisations. They were the ony group to source management consutants. These sources aign we with the organisationa roe of non-cinica managers as we as the diversity in professiona background of this group. Non-cinica managers were reported to show the east preference (15/25) for accessing evidence through their professiona networks out of the different professiona groups: doctors (22/24), nurses (53/61), pharmacists (10/10) and aied heath professionas (6/6). Nurses reported a uniform and consensus view within this group, reporting use of a wide range of sources. Doctors, aied heath professionas and pharmacists dispayed very simiar patterns of reported evidence use with a strong preference for professiona networks and most making use of academic institutions. Across the professiona groups, and not surprisingy given the context of the interviews was innovation, text books were not reported as an evidence source. Mass media was evident as a source for ony a few nurses and non-cinica managers. Peer-reviewed management journas were mentioned as a source by ony a few of the aied heath professionas. Queen s Printer and Controer of HMSO 2014. 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. 23

MAKING SENSE OF EVIDENCE IN THE HEALTH-CARE ORGANISATIONAL AND MACRO CONTEXT (a) Peer-reviewed journas academic Own knowedge 25 Peer-reviewed journas practitioner E-databases 20 Peer-reviewed journas cinica Academic institutions 15 10 Peer-reviewed journas manageria DH heath agencies 5 Textbooks management Management consutants 0 Textbooks cinica Doctors Industry Professiona networks Peers/coeagues Mass media Other heath organisations Interna updates Own work experience (b) Academic institutions DH heath agencies Management consutants Own knowedge E-databases Peer-reviewed journas academic 60 50 40 30 20 10 0 Peer-reviewed journas practitioner Peer-reviewed journas cinica Peer-reviewed journas manageria Textbooks management Textbooks cinica Nurses Industry Professiona networks Peers/coeagues Mass media Other heath organisations Interna updates Own work experience FIGURE 2 Evidence sources breakdown by professiona group. (a) Doctors; (b) nurses; (c) non-cinica managers; (d) aied heath professionas; and (e) pharmacists. DH, Department of Heath. (continued) 24 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 (c) Peer-reviewed journas academic Own knowedge E-databases 25 20 Peer-reviewed journas practitioner Peer-reviewed journas cinica Academic institutions 15 10 Peer-reviewed journas manageria DH heath agencies 5 Textbooks management Management consutants 0 Textbooks cinica Non-cinica Industry Professiona networks Peers/coeagues Mass media Other heath organisations Interna updates Own work experience (d) Peer-reviewed journas academic Own knowedge E-databases 6 5 4 Peer-reviewed journas practitioner Peer-reviewed journas cinica Academic institutions 3 Peer-reviewed journas manageria DH heath agencies Management consutants 2 1 0 Textbooks management Textbooks cinica Aied Heath Industry Professiona networks Peers/coeagues Mass media Other heath organisations Interna updates Own work experience FIGURE 2 Evidence sources breakdown by professiona group. (a) Doctors; (b) nurses; (c) non-cinica managers; (d) aied heath professionas; and (e) pharmacists. DH, Department of Heath. (continued) Queen s Printer and Controer of HMSO 2014. 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. 25

MAKING SENSE OF EVIDENCE IN THE HEALTH-CARE ORGANISATIONAL AND MACRO CONTEXT (e) Peer-reviewed journas academic Own knowedge 10 Peer-reviewed journas practitioner E-databases 8 Peer-reviewed journas cinica Academic institutions 6 4 Peer-reviewed journas manageria DH heath agencies 2 Textbooks management 0 Pharmacists Management consutants Textbooks cinica Industry Professiona networks Peers/coeagues Mass media Other heath organisations Interna updates Own work experience FIGURE 2 Evidence sources breakdown by professiona group. (a) Doctors; (b) nurses; (c) non-cinica managers; (d) aied heath professionas; and (e) pharmacists. DH, Department of Heath. Innovation decisions: awareness and use of centra evidence sources incuding sources concerning infection prevention and contro Figure 3 detais the reported awareness and use of centra evidence sources, incuding sources directy inked to IPC. Centra here refers to those sources avaiabe across professiona groups, generated by the Department of Heath or one of the Department of Heath s arm s ength bodies. (a) Rapid Review Pane Cean Safe Care website 25 Smart Ideas Former NHS PASA 20 Showcase hospitas The NHS Nationa Technoogy Adoption Centre 15 Design Bugs Out The NHS Institute for Innovation and Improvement The Nationa Innovation Centre 10 5 0 Smart Soutions Product surgeries Aware Used Knowedge transfer networks The Cochrane Library NIHR SDO NICE Centre for Evidencebased Purchasing NHS Evidence NPSA Nationa Service Frameworks 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. NHS PASA, NHS Purchasing and Suppy Agency; NPSA, Nationa Patient Safety Agency; SDO, Service Deivery and Organisation programme. (continued) 26 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 (b) Rapid Review Pane Cean Safe Care website 60 Smart Ideas Former NHS PASA 43 50 36 Showcase hospitas The NHS Nationa 36 40 38 Design Bugs Out Technoogy Adoption Centre 30 14 34 20 The NHS Institute for 43 Smart Soutions Innovation and Improvement 9 10 15 0 The Nationa 22 Product surgeries Innovation Centre 17 Knowedge transfer networks 17 14 53 The Cochrane Library Aware Used NIHR SDO Centre for Evidencebased Purchasing NHS Evidence 47 NPSA 60 Nationa Service Frameworks 45 NICE 59 (c) The Nationa Innovation Centre Rapid Review Pane Cean Safe Care website 25 Smart Ideas Former NHS PASA The NHS Nationa Technoogy Adoption Centre The NHS Institute for Innovation and Improvement 20 15 10 5 0 Showcase hospitas Design Bugs Out Smart Soutions Product surgeries Aware Used Knowedge transfer networks NIHR SDO Centre for Evidencebased Purchasing NHS Evidence NPSA NICE Nationa Service Frameworks The Cochrane Library 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. NHS PASA, NHS Purchasing and Suppy Agency; NPSA, Nationa Patient Safety Agency; SDO, Service Deivery and Organisation programme. (continued) Queen s Printer and Controer of HMSO 2014. 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. 27

MAKING SENSE OF EVIDENCE IN THE HEALTH-CARE ORGANISATIONAL AND MACRO CONTEXT (d) The NHS Nationa Technoogy Adoption Centre The NHS Institute for Innovation and Improvement The Nationa Innovation Centre Cean Safe Care website Former NHS PASA Rapid Review Pane 6 5 4 3 2 1 0 Smart Ideas Showcase hospitas Design Bugs Out Smart Soutions Product surgeries Aware Used Knowedge transfer networks The Cochrane Library NIHR SDO Centre for Evidencebased Purchasing NHS Evidence NPSA Nationa Service Frameworks NICE (e) The NHS Nationa Technoogy Adoption Centre The NHS Institute for Innovation and Improvement Rapid Review Pane Cean Safe Care website Former NHS PASA 10 9 8 Smart Ideas 7 6 5 4 3 2 1 0 The Nationa Innovation Centre Showcase hospitas Design Bugs Out Smart Soutions Product surgeries Aware Used Knowedge transfer networks The Cochrane Library NIHR SDO Centre for Evidencebased Purchasing NHS Evidence NPSA Nationa Service Frameworks NICE 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. NHS PASA, NHS Purchasing and Suppy Agency; NPSA, Nationa Patient Safety Agency; SDO, Service Deivery and Organisation programme. 28 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 The majority of respondents across the five professiona groups reported awareness of the NICE, the Nationa Patient Safety Agency (NPSA) and Nationa Service Frameworks. In addition, the majority reported using these sources and a nurses, pharmacists and aied heath professionas reported using NICE guideines. Comparativey, NHS evidence was ess known and, consequenty, ess used. The majority, with the exception of non-cinica managers, were aware of The Cochrane Library. Non-cinica managers reported use of Nationa Service Frameworks ess frequenty, which is broady in ine with their non-cinica roes. Overa, pharmacists and aied heath professionas dispayed very simiar patterns of reported awareness and use of centra sources. With regards to centra sources specific to IPC, non-cinica managers, aied heath professionas and pharmacists were east aware, with the former NHS Purchasing and Suppy Agency (PASA) being the ony source known, or reported to be used, by these respondents. Haf of the doctors were aware of the former NHS PASA, Cean Safe Care website, HPA Rapid Review Pane (RRP) and the Department of Heath s Showcase Hospitas programme, with fewer reporting using these sources. A arger proportion of nurses were aware, and reported use, of these sources. Across the professiona groups, a sma minority were aware of the Smart Soutions programme, Smart Ideas, Product Surgeries, Centre for Evidence Based Purchasing and the Nationa Technoogy Adoption Centre. Innovation decisions: perceived importance of evidence types Figure 4 detais responses on the perceived importance of different types of evidence (such as systematic reviews, guideines, economic cost anayses and expert opinion). As demonstrated in the quaitative anaysis, high importance was accorded to economic cost anaysis (incuding cost-effectiveness, cost benefit, cost-minimisation and cost utiity anayses) by the majority of respondents across the professiona groups. Overa, nurses gave high importance to a wide range of evidence types. Doctors responses peaked on guideines and systematic reviews; quantitative research was accorded high importance by the majority of doctors. Non-cinica managers were reported to pace high importance on the business case and reated evidence. They aso reported high preference for ocay generated evidence, such as empirica trias in other trusts, and the persona experience of coeagues. (a) Use by esteemed heath care Tria and pioting by your trust Suppier marketing Systematic review and meta-anaysis Rapid Review Pane recommendation Quantitative research studies Quaitative research studies Own research Mutipe case studies research Business case 20 18 16 14 12 10 8 6 4 2 0 Cohort studies Cross-sectiona surveys Economic cost anayses Empirica tria in other trusts Experience of coeagues Expert opinion Guideines Laboratory studies Mixed-methods research studies Impementation research Medium importance High importance 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. (continued) Queen s Printer and Controer of HMSO 2014. 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. 29

MAKING SENSE OF EVIDENCE IN THE HEALTH-CARE ORGANISATIONAL AND MACRO CONTEXT (b) Business case Use by esteemed heath care 50 45 Tria and pioting by your trust 40 35 Suppier marketing 30 25 Systematic review 20 and meta-anaysis 15 10 Rapid Review Pane 5 recommendation 0 Quantitative research studies Quaitative research studies Own research Mutipe case studies research Cohort studies Cross-sectiona surveys Economic cost anayses Empirica tria in other trusts Experience of coeagues Expert opinion Guideines Laboratory studies Mixed-methods research studies Impementation research Medium importance High importance (c) Business case Use by esteemed heath care 20 Tria and pioting by your trust 18 16 Suppier marketing 14 12 10 Systematic review and 8 meta-anaysis 6 4 2 0 Rapid Review Pane recommendation Quantitative research studies Quaitative research studies Own research Mutipe case studies research Mixed-methods research studies Cohort studies Cross-sectiona surveys Economic cost anayses Empirica tria in other trusts Experience of coeagues Expert opinion Guideines Impementation research Laboratory studies Medium importance High importance 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. (continued) 30 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 (d) Use by esteemed heath care Tria and pioting by your trust Suppier marketing Systematic review and meta-anaysis Rapid Review Pane recommendation Quantitative research studies Quaitative research studies Own research Mutipe case studies research Business case Cohort studies 4.5 5 Cross-sectiona surveys 3.5 4 Economic cost anayses 2.5 3 1.5 2 0.5 1 0 Empirica tria in other trusts Experience of coeagues Expert opinion Guideines Impementation research Laboratory studies Mixed-methods research studies Medium importance High importance (e) Business case Use by esteemed heath care 10 9 Tria and pioting by your trust 8 7 Suppier marketing 6 5 Systematic review and 4 meta-anaysis 3 2 Rapid Review Pane 1 recommendation 0 Quantitative research studies Cohort studies Cross-sectiona surveys Economic cost anayses Empirica tria in other trusts Experience of coeagues Expert opinion Medium importance High importance Quaitative research studies Guideines Own research Impementation research Mutipe case studies research Laboratory studies Mixed-methods research studies 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. Queen s Printer and Controer of HMSO 2014. 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. 31

MAKING SENSE OF EVIDENCE IN THE HEALTH-CARE ORGANISATIONAL AND MACRO CONTEXT Organisationa context: infuences on the use of evidence The tempora dimension emerged as a strong theme infuencing the use of evidence, but particuary so in the hospita context. The macro environment of infection contro in Engand was widey reported to have affected the nature and speed of decision-making in the hospitas studied. Notaby, pressures to make decisions did not aways aow the preferred evidence synthesis to inform decision-making: Change is forced upon you from my own persona experience in infection prevention and contro. For exampe, a few years ago we had a huge outbreak of C. difficie, so we had to do something immediatey in response, or peope s ives were at risk. You can t sort of gather evidence and then go through a the processes; you have to make an instant decision. I had to make a decision overnight, what we were going to do to prevent this outbreak escaating. So obviousy I was aware of the Department of Heath Guidance, other peope s experience. I had to make reasonabe rapid decision. T4M1 doctor The use of evidence stemming from poicy mandates featured, not surprisingy, in the accounts from non-cinica managers; in addition, simiar accounts were reported by other respondent groups with reference to non-cinica managers. The use of this type of evidence was infuenced not ony by the organisationa roe of non-cinica managers, but aso by the wider poicy context and pressures. These pressures, athough evident to other respondents to varying degrees, were nonetheess more acutey reevant to non-cinica managers. Respondents across a groups mentioned that the pressures in IPC were intensified by an organisationa and sometimes departmenta drive to urgenty respond to IPC issues: We again it comes, if you have individua areas within an organisation for whom a change is perceived by them as being very important, and so therefore they wi, if in a sort of unrefined way a deveopment resuts in increased patient benefit, the peope that practise in that area wi undoubtedy push very hard for that. They wi not necessariy be concerned about what the organisationa consequences of that change wi be. And so you require, that s the roe of senior management, is to try and, if you ike, harmonise audabe ambition in some areas with what can be practicay achieved for the best good of the patients as a whoe. T3M14 doctor High importance was reported to be given to meeting the organisationa IPC targets, as they constituted one of the key performance indicators for the trusts. In the respondents views, such pressures often resuted in staff feeing the necessity to act and make decisions rapidy. This had a tempora dimension, narrowing the time frame in which evidence coud be gathered, synthesised and used to inform decisions. As the quotes beow iustrate, many respondents perceived such pressures to adversey affect the quaity and effectiveness of organisationa decision-making: [...] I suppose the pressures often force rapid reactions which are often not particuary evidence based. And I think what we often find, is we respond quicky, in a et s do something way and then we ook back that actuay after a time the evidence for that wasn t fantastic, actuay we didn t reay ook at the evidence what we coud have done. T1M8 doctor For IPC, I just think sometimes they (the pressures) can act as a distraction and therefore prevent the proper eve of thoroughness we want around ooking at pans and seeing. T7M10 aied heath professiona However, for other respondents a thorough approach to evidence gathering and reviewing was primariy conditioned by intrinsic individua motivation and organisationa impetus for continuous improvement 32 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 and critica thinking. Hence, according to this group of respondents, poicy and organisationa pressures in IPC incentivised staff to ook out for innovations and source evidence in their quest to find soutions to probems: I woud say, [the pressure] incentivises the use of evidence; so if you take C. diff[icie] for exampe we ve tried to tap into a sorts of evidence to get on top of our C. diff[icie] rate. So if you take the, hydrogen peroxide, the ceaning, we ve neary exhausted a sorts of evidence base now to try and get on top of that figure. So I think it incentivises. You re aways striving, aren t you? Is there something ese out there that we haven t thought about that tackes a particuar infection? T4M5 nurse I think they (the pressures) incentivise. Because we re constanty under pressure, pressuring ourseves and pressure externay to improve things, it is an incentive to constanty ook for, to review our processes and ways of working. T9M1 nurse I don t think they inhibit I think there is more incentive to ook at new products to see what you are doing to criticay anayse where you are going and ook at the new innovations that are out there and what other trusts are doing. And constanty keep your eye on the ba so to speak. I think 10 years ago it was we have aways done this, we re aways going to do it, it has aways worked there is no probem and it was a bit ike putting your head in the sand. Whereas now you have constanty got to ook at what you re doing and why you re doing it. T6M5 nurse Data from the research interviews aso indicated diverse attitudes towards the use of evidence in decisions between the university-affiiated trusts (especiay T1, T5, T7 and T8) and the non-affiiated ones (T4 and T6). The atter are cassified as ess-research-orientated organisations, as documented in Chapter 6. It was reported by respondents in a university-affiiated trusts that there was an organisationa norm of high expectation to use evidence (or to show the use of evidence to others) to justify innovation decisions and change in practices. This organisationa norm was criticised as contributing to sowing down decisions: If you re ooking at, making change then it has to be justified, and therefore it is the quaity of the evidence that supports that change. So without that then it is unikey you re going to reay make much headway in an organisation, particuary in an organisation ike this. The big teaching hospitas, teaching trusts pride themseves on their academic status. The downside of that often is the academic attitude that they want the evidence to the highest degree, whereas intuitivey you re saying this wi work and wi make an improvement. And sometimes you reay have to sort of cross every t [and] dot every i to get there. [...] it sows, it reay sows the process down sometimes. T8M1 nurse Financia pressures were viewed by the respondents as a doube-edged sword with regards to the use of evidence. On one hand, such pressures were perceived to promote and incentivise the sourcing of evidence: When you ve got financia constraints I think if there is a good thing about financia constraints, I think it then actuay pushes you to ook for the evidence more to make the best of the resource that you have got... We have had, ike everywhere ese, difficut financia terms both within our research centre here and the trust itsef over a coupe of years. And it does make you ook much more carefuy at what you do. It is not atogether a bad thing to have financia constraints because it does make you reassess whether what you are doing is reay the most vauabe and what s the evidence, and what you are doing works the best and is there a better way of doing it. T5M2 aied heath professiona Queen s Printer and Controer of HMSO 2014. 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. 33

MAKING SENSE OF EVIDENCE IN THE HEALTH-CARE ORGANISATIONAL AND MACRO CONTEXT A prime exampe of how financia constraints promote the use of evidence in organisationa decision-making was found in T4. The trust experienced significant interna financia turmoi during the study period (see Chapter 6 for more information). This infuence from the organisationa context was reported to have nurtured the standardisation and formaisation of innovation decision mechanisms, increasing the demand for business cases, as we as requiring a more systematic and thorough assessment of the innovation evidence base: [...] maybe three years ago when I started here it was pretty reaxed in a sense that it was a trust that was in profit, [...] now we re a trust in deficit. We have a arge financia deficit and therefore the mechanisms for innovation and change have become more formaised, which isn t necessariy a bad thing because I think before perhaps they were too informa and perhaps parochia. So, woud go up to the medica director and say, I think this is a good thing, and, yes, it seemed a good thing and it woud happen. But the process now is more rigorous and therefore there is a financia eement, everything has a forma business case, ardy, ardy, ardy a. T4M2 pharmacist On the other hand, organisationa financia pressures were aso perceived to have inhibited the use of evidence, with a potentiay adverse impact on patient safety and care: It (the pressure) is a disincentive to use evidence when, for exampe, severe financia targets are ikey to reduce the number of stoo specimens we send for C. diff[icie] testing and that coud utimatey be harmfu to patients. T9M11 pharmacist Non-cinica managers were widey reported to focus on performance and tangibe organisationa outcomes. The non-cinica managers in our sampe have a range of educationa and professiona backgrounds incuding engineering, management, finance and accounting. More than any other professiona group in our study, they reported high preference for oca testing, and the generation of oca data to enabe them to identify rea improvement in service performance or cost-savings: If we were instaing a new type of ight fitting or new type of contro and it woud reduce our energy consumption then the evidence woud be reduced energy consumption, so evidence is the outcome reay. T1M9 non-cinica manager [...] Improvement in performance. What I woud see as evidence probaby woudn t be seen, as a scientist woud, I want to see the quaitative and quantitative evidence. Or quantitative measures of some improvement in a service that adopts an innovation. T2M11 non-cinica manager A research paper, a presentation, an abstract, something associated with a rea outcome any tangibe or rea outcome is assessed on the basis of the documentation that goes with it. T1M1 non-cinica manager If you are trying to put a case forward for something in particuary anything that is going to cost money you have to be abe to provide fast and hard evidence that is going to make a difference or what the different is whether it is quaity and improvement in standards. T2M2 non-cinica manager When asked about the use of evidence for assessing specific new products or activities, non-cinica managers amost unanimousy reported that they used as evidence primariy quantitative, hard data presented in documentary form. More importanty, they reported that what counted as evidence for them 34 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 was information demonstrating organisationa productivity improvements in their area of service. Their forma organisationa accountabiity and roe conditioned the acceptance as evidence of those sources of information that aowed them to identify such efficiency improvements. Macro context infuences on the use of evidence This section ooks at how, and to what extent, the macro context was reported in the research interviews to mediate the use of evidence. The quick pace of change, poicy, financia and cinica targets, pubic expectations and patient fear constituted the widey reported externa pressures infuencing the use of evidence in IPC. Some IPC poicy interventions, particuary infection targets, were perceived as being imposed and, at times gave rise to cinica scepticism, as this doctor reported: Imposed targets usuay are a disincentive to serve innovation I woud say. [...] I think with infection contro there is a cinica scepticism about the evidence base for a ot of the poicy. [...] Bare beow the ebows which is nationa poicy a ot of the infection diseases experts say there is no evidence for this at a. And this is an exampe of a nationa poicy that was imposed without providing any evidence. T1M19 doctor Such cinica scepticism was aso seen among senior doctors towards centra guideines: I suspect that it, a ot of change that is put down from above in terms of the ways in which hospitas function, the way in which we are expected to do things, often does not seem it, anyway, to come with a massive basis of evidence base behind it, tends to be, we think this woud be a good idea, sometimes with the brackets after it, we suspect this is what our poiticians woud ike us to do, and kindy do it. And I think we are sometimes very bad at stopping and saying, et us piot this and see whether it actuay does produce an advantage, athough there are downsides that have not yet been thought about, it s great unti we did it woud be a word that comes to mind. T6M3 senior doctor I think we are now are being bombarded, is a sighty strong word, but certainy the number of NICE guideines that appear on a monthy basis is quite substantia and those are pretty much, by the trust anyway, simpy accepted at face vaue. It isn t reay possibe to question NICE guidance now... I do have some concerns that whatever [the] NICE says is what must happen. I think that can, under certain circumstances, be a bad thing. T5M5 doctor In response to the perceived top-down approach, particuary in reation to poicies such as bare beow the ebows and no tie which were incuded as part of good practices, for exampe, in the Department of Heath s 2010 uniform and work wear guidance 78 some doctors insisted on seeing the evidence in support of this guidance, which was often seen by others as a tactic to justify their inaction in foowing such guideines: We convince peope that they need to wash their hands. There has been quite a few debates around that. Some of the consutants were saying it was not proven that you have to wash your hands. [...] It kind of makes sense, doesn t it, to wash your hands in between everything that you do. It s got to be better than not do it. So it s one of those things you just say, don t be siy. But for exampe, the issues about ties, the consutants were tod that they coudn t wear a tie, so the neuroogists a Queen s Printer and Controer of HMSO 2014. 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. 35

MAKING SENSE OF EVIDENCE IN THE HEALTH-CARE ORGANISATIONAL AND MACRO CONTEXT brought in a tie that they reguary used and they a cut the end off it. And they a had them cutured to prove that is no infection on the end of their tie I am quite sure they a washed them in the washing machine before they did it, but anyway. T5M1 aied heath professiona The foowing respondent indicated what motivated him to justify oca decisions (i.e. stick to oca antibiotic poicy) through exercising a greater eve of oca autonomy and not foowing a nationa recommendation by the Department of Heath at face vaue: I suppose they incentivise evidence when we have to justify not foowing a recommendation from the Department of Heath. So for exampe in certain areas we continue to use cephaosporin and quinoone antibiotics which are considered to be quite high risk for C. diff[icie]. We had to research the iterature to argue that there were potentia to detrimenta consequences to switching to ow risk antibiotics in certain popuations. T9M11 pharmacist In other cases, respondents taked about breathing space after some years of intense focus upon the impementation of certain innovations. Revaidation of innovations is seen under these circumstances to justify continuous use or discontinuance: [...] I suppose they (the pressures) often force rapid reactions which are often not particuary evidence based. And I think what we often find, is we respond quicky, in a et s do something way and then we ook back that actuay after a time the evidence for that wasn t fantastic, actuay we didn t reay ook at the evidence maybe what we coud have done. We had an experience of that where we thought maybe we shoud use this hydrogen peroxide in response to outbreaks of C. diff[icie] and there was a ot of activity around getting access to the machines etc., and then we ooked at it after a period of time and thought hang on actuay the evidence of this making any ong term difference is not robust so et s not do that. T1M8 doctor Externa drivers, incuding sudden financia constraints, appearance of competing aternative innovations or centra poicy changes, can aso act as triggers for rethinking and innovation. The foowing respondent indicated how ongoing sensemaking of ocay produced evidence was used to justify budgeting in T8: I think it is important when you re impementing a major change in a trust s hygiene poicy or whatever that you put in pace some kind of robust surveiance internay so that you can confirm and so that you know when it comes to the next round of financia budgeting that you ve actuay got data internay that aows you to justify. T8M2 doctor Some other IPC practices were seen as common sense without the expectation of evidence to back up action in this highy systematic way demanded by others: It did seem very ogica from our knowedge having an aseptic non-touch technique you can ook at the research. But aso from our knowedge of an aseptic non-touch technique it did, the methodoogy it reduced the risk of introducing infections into wounds or introducing infections into ines. You coud even say a no brainer this is just common sense that it s packaged around a methodoogy. T9M7 nurse The majority of respondents perceived either externa or interna pressures to improve IPC performance; however, most respondents identified more externa rather than interna pressures to pay an important roe. Regarding externa pressure at the nationa eve, targets or trajectories set by the Department of Heath or compiances reguated by the CQC or Monitor were the main source of concern for trust staff, 36 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 being expressed as a concern by approximatey haf of respondents; these were often pressures mandating prescriptive action by NHS staff. The expectations of patients or the pubic were the second argest pressure, being voiced as a pressure by approximatey one-third of respondents. Pubic expectations are often instigated or voiced through the mass media. The historica context aso payed a part. Other trusts poor performance on infection was pubicy severey scoded; as a resut, this created a high profie drive to maintain or raise the organisationa image: [...] a raised profie, I think as peope then started to get the education from the infection team that went aong with that high profie drive, and I think a ot of this was down to the fact a number of other trusts had been hit quite hard nationay and were being very pubicy berated for their poor infection performance. T9M3 nurse The third argest source of perceived externa pressure was from regiona authorities or commissioners, who impose financia penaties if the trust s performance is not met; this was identified by approximatey one-quarter of respondents. A few respondents aso commented that their pre-foundation-trust (FT) status became part of the environmenta pressures at the time of the interview. As the trusts performance on the main HCAIs can be key for successfu appication for FT status, this theme was considered to be of importance in reation to other externa pressures such as targets. Some respondents gave quaitative significance to unreaistic targets: We MRSA rates were dropped down dramaticay some years ago. It s somewhat irritating reay we have a miion patient come to us a year because our MRSA absoute number was about six. They said we need to haf that. You say hang on a minute there you have given an organisation somewhere ese the same size as us a target of 106, how does that stack up. They said it s about improving on your own performance, that s right but there is a point you get to when you say actuay if we hit three tota how we gonna get to one and a haf out of a miion patient contacts per year. That s just comes a bit absoute but nobody ese accepts the argument but that s what it be. T5M15 doctor Overa, the pressures in the views of respondents incentivised more than inhibited evidence sourcing for decision-making: I actuay think it has, I think it s improved the use of evidence because as the pressure s come on, and it s got harder and harder to meet the target, you start to ook more and more at what the evidence actuay is showing you and where you best target your resources. T4M10 nurse The evidence was often required to demonstrate very quick wins to persuade and convince others at some trusts: I think undoubtedy that the targets that we have to meet in terms of achieving certain goas within infection prevention are kind of here and now targets. So any innovations, any changes made have to be very kind of very quicky tangibe. And I think it woud be more difficut for the trust or departments to introduce changes that have a onger term affect. Because it woud be more difficut to kind of demonstrate the evidence potentiay or more difficut the justification to making changes that woud have effect 12 to 15 months down the ine. T4M11 nurse Queen s Printer and Controer of HMSO 2014. 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. 37

MAKING SENSE OF EVIDENCE IN THE HEALTH-CARE ORGANISATIONAL AND MACRO CONTEXT Respondents aso reported their reactive organisationa attitude through a fire-fighting attitude towards probem-soving: But I think we have to turn our activity to the prevention side. It s difficut because you need to dedicate the time to the prevention that invoves contro. The fire-fighting stuff is sti happening so it s reay difficut to kind of, to baance it. I think we need to invest more in the prevention side of it. T1M3 nurse However, T9 respondents indicated their more proactive organisationa attitude towards evidence use: I think our track record is that we ve taken a competey systematic approach to try and, to improve the infection contro performance within the organisation. And I think that s been right the way through from ensuring basic practice is improved, so things ike the, you know, naked beow the ebow, you know, appropriate dress code, hand washing poicies, audits and compiance around administration of IV [intravenous] antibiotic. A those, a those things where the evidence points to potentia for introduction of sources of infection. Isoation poicy, those type of things. So getting some of those fundamentas right, auditing them, and having a sustained programme of education, engagement and performance management. And we ve done that over severa years. So I think the, the state of pay in this organisation is one of, you know, ong term sustainabiity in terms of the way that we ve used evidence. T9M5 nurse Others reported mixed attitudes towards evidence use: [...] we fire-fight at the moment as an interim period but there are peope ooking forward at the future. So we are kind of taking a two-pronged approach. So we do have peope working on the ong-term. T3M9 non-cinica manager The attitude of hospita staff was affected by priority shifts at an organisationa eve: We have improved a ot recenty in our infection contro, so the pressure has eased, a ot of it, because that s what makes you worry sometimes, if the pressure from outside ease then the focus might ease. I m not saying that here, what wi be introduced is compacency, and peope are just in status quo, nothing is happening and we re not going to improve, and there s a ot of pressure from the financia side because to do something better you need financia support, and you d be arguing, I need this, I need this and, because they ve not got priority now, yeah. And then the infection contro wi move down [...], I m quite sure we have seen a ot of compacency creeping in. T6M6 doctor Thus, the perceived impact of externa pressures was often viewed to infuence evidence use in decision-making either directy or indirecty. Nurses and non-cinica managers inked use of evidence to justification of own decisions or persuading others, frequenty referring to the need for generation of oca evidence. Refection on this chapter Evidence sources and types were portrayed as variaby prioritised and used by decision-makers depending on their professiona background. Doctors reported a strong preference for science-based, peer-reviewed and pubished evidence. Nurses drew upon a wider range of evidence sources and types than a other groups in our study sampe. Non-cinica managers tended to prioritise evidence inked to productivity and cost improvements. They aso reported a preference for benchmarking information on impementation 38 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 produced by nationa-eve sources, and from oca trias in their own or other hospitas. Doctors and nurses prioritised evidence on the cinica efficacy and effectiveness of innovations. Non-cinica managers reied more on their own or peer experientia knowedge than doctors, who showed a preference for more systematic forms of knowedge. Non-cinica managers and nurses considered evidence on ease of use, incuding oca trias of innovative technoogies, to be of high importance. The quick pace and high magnitude of change in IPC, poicy, financia and cinica targets, high pubic expectations, the pursuit of creating a positive organisationa image, a drive for continuous improvement, intensified media pressures and scrutiny on hospita infections constituted the widey reported organisationa and externa pressures infuencing the use of evidence in IPC. According to the accounts of most respondents, such pressures incentivised and promoted the use of evidence in organisationa and cinica decisions. An additiona contextua pressure inked to research-engaged organisations was the reported organisationa norm of high expectations for the use of evidence, or the pubic demonstration of engagement with evidence for maintaining credibiity. Queen s Printer and Controer of HMSO 2014. 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. 39

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Chapter 6 Organisationa context: the macrocases of the eight NHS trusts studied In this chapter, our anaytic attention focuses mainy on the organisationa context (aso exporing key infuences beyond it) to eicit a historica and oca contextua dimension for each empirica site to hep better situate contemporary issues during the study period (2007 12). The findings presented in this chapter draw mainy on secondary data sources and are summarised in a cross-case comparative account. Contextua data heped us to outine key characteristics and recent trends of important factors in each of the eight macrocases, incuding trust size, ocaity, resources, espoused vaues and vision, critica contextua events, research and innovation activity, and communication patterns. Changes in key areas of trust performance, the magnitude of shocks and continuity in eadership are outined. The aim is to sensitise anaysis in subsequent chapters of the potentia impact of oca and historica contexts on the socia and organisationa processes reated to evidence access and utiisation. In addition, this chapter provides the audience with a means of transating findings to own context by comparing these wider contextua factors. Trust size and financia and human resources Tabe 4 shows basic characteristics of each trust trust size and number of site(s) and financia and human resources. This information was gathered from trusts annua reports and financia accounts for 2007/08, 2008/09, 2009/10, 2010/11 and 2011/12; trusts quaity accounts for 2009/10; and the CQC inspection reports on the prevention and contro of infections for 2009 and 2010. 79 Based on the number of staff, there appeared to be three different custers by trust size during the study period: (1) T1 and T7 as reativey arge organisations; (2) T5 and T9 as medium; and (3) T2, T3, T4 and T6 as reativey sma. This was refected in the financia turnover. Regarding the number of sites, T5 is the ony trust that operates in a singe site; T1 has three main sites and the remaining six trusts have two sites. The ast coumn of the tabe shows the ratio of the number of staff on the IPC team to the tota number of trust staff. These ratios appeared to be associated with the number of sites in each trust to some degree; for exampe, a singe-site trust, T5, had the owest ratio (0.12%), whereas the trusts that run more hospitas in mutipe sites had higher ratios. Organisationa vaues, vision and aims In this section, we assess organisationa vaues, vision or aims for each trust, based on argey trust-based secondary sources, but aso suppemented by quaitative interview data from phase 1. This is to provide some contextua background regarding principes (espoused and actioned) and perceived egitimacy and creditabiity. Organisationa vaues, vision or aims varied across the different trusts. Nevertheess, high-quaity, safe and integrated care was noted as the overarching core eement of the pubicy decared vaues, visions or aims for the majority of participating trusts. T7 was an exception and did not expicity articuate these aims but paced emphasis on patient-centred care or patient experience. Vaue for money or finance-reated eements were expressed by T2, T4, T5 and T6. Queen s Printer and Controer of HMSO 2014. 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. 41

ORGANISATIONAL CONTEXT: THE MACROCASES OF THE EIGHT NHS TRUSTS STUDIED TABLE 4 Trust size and financia and human resources Trust Number of beds (2009/10) Popuation covered (M) Number of staff (2007/08 2011/12) Financia turnover ( M) (2007/08 2011/12) Number of sites/ campuses IPC staff : trust staff ratio a (2010/11) T1 1600 1.9 (S), 3.0 (T) 9100 10,500 840 940 Mutisite 0.23% T2 1200 0.3 (S), > 2.0 (T) 5500 6000 340 420 Mutisite 0.17% (2008) T3 900 0.5 (S), 1.0 (T) 5700 7000 350 570 Mutisite 0.14% T4 1400 0.5 (S), 2.0 (T) 5800 6900 410 450 Mutisite N/A T5 1400 0.2 (S), > 1.0 (T) 8500 9900 570 760 Singe site 0.12% T6 900 > 0.5 3700 4500 270 350 Mutisite 0.31% T7 2300 0.5 (S), 1.7 (T) 11,900 13,700 690 860 Mutisite 0.30% T9 1100 1.3 (S), > 3.0 (T) 6700 7800 440 540 Mutisite 0.25% M, miion; NA, not appicabe; S, secondary care; T, tertiary care. a IPC staff refers to staff within the IPC team incuding the DIPC. Sources: trusts annua reports and financia accounts for 2007/08, 2008/09, 2009/10, 2010/11, 2011/12; trusts quaity accounts for 2009/10; and CQC s inspection reports on the prevention and contro of infections for 2009, 2010. 79 Research and/or innovation were aso a popuar vaue expressed in the majority of trusts. Exceptions were T3 and T6: T3 paced a stronger focus and efforts on teaching as a ess mature university-affiiated NHS trust, whereas T6 has shifted towards a focus on innovation but not research. T1 paced importance on innovation, couped with a focus on pride and achievement; respondents reiterated this desire and pressure to be seen as eaders and a centre of exceence for research. As part of their vision, vaues or aims, T1 and T3 incuded staff attitude/behavioura change eements. T3 coaborates with the oca medica schoo, and had a research strategy incuding behavioura medicine. Therefore, these organisations were highy conscious of heterogeneous behaviour in their practice a crucia eement in the pursuit of effective and sustainabe impementation of innovations. Staff engagement or teamwork is aso an important eement for the reaisation of behavioura change and enhancing a sense of ownership; notaby this theme constituted the vaues or vision of T2, T6, T7 and T9. The question arises of whether, and to what extent, these formay set out organisationa vaues, vision or aims were shared or tricked down to individuas or teams and how they then affected the use of evidence in manageria decisions. One senior respondent from phase 1 commented: [...] the cuture of the organisation is that we do want to be eading edge and we want to be innovative and we want our practice to be evidence base. But some of them are [...] either about persona about me because I ve an enquiring mind [...] but aso executive group and the team I work with are aso sort of have that cuture. So the infection contro team for exampe if we are ooking at a soution for something I woud work with Dr XXX, the Director of Infection Prevention and Contro, and we woud tak about something, and then she woud ook for either an evidence-based or if one didn t exist we d set something up. So there is something around the peope and the teams you work with and that generates sometimes from the bottom up. T7M5 nurse These informa, persona, as we as forma, rationa-poicy paradigms (which aigned with organisationa objectives, aims or vaues) were important aspects in heping to better understand how staff made sense of evidence within the organisationa context. An approach of inquiring minds was viewed to be inked to oca creativity, oca trias or first-ine innovation. In these cases, decision-making did not necessariy 42 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 invove an externay produced evidence base, but rather oca generation of evidence was encouraged. The same respondent articuated further: Obviousy my roe is around eading nursing but aso eading the cinica operations of the hospita. So when we are making decisions ideay we woud ook for an evidence base for those decisions which isn t aways possibe. And we woud try to use innovations from other centres, or the evidence from the research base. [...] I woudn t aways say it was research based or we woud ook for another innovation that had some evidence of success in another organisation or in another country. Of course that doesn t aways happen and decisions don t aways come with evidence base and some things we try, are sort of first-ine innovations. So we think of the idea and we try it. T7M5 nurse Another respondent, with a non-cinica background, suggested that managers strategic communication was articuated around reevance to patient experience, which was one of the organisationa aims at T7, as a means of convincing or persuading others (making sense for others): [...] inevitaby, we work with front ine teams and we choose certain ways of working there. We obviousy present at forma executive meetings and that often requires a different type of communication. I suppose going back to an earier point kind of presenting things from the patients experience can be something that unites from there to there. And that for me is an important consistency, it s about how you use patient experience and patient stories to improve communication. T7M13 non-cinica manager Thus, using reevant anguage ed to effective interconnectedness in engagement across different eves of peope, from front-ine to senior management, at T7. Trust performance and patient experience Tabe 5 shows the trusts recent performance on financia management and degree of quaity of care as we as the incidence of major HCAIs. The former was assessed through the Annua Heath Check, which was conducted by the Heathcare Commission (repaced by the CQC 80 in Apri 2009). The performance data on the incidence of MRSA bacteraemia and C. difficie infection came from the Heathcare Commission 81 /CQC 82 as part of the Annua Heath Check in earier years (2007/08 and 2008/09), and from the trusts themseves through their annua reports and/or quaity accounts in ater years (2009/10 onwards). Major HCAIs have been subject to mandatory surveiance, for exampe, MRSA bacteraemia since Apri 2001 and C. difficie infection since January 2004. 86 The number of cases for these HCAIs was assessed against their annua reduction targets (under mandatory surveiance) set externay by the Department of Heath. There was aso a oca target for each trust set by their respective strategic heath authority or primary care trust (as part of the Commissioning for Quaity and Innovation scheme), which was stricter than the nationa targets set by the Department of Heath for each trust. 87,88 We assessed the ast indicator in the tabe, patient experience, by using annua inpatient survey data that were reported by the CQC. As shown in the tabe footnotes, seven IPC-reated questions were seected in the foowing areas: (a) ceaniness of rooms and wards; (b) ceaniness of toiets and bathrooms; (c) posters regarding hand wash ges; (d) avaiabiity of hand wash ges; (e) hand ceaning (doctors); (f) hand ceaning (nurses); and (g) having enough nurses on duty. 83 85 Each of these indicators is assessed against the country s average; in other words, each datum fas into the category of either better, about the same or worse than country average. Sampe size for the annua inpatient survey (CQC) varied across the trusts, ranging from 292 to 508 patients (average 400 patients) in 2009, 2010 and 2011. 83 85 T1 had the owest response rate (average 37%, 316 patients) during the aforementioned period, whereas T4 tended to have the highest response rate (average 55%, 469 patients). The sampe size in this survey appears to be very sma, when compared with the actua number of inpatients (eective and non-eective) treated at each Queen s Printer and Controer of HMSO 2014. 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. 43

ORGANISATIONAL CONTEXT: THE MACROCASES OF THE EIGHT NHS TRUSTS STUDIED TABLE 5 Trust performance and patient experience Trust Annua Heath Check quaity of care (2007/08, 2008/09) a Annua Heath Check use of resources/financia management (2007/08, 2008/09) a T1 Good (2007/08); good (2008/09) Good (2007/08); good (2008/09) T2 Good (2007/08); exceent (2008/09) Exceent (2007/08); exceent (2008/09) T3 Exceent (2007/08); good (2008/09) Fair (2007/08); good (2008/09) T4 Exceent (2007/08); exceent (2008/09) Good (2007/08); fair (2008/09) T5 Fair (2007/08); good (2008/09) Good (2007/08); good (2008/09) T6 Good (2007/08); good (2008/09) Fair (2007/08); good (2008/09) Incidence of MRSA bacteraemia b (2007/08, 2008/09, 2009/10, 2010/11, 2011/12) Achieved (2007/08); achieved (2008/09); achieved (2009/10); underachieved (1.5 times higher) (2010/11); d underachieved (1.4 times higher) (2011/12) d Underachieved (1.7 times higher) (2007/08); e achieved (2008/09); achieved (2009/10); achieved (2010/11); f achieved (2011/12) f Underachieved (1.5 times higher) (2007/08); achieved (2008/09); achieved (2009/10); achieved (2010/11); f achieved (2011/12) d Achieved (2007/08); achieved (2008/09); achieved (2009/10); achieved (2010/11); f achieved (2011/12) d Achieved (2007/08); achieved (2008/09); achieved (2009/10); underachieved (1.2 times higher) (2010/11); e achieved (2011/12) d Underachieved (1.4 times higher) (2007/08); achieved (2008/09); achieved (2009/10); achieved (2010/11); d underachieved (1.4 times higher) (2011/12) d Incidence of C. difficie infection b (2007/08, 2008/09, 2009/10, 2010/11, 2011/12) N/A (2007/08); achieved (2008/09); achieved (2009/10); achieved (2010/11); d underachieved (1.1 times higher) (2011/12) d N/A (2007/08); achieved (2008/09); achieved (2009/10); achieved (2010/11); f achieved (2011/12) f N/A (2007/08); achieved (2008/09); achieved (2009/10); achieved (2010/11); d achieved (2011/12) d N/A (2007/08); achieved (2008/09); achieved (2009/10); achieved (2010/11); f achieved (2011/12) d N/A (2007/08); achieved (2008/09); achieved (2009/10); achieved (2010/11); e achieved (2011/12) d N/A (2007/08); achieved (2008/09); achieved (2009/10); achieved (2010/11); d achieved (2011/12) d Adut inpatient survey resuts regarding IPC-specific questions (2009, 2010, 2011) c Overa rating Worse in (c) and (d); better in (e) in 2009. Improved from 2010 onwards about the same for a 2, 2, 0, 1, 1 = 6 Consistenty about the same for a indicators throughout 2009 11 2, 2, 1, 2, 2 = 9 Worse in (e) in 2010. About the same for remaining indicators during 2009 and 2010 2, 1, 1, 2, 1 = 7 Worse in (c) during 2009 and 2010, but improved in 2011. About the same for remaining indicators throughout 2009 11 2, 1, 2, 2, 0 = 7 Consistenty about the same for a indicators throughout 2009 11 1, 2, 1, 2, 2 = 8 Consistenty about the same for a indicators throughout 2009 11 2, 1, 0, 2, 2 = 7 44 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Trust Annua Heath Check quaity of care (2007/08, 2008/09) a Annua Heath Check use of resources/financia management (2007/08, 2008/09) a Incidence of MRSA bacteraemia b (2007/08, 2008/09, 2009/10, 2010/11, 2011/12) Incidence of C. difficie infection b (2007/08, 2008/09, 2009/10, 2010/11, 2011/12) Adut inpatient survey resuts regarding IPC-specific questions (2009, 2010, 2011) c Overa rating T7 Exceent (2007/08); exceent (2008/09) Exceent 2007/08); exceent (2008/09) Achieved (2007/08); achieved (2008/09); achieved (2009/10); achieved (2010/11); d achieved (2011/12) d N/A (2007/08); achieved (2008/09); achieved (2009/10); achieved (2010/11); d underachieved (1.3 times higher) (2011/12) d Better in (g) in 2010 ony. Consistenty about the same for the rest throughout 2009 and 2011 2, 2, 2, 1, 2 = 9 T9 Good (2007/08); fair (2008/09) Good (2007/08); good (2008/09) Underachieved (1.5 times higher) (2007/08); underachieved (1.1 times higher) (2008/09); achieved (2009/10); achieved (2010/11); d achieved (2011/12) d N/A (2007/08); achieved (2008/09); achieved (2009/10); achieved (2010/11); d achieved (2011/12) d Consistenty about the same for a indicators throughout 2009 11 1, 2, 0, 2, 2 = 7 N/A, not appicabe. a Care Quaity Commission 2008/09 NHS performance ratings: overa and component eve scores. 80 b Heathcare Commission Data set for the 2007/08 new nationa targets assessment; 81 CQC 2008/09 NHS performance ratings: existing commitments and nationa priorities indicator scores. 82 c CQC s annua inpatient survey 2009, 2010 and 2011. 83 85 d Trusts quaity accounts 2010/11, 2011/12. e Trusts infection (prevention and) contro annua report 2007/08, 2010/11. f Trusts annua reports and financia accounts 2010/11, 2011/12. For the assessment of adut inpatient survey resuts, seven IPC-reated questions were seected in the foowing areas: (a) ceaniness of rooms and wards; (b) ceaniness of toiets and bathrooms; (c) posters regarding hand wash ges; (d) avaiabiity of hand wash ges; (e) hand ceaning (doctors); (f) hand ceaning (nurses); and (g) having enough nurses on duty. Score 0, two outcomes in sub-optima performance (i.e. fair/underachieved/worse); score 1, one outcome in sub-optima performance; score 2, no outcome in sub-optima performance, but a in optima or good performance (i.e. good/exceent/achieved/better/about the same). Overa rating for trust performance and patient experience :, worse, score 6;, moderate, score 7 8;, better, score 9. Queen s Printer and Controer of HMSO 2014. 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. 45

ORGANISATIONAL CONTEXT: THE MACROCASES OF THE EIGHT NHS TRUSTS STUDIED trust; for exampe, in the case of T3, the sampe in the survey represented approximatey 0.6% of the inpatients during 2010/11 and this itsef has attracted mixed reactions from NHS organisations over the years. Nevertheess, these were the ony officiay avaiabe inpatient survey data that aowed comparison across the trusts. The overa rating shows the resut of the aforementioned indicators around trust performance and how patients thought about the trust in reation to IPC practices. T3, T4, T5, T6 and T9 achieved reativey moderate scores on performance and patient experience. T2 and T7 had a better overa rating, whereas T1 had the worst overa rating among the participating trusts. Notaby, T1 appeared to be strugging to meet the targets for MRSA bacteraemia and/or C. difficie infection between 2010/11 and 2011/12. The resuts in Tabe 5 masked some reaities and additiona pressures faced in IPC. First, the targets for MRSA bacteraemia and C. difficie infection have become tougher in recent years. A trusts had the MRSA bacteraemia target of 10 or ess, and haf the trust cases (T2, T4, T6 and T9) set MRSA bacteraemia targets of five or ess during 2011/12. This embodied an enormous externa pressure for these trusts, which was echoed in the interviews with managers in each trust (previousy discussed in Chapter 5). One respondent expained as foows: We they get tighter based on previous year s performance when you come in under ast year s target and then you find that it has been brought way, way ower. T7M2 nurse These HCAI issues were perceived to be of higher importance in trusts submitting FT appications. Second, improvements in the reduction of HCAI cases can be masked by setting higher targets; as a resut, despite a reduction in HCAI cases the reative performance score against targets might show deterioration. Third, through technoogica advancement towards a more sensitive and accurate test, incuding new assay kits for C. difficie that used improved moecuar techniques, more C. difficie cases were detected in the aboratories. This can have negative add-on effects on the trust; in other words, the trust coud not meet the target and, therefore, had to seek a more reaistic target and negotiate with commissioners. Fourth, as a resut of restructuring, incuding mergers, the standardisation of processes and systems became a the more important. The deay in the standardisation/streamine of information systems across the different sites, as we as the standardisation of assay methods for microorganisms across the different sites, raised serious concerns in some trusts, as they coud not simpy merge the data between the sites for anaysis and management and, moreover, coud not compare the data and spot the negative outiners for action within the trust. Fifth, in a more gobaised word, the emergence and threats of pandemics of new microorganisms have posed a huge chaenge to NHS trusts. Finay, other microorganisms were recenty added to mandatory surveiance: for exampe, methiciin-sensitive Staphyococcus aureus (MSSA) bacteraemia since January 2011 and Escherichia coi bacteraemia since June 2011. 86 This imposed extra pressure on trusts. As expained in Chapter 5, according to the interview data, some trust managers voiced concerns that these new targets, as we as increasingy unreaistic/tougher targets, contributed to significant externa pressures. Magnitude of shocks, crises and critica events Tabe 6 gives a picture of the magnitude of shocks, crises and critica events at each trust during the study period. The first (mergers, redeveopments/expansions, FT appication/status attainment) and the third (continuity of eadership CEO and DIPC) indicators represent inner shocks, and the ast indicator (heath 46 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 TABLE 6 Magnitude of shocks, crises and critica events Trust Mergers, redeveopments/expansions, FT appication/status attainment a,b T1 Merger of two trusts and integration with a oca university in the mid to ate 2000s; a series of improvements of infrastructure and equipment, costing 60 70M annuay during the ate 2000s. Expected to submit a FT appication in 2013 T2 Merger in the mid-1990s; a series of redeveopment projects over recent years, incuding a 90M redeveopment of hospitas that was competed in the ate 2000s; the new hospita redeveopment project (under PFI scheme) was under way at the time of the study, costing over 400M and to be finished in the mid-2010s. Expected to be approved as a FT shorty after the study T3 In the ate 2000s, the redeveopment, expansion and refurbishment of faciities and buidings occurred through the investment of over 50M atogether. A 400M hospita redeveopment with new state-of-the-art faciities newy approved by a strategic heath authority in the eary 2010s. The main construction work was expected to begin in 2013. Aimed to submit a FT appication in 2013 Trust financia crisis a (a trust s year-end position 2007/08 2011/12) [deficit as percentage of NHS trust turnover (%)] Dramaticay fuctuated over recent years, with deficits of 59.3M [7.1%] (2008/09) and 20.5M (2011/12) adjusted retained deficit of 8.4M [0.9%] (2011/12) 2009/10 saw a deficit of 15.9M (adjusted retained surpus of 4.0M), foowed by a recovery with consecutive surpuses of 4.8M (2010/11) and 6.0M (2011/12) adjusted retained surpuses of 4.4M (2010/11) and 5.5M (2011/12) After some consecutive years of retained deficits the trust achieved a stabe position in the ate 2000s, but has experienced difficut financia years recenty, with deficits of 12.1M [2.2%] 2010/11 and 16.2M [2.8%] 2011/12 Continuity of eadership a (CEO, DIPC) Unstabe CEO position (changed twice in the mid to ate 2000s and eary 2010s); stabe DIPC (from the mid to ate 2000s onwards) Unstabe CEO and DIPC position in the mid to ate 2000s and then became stabe CEO changed twice in the mid to ate 2000s and in the eary 2010s; DIPC changed twice in the ate 2000s and eary 2010s Heath profie c (the Network of Pubic Heath Observatories) (2008 12) Overa rating 0.0 (2008 09), 2.0 (2009 10), 0.0 (2010 11), 3.0 (2011 12) 3, 2, 1, 3 = 9 2.6 (2008 09), 4.8 (2009 10), 1.0 (2010 11), 0.0 (2011 12) 2, 0, 2, 3 = 7 2.6 (2008 09), 4.0 (2009 10), 0.4 (2010 11), 1.3 (2011 12) 2, 2, 2, 3 = 9 continued Queen s Printer and Controer of HMSO 2014. 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. 47

ORGANISATIONAL CONTEXT: THE MACROCASES OF THE EIGHT NHS TRUSTS STUDIED TABLE 6 Magnitude of shocks, crises and critica events (continued) Trust Mergers, redeveopments/expansions, FT appication/status attainment a,b Trust financia crisis a (a trust s year-end position 2007/08 2011/12) [deficit as percentage of NHS trust turnover (%)] T4 Through a > 250M major redeveopment under PFI scheme, the creation of a modern and fit-for-purpose hospita with state-of-the-art faciities competed in the ate 2000s. Estabished the FT Project Board during study, and aimed to submit its appication by 2013 Punged into deficits of 6.1M [1.4%] (2008/09) and 77.1M [17.8%] (2009/10); this was foowed by a swift recovery with retained surpuses of 6.0M (2010/11) and 1.8M (2011/12) adjusted retained surpus of 0.1M (2011/12) T5 Merger of two trusts in the eary 2000s. In the ate 2000s, many hospitas/services reocated under new hospitas deveopment ( 500M under PFI). Became a FT in the ate 2000s The 2009/10 saw a huge deficit of 179.8M [27.2%], foowed by a great recovery with a deficit of 3.6M [0.5%] (2010/11) and a surpus of 56.1M (2011/12) T6 Merger of two trusts in the ate 1990s. Became one of the first trusts that breached the Hygiene Code; warned by the Heathcare Commission in the mid to ate 2000s. Expected to become a FT shorty after the study Recorded reativey gradua consecutive fas from 2007/08 to 2009/10, with a deficit of 9.6M [2.9%] in 2009/10; however, 2010/11 saw a heathy recovery with a surpus of 3.1M, foowed by an adjusted retained surpus of 2.2M during 2011/12 T7 Merger of two trusts in the eary 2000s. Became a FT in the mid-2000s. A series of redeveopment, expansion and refurbishment projects across the hospitas, costing approx. 100M over recent years; the majority of new hospita faciities opened in the ate 2000s Recorded consecutive fas, in particuar a deficit of 54.2M [6.9%] in 2009/10; this was foowed by a recovery with surpuses of 4.4M (2010/11) and 8.0M (2011/12) Continuity of eadership a (CEO, DIPC) Stabe CEO (from the mid-2000s onwards); DIPC changed in the eary 2010s Stabe CEO (from the eary 2000s onwards) and DIPC (from the ate 2000s onwards) Unstabe CEO position in the eary 2010s; DIPC changed in the ate 2000s Unstabe CEO position in the mid to ate 2000s; stabe DIPC (from the mid-2000s onwards) Heath profie c (the Network of Pubic Heath Observatories) (2008 12) Overa rating 1.3 (2008 09), 1.3 (2009 10), 1.4 (2010 11), 0.3 (2011 12) 2, 3, 1, 4 = 10 0.5 (2008 09), 3.1 (2009 10), 1.2 (2010 11), 1.1 (2011 12) 2, 4, 0, 2 = 8 3.5 (2008 09), 0.0 (2009 10), 0.5 (2010 11), 0.0 (2011 12) 1, 1, 2, 1 = 5 2.5 (2008 09), 3.0 (2009 10), 0.0 (2010 11), 1.2 (2011 12) 1, 1, 1, 2 = 5 48 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Trust Mergers, redeveopments/expansions, FT appication/status attainment a,b Trust financia crisis a (a trust s year-end position 2007/08 2011/12) [deficit as percentage of NHS trust turnover (%)] Continuity of eadership a (CEO, DIPC) Heath profie c (the Network of Pubic Heath Observatories) (2008 12) Overa rating T9 The trust was formed in the eary 1990s. Major hospita deveopments began in the ate 2000s with the investment of 30M. This was foowed by a 60M extension of hospita buidings in the ate 2000s. Became a FT during study Recorded reativey gradua consecutive fas with deficits of 2.3M [0.5%] (2009/10) and 4.3M [0.8%] (2010/11), but demonstrated a sight recovery ast year, to a deficit of 0.3M (2011/12) adjusted retained surpus of 3.9M (6 months ended 31/03/12, adjusted retained surpus) Stabe: CEO (from the mid-2000s onwards) and DIPC (from the mid-2000s onwards) 6.0 (2008 09), 2.0 (2009 10), 2.0 (2010 11), 1.0 (2011 12) 2, 2, 0, 3 = 7 PFI, private finance initiative. a Trusts annua reports and financia accounts 2007/08, 2008/09, 2009/10, 2010/11, 2011/12. b CQC s inspection reports on the prevention and contro of infections 2009, 2010. 79 c The Network of Pubic Heath Observatories heath profie data 2008, 2009, 2010, 2011 and 2012. 89 Square brackets indicate a deficit. The transition of financia methodoogy from UK Generay Accepted Accounting Principes to Internationa Financia Reporting Standards occurred during 2009/10. Heath profie data consider five domains composed of 32 indicators: (1) our communities (deprivation; proportion of chidren in poverty; statutory homeessness; achieved five A* C GCSEs incuding Engish and mathematics; vioent crime; ong-term unempoyment); (2) chidren s and young peope s heath (smoking in pregnancy; breast feeding initiation; obese chidren year 6; acoho-specific hospita stays under 18; teenage pregnancy under 18); (3) aduts heath and ifestye (aduts smoking; increasing and higher-risk drinking; heathy eating aduts; physicay active aduts; obese aduts); (4) disease and poor heath (incidence of maignant meanoma; hospita stays for sef-harm; hospita stays for acoho-reated harm; drug misuse; peope diagnosed with diabetes; new cases of tubercuosis; acute sexuay transmitted infections; hip fracture in those aged 65 years); and (5) ife expectancy and causes of death (excess winter deaths; ife expectancy mae; ife expectancy femae; infant deaths; smoking-reated deaths; eary deaths heart disease and stroke; eary death cancer; road injuries and deaths). Each datum was cacuated against the Engand average. Aggregated number of indicators was counted: e.g. pus 1 for each significanty better, ni for each not significanty different and minus 1 for each significanty worse. For trusts that operate in more than one oca area, the data from these oca areas was aggregated and its average figure was taken into account for the fina assessment. The difference of score between significanty better and significanty worse was counted for each year, and then each year was compared against the previous year to observe the change in score. These scores are shown within the coumn Heath profie in an attempt to capture the change in heath profie indicators for each year (2008 09, 2009 10, 2010 11, 2011 12). A trust scored 3 if the score change was 4.0, < 2.7; scored 2 if it was 2.7, < 1.3; scored 1 if it was 1.3, < 0; and scored 0 if it was 0. If the change of scores against previous year was < 0, this meant the trust had an overa environmenta shock ocay, and the score represented the degree of shock. The scores were then aggregated per trust to obtain the fina scores, which were considered for the assessment of category Heath profie. Assessment of overa rating: Score 0, no mergers, redeveopments/expansions and FT appication/status attainment during study period; score 1, either redeveopments/expansions or FT appication/status attainment during study period; score 2, both redeveopments/expansions and FT appication/status attainment during study period; score 3, experienced a (merger, redeveopments/expansions and FT appication/status attainment) during study period. Magnitude of trust financia crisis as aggregated score for Deficit as percentage of NHS trust turnover (%) during the study period: the trust scored 1 if it was 0.5%, < 9.4%; scored 2 if it was 9.4%, 18.3%; and scored 3 if it was > 18.3%, 27.2%. Score 0, stabe eadership for both CEO and DIPC; score 1, unstabe eadership for either CEO or DIPC; score 2, unstabe eadership for both CEO and DIPC. Overa rating for magnitude of shocks :, reativey ow eve of shocks, score 5 6;, moderate eve of shocks, score 7 8;, reativey high eve of shocks, score 9 10. Queen s Printer and Controer of HMSO 2014. 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. 49

ORGANISATIONAL CONTEXT: THE MACROCASES OF THE EIGHT NHS TRUSTS STUDIED profies from the Network of Pubic Heath Observatories 89 ) was seected as an outer constraint. The second indicator, a trust s year-end position, considers both inner and outer financia shocks. T1 was the ony trust that went through a merger process during the period observed (from 2007/08 onwards). The majority of trusts (except for T6) had gone, or were going, through hospita (re)deveopment, expansion/extension or refurbishing processes to modernise the hospitas with purpose-buit, state-of-the-art technoogy buidings and faciities. This coincided with the government s Deep Cean Programme, which aimed at enhancing patients hospita experience and improving hospitas pubic image. According to the Department of Heath s Cean, safe care: reducing infections and saving ives, reeased in January 2008, 6 a tota of 57.5M was invested in the Deep Cean Programme for a hospitas across the country during 2007/08 and these hospitas were expected to compete the programme by the end of March 2008. IPC team members were often invoved in the panning/designing stages of the redeveopment, expansion and refurbishment, and gave advice to ensure that the new buidings and faciities were IPC sensitive/friendy (i.e. T3). A non-ft hospitas are now attempting to gain foundation status, consistent with government pans. The FT appication invoves a ong process mobiising oca peope and key oca organisations, setting up governors councis, a of which requires much energy and effort from the trust as an organisation. Some trusts seem to have taken a strategic approach to when they shoud appy for FT status; for exampe, T3 considered the timing to become a FT, and intentionay deayed its appication process, as they were aso considering major hospita redeveopment during the same period. It is ogica for T3 to have focused on controing the major HCAIs (MRSA bacteraemia and C. difficie infection) before embarking on the foundation appication. An outier among our sampe is T6, which was subject to a significant additiona shock as one of the first trusts to breach the Hygiene Code and be warned by the Heathcare Commission. Regarding the year-end financia position for trusts, the great majority of participating trusts experienced deficits during the observed period. Anaysis of the degree of each trust s financia crisis, by the borrowing indicator deficit as percentage of NHS trust turnover (%), 90 reveaed that T4 and T5 portrayed a more severe degree of deficit, 17.8% (2009/10) at T4 and 27.2% (2009/10) at T5, than other trusts, which showed deficits < 10% of turnover. This was echoed in the interviews with T4 and T5 respondents during phase 1. Moreover, finance as a newy emerged priority was prevaent in the interviews with respondents from T3. Our findings from phase 1 were consistent with the secondary sources. The continuity of eadership is aso a key factor when considering the extent of inner shocks. T5 and T9 enjoyed the continuing eadership of both the CEO and the DIPC during the observed period, whereas T2, T3 and T6 experienced changes of both eaders (CEO and DIPC). The remaining trusts (T1, T4 and T7) had a moderate inner shock, experiencing changes of either the CEO or the DIPC. Heath profie indicators appeared to be associated with the ocation of each trust. Trusts within centra/north Engand had poorer oca popuation heath profies than their counterparts in south Engand and London. 89 The heath profie indicators were reviewed for changes over recent years (2008 12). We attempted to interpret this as part of the outer shock/constraint in the oca area(s) where each trust operated. According to the overa ratings for each trust, T1, T3 and T4 experienced reativey severe inner and outer shocks, whereas T6 and T7 experienced much mider impacts. T2, T5 and T9 experienced moderate shocks and crises during the observed period. There are some caveats when interpreting the data in Tabe 6. First, treating each indicator in Tabe 6 equay can be probematic. There is a risk of underestimating a possibe tremendous effect: for exampe, the recent merger in T1, which is currenty operating five hospitas across three major hospita sites, may have varying short-term and ong-term shocks. A merger of an organisation is a disruptive process, 50 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 especiay when constituent organisations have hed strong individua identities and pride. There is a need to consoidate structura and cutura differences, poitica capita and power cashes. It is aso a time-consuming process. For exampe, T5 underwent a merger in the eary 2000s and, during the study period, found itsef in a situation in which it had been freed from demarcation ony recenty. One respondent suggested: A ot of it (demarcation) is broken down now. When the XXX hospita trust merged with the YYY hospita trust in [... ], it has taken us probaby 8 or 9 years to break down our organisationa roes. T5M3 non-cinica manager Second, a combination of certain crises might have an exponentia effect rather than simpy being aggregated. Third, how quicky the changes in heath profie indicators might have an impact on the trust at an organisationa eve is unknown. Moreover, the Network of Pubic Heath Observatories warns us that a green circe [better than Engand average] may sti indicate an important pubic heath probem in its heath summary chart for each geographica area. 89 Nevertheess, one can say that each category within the tabe, to a arge extent, iuminates the degree of shocks, critica events and crises internay (within the trust) and externay (in the oca areas), and the overa rating can give us a favour of recent changes of inner (in terms of structura, financia, manageria) and outer (oca popuations) contextua conditions where each trust has been operating. Research activity To assess the research activity domain at each trust, we seected five aspects based on secondary data: (a) university affiiation [with medica and/or nursing schoo(s)]; (b) forma research organisationa structure that ooked at the existence of research and innovation divisions, BRC, BRUs, AHSC and other research-reated organisationa structures; (c) research-supporting infrastructure and research initiatives, such as research forums, toos, networks, research training and access to eectronic resources; (d) intensity of research activity reported, as captured by the number of cinica research studies, the number of studies supported by the Nationa Institute for Heath Research (NIHR), the number of Research Passports issued and the number of pubications; and (e) IPC-reated evauations or trias reported by the trust, for exampe, a tria of the siver aoy urinary catheter. The figures in Tabe 7 show the aggregated number of the data: for exampe, we counted 1 for forma research organisationa structure if the trust reported its AHSC status. Regarding intensity of research activity reported, a the data were not aways avaiabe from a the trusts, but we attempted to compare the possibe maximum avaiabe indicators across the trusts. Within this chapter, the quantitative data set for each variabe was divided into three groups according to tertie distribution. The cut-off points in each scoring tabe or the formua under each tabe were cacuated based on this approach and each group was given a score accordingy. If it was infeasibe to give the equa scae to these three groups, sighty more weight was usuay given to the midde tertie and the upper and bottom terties were aways given equa weight. These scores were aggregated per trust in each domain in order to obtain an overa rating in a simiar fashion to scoring through the appication of the tertie distribution. For exampe, when the tota scores for a trusts in the Research activity domain ran from 3 to 12, we assigned to the bottom tertie (3 5) refecting fewer research activities, to the midde tertie (6 9) indicating a moderate number of research activities and to the upper tertie (10 12) refecting a greater number of research activities. There is a significant difference between two custers of trusts: university-affiiated trusts and non-affiiated trusts. The atter (T4 and T6) were ess research orientated, reporting fewer research activities. Among the university-affiiated trusts, T1, T5 and T7 seem to have taken a particuary strong research stride, Queen s Printer and Controer of HMSO 2014. 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. 51

ORGANISATIONAL CONTEXT: THE MACROCASES OF THE EIGHT NHS TRUSTS STUDIED TABLE 7 Research activity (reported 2007/08 spring 2011) Trust [a] [b] [c] [d] [e] Overa rating (tota score) T1 Medica 29 29 6 11 (1+3+2+2+3=11) T2 Medica 17 37 3 3 (1+2+2+2+1=8) T3 Medica 5 43 1 2 (1+1+3+1+1=7) T4 N/A 1 24 3 1 (0+1+1+2+1=5) T5 Medica 14 48 8 10 (1+2+3+3+3=12) T6 N/A 3 19 0 1 (0+1+1+0+1=3) T7 Medica; nursing 14 45 7 7 (2+2+3+3+2=12) T9 Medica 10 40 2 5 (1+2+3+1+2=9) N/A, not appicabe. [a] University affiiation [with medica and/or nursing schoo(s)]. [b] No. of forma research organisationa structures. [c] No. of research-supporting infrastructures and research initiatives. [d] Aggregated score for intensity of research activity reported (2009/10). [e] No. of IPC-reated evauations reported. The figures (tota scores) within parentheses show the scores cacuated based on the tabe beow. Key [a] [b] [c] [d] [e] Overa rating Scored 2 when it was affiiated to both medica and nursing schoos Scored 3 when the aggregated number was 21 29 Scored 3 when the aggregated number was 39 48 Scored 3 when the score was 7 8: a greater number of reevant activities was reported Scored 3 when the aggregated number was 9 11 Assigned when the tota score was 10 12: a greater number of research activities Scored 1 when it was affiiated to either medica or nursing schoo Scored 2 when the aggregated number was 10 20 Scored 2 when the aggregated number was 29 38 Scored 2 when the score was 3 6: moderate number of reevant activities was reported Scored 2 when the aggregated number was 4 8 Assigned when the tota score was 6 9: moderate number of research activities Scored 0 when it had no university affiiation Scored 1 when the aggregated number was 1 9 Scored 1 when the aggregated number was 19 28 Scored 1 when the score was 1 2: fewer reevant activities were reported Scored 1 when the aggregated number was 1 3 Key for [d] (aggregated score for intensity of research activity reported) to support the above tabe. Assigned when the tota score was 3 5: fewer research activities No. of cinica research studies (2009/10) No. of studies supported by NIHR (2009/10) No. of Research Passports issued (2009/10) No. of pubications [d] Scored 3 if the number was 594 870 Scored 2 if the number was 317 593 Scored 3 if the number was 214 250 Scored 2 if the number was 177 213 Scored 3 if the number was 81 110 Scored 2 if the number was 50 80 Scored 3 if the number was 1948 2870 Scored 2 if the number was 1023 1947 [d] refers to the aggregated score from a four eements of research activities (no. of cinica research studies; no. of studies supported by the NIHR; no. of Research Passports issued; and no. of pubications) reported by each trust Scored 1 if the number was 40 316 Scored 1 if the number was 140 176 Scored 1 if the number was 20 49 Scored 1 if the number was 100 1022 Scored 0 if no data were avaiabe Scored 0 if no data were avaiabe Scored 0 if no data were avaiabe Scored 0 if no data were avaiabe 52 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 confirmed through the majority of aspects observed. The fact that T1, T5 and T9 were Showcase Hospita trusts appeared to refect the higher number of IPC-reated evauations reported by the trust. Tabe 7 does not capture the transient nature of forma research structures, and does not incude the atest status of BRCs and BRUs, which were renewed in 2012 (see Tabe 1 in Chapter 3). The majority of trusts maintained their status, but T7 ost both BRC and BRU status in 2012. No major research structura change was witnessed at T3, T4 or T6 during the same period. Whereas T3 had a quasiresearch structure, T4 and T6 did not have BRC or BRU status at any point during the study period. In phase 1 the respondents were asked about research invovement and experiences. With regard to conducting research themseves, a number of prompts/triggers were identified by the respondents the most cited were as foows: fet the need to improve services or update practice, which was cited by one-third of respondents; this was foowed by identification of (recurring) probems, or a gap in knowedge, or probem soving, cited by one-quarter of respondents; and better patient outcomes, benefits, experiences and/or safety, to a esser degree. Finance as a trigger (i.e. cost-saving, vaue for money, cost-effectiveness) was considered by ony a few respondents in the non-cinica managers and nursing managers groups. Organisationa roe aso featured: I think again it depends on what roe they re in. For me it s about improving the patient care and patient fow, so that woud be my, you know, that woud prompt me to find information, but for others it may be how to run a more cost effective endoscopy service or something ike that. So it depends on the individua and what they re managing. T6M8 nurse [...] we do, do a ot of research here and we for exampe may say. I mean it rarey comes from the management team to be honest. A ot are cinica and cinicay driven. T7M5 nurse Other important themes were reated to sensemaking for sef and others: incuding verification or vaidation of existing practice (i.e. verifying something unfamiiar, vaidating evidence, for proving one s own (others ) practice, and vaue judgement); supporting or justifying decisions on the introduction of certain innovations; buiding up an evidence base for proving the effectiveness/benefits of the innovation; or chaenging the product introduced. The verification of existing practice often requires critica thinking and an inquiring mind in seecting the optimum treatment or innovation as an individua/team. This approach was highighted by the foowing respondent, who echoed aso the tempora nature of evidence discussed in Chapter 4: Either because a new thing has been deveoped and evidence is needed either way, it is a good or bad thing, does it work, is it effective, or to answer the things we do on a daiy basis, we aways do it this way, why? I think we are getting better in heath care in asking why, chaenging ourseves and chaenging kind of assumptions we had for ong time. H.[eicobacter] pyori causes ucers, we know that now 10 to 20 years ago it was stress. You know it is never assuming things and constanty questioning and deveoping a hypothesis and testing it. T3M2 nurse [...] I think it is just an inquiring mind, peope want to know or test out and then therefore get the best treatment, so that they can fee assured that they re doing the right treatment or intervention. T7M10 aied heath professiona I don t know [...] what makes other peope do it. What woud make me want to do it is if the evidence isn t aready out there and strong and you ve worked on historica practice for so ong it woud be actuay nice to know scientificay whether what you are doing is making a difference. Queen s Printer and Controer of HMSO 2014. 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. 53

ORGANISATIONAL CONTEXT: THE MACROCASES OF THE EIGHT NHS TRUSTS STUDIED Utimatey it s around patients benefits but I think for me, there is a big gap particuary in infection prevention contro where we have historicay done things one way but there isn t the evidence to support that one way or another and I think effective practice making practice meaningfu I think there needs to be a ot more in that. T6M4 nurse In reation to patient-centred drivers as a source of motivation, T2 and T3 cited this above other drivers, which trianguates with espoused organisationa cuture and vision. The patient-centred eement was more evident among nurses from T2 and T3 (a haf of respondents from each trust) than their counterparts (e.g. one-third of respondents from T7 and approximatey one-quarter of respondents from T9). Based on secondary data anaysis, T2 and T3 were beacons for patient safety these were the ony trusts among our sampe to have visited and directy observed internationa eaders and pioneers of patient safety modes in the USA. Further, documentary anaysis reveaed the successfu transfer of essons to oca management practices at hospita and ward eve through the deveopment of a safe and supportive cuture, and changes in organisationa structure and practices. Innovation activity This section examines how innovative each trust has been, and more specificay how many IPC-reated innovations have been reported by the trust over recent years. The figures within Tabe 8 show the aggregated number of the data based on trust-specific secondary sources: for exampe, we counted 1 for the first coumn, [a], if the trust reported IPC- or patient-safety-reated innovations that were deveoped by the trusts themseves, seemingy refecting oca innovation capacity. Simiary, we counted 1 for the TABLE 8 Innovation activity (reported 2007/08 spring 2011) Trust [a] No. of ocay deveoped IPC-/patient-safety-reated innovations [b] No. of innovations reported as the first in the UK ; cutting edge Overa rating (tota score) T1 10 13 (2+3=5) T2 9 3 (2+1=3) T3 12 10 (3+3=6) T4 7 4 (1+1=2) T5 9 5 (2+2=4) T6 8 1 (1+1=2) T7 12 7 (3+2=5) T9 7 8 (1+2=3) The figures (tota scores) within parentheses show the scores cacuated based on the tabe beow. Key [a] [b] Overa rating Scored 3 when the aggregated number was 11 12 Scored 2 when the aggregated number was 9 10 Scored 1 when the aggregated number was 7 8 Scored 3 when the aggregated number was 10 13 Scored 2 when the aggregated number was 5 9 Scored 1 when the aggregated number was 1 4 Assigned when the tota score was 5 6: a greater number of activities that refect oca innovation capacity and pro-first cuture Assigned when the tota score was 3 4: moderate number of activities that refect oca innovation capacity and pro-first cuture Assigned when the tota score was 2: fewer activities that refect oca innovation capacity and pro-first cuture 54 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 second coumn, [b], if the trust reported the adoption of innovations by using terms such as the first in the UK or cutting edge, ground breaking or simiar. This has an impication of organisationa wiingness to become a front runner when it comes to adopting reativey ess-estabished innovations, seemingy refecting pro-first organisationa cuture. Based on the above quantitative resuts, T1, T3 and T7 reported a greater number of activities, seemingy refecting a greater eve of oca innovation capacity and pro-first cuture during the observed period, and respondents who were aware of this organisationa identity: [...] the fact that it [Bioque vapour hydrogen peroxide (VHP) Room Bio-Decontamination Service (RBDS)] is innovative and we are one of the first trusts in the country to get on board with it, actuay quite appeas to the execs because they can then say take a ook at us, we re ahead of the game and make them fee quite proud of themseves, in that respect. T3M2 nurse We can say that these trusts were eager to be perceived as the first or cutting-edge organisations, wiing to take a risk in becoming the first of its kind ; therefore, they have demonstrated an open-minded, pro-change organisationa cuture. On the other hand, based on the above quantitative resuts, T4 and T6 reported fewer reevant activities; this might refect a ess proactive attitude towards something very new. T2, T5 and T9 showed a moderate attitude towards deveoping innovation ocay as we as introducing cutting edge or reativey ess-estabished innovation imported from outside the organisation. Our primary data (interviews) captured what was evident through secondary sources for T9: It s one of degrees, as I say, if we were way behind the ba and someone came back from another trust and say, They re doing this, why aren t we doing it?, then that, you then have perhaps a forma expectation to deveop that particuar aspect but [...] the assumption is that we are at the eading edge for most things or we ve activey made a decision that we re not going to be at the eading edge because either it doesn t suit us or whatever. [...] there are no doubt some things we re at the traiing edge but again the expectation is that that is an active decision that we re deiberatey hoding back because we ve made an assessment and we see some risks associated with it or it doesn t fit with the overa strategy of the trust. T9M2 doctor The above respondent at T9 reported a risk averse attitude towards introducing cutting-edge innovation and his or her decision-making was rather incined to the active rationa paradigm. Based on the secondary data anaysis, T1 showed a strong organisationa appetite to take a risk in the innovation fied, whereas T6 seemed to be a risk averse organisation. We wi now ook at the number and the type of IPC-reated innovations reported by the trusts. We aso compare the number of innovations with the number of staff for each trust (Tabe 9). The innovations identified here are a wide range of IPC interventions or interventions that might directy or indirecty affect IPC. These were reported by the trusts themseves. They ranged from sma to arge and from technoogica/technica/product to organisationa/administrative/programmatic to process/protoco types of innovations. Based on trust-specific secondary data, the innovation activities and innovation types were anaysed for each trust. The sources incuded the foowing: trusts annua reports and financia accounts (2007/08, 2008/09, 2009/10, 2010/11, 2011/12), trusts quaity accounts reports (2009/10), DIPC reports (when avaiabe), trust board meeting minutes (when avaiabe), staff magazines, newsetters, buetins and other pubicy avaiabe materias (between 2007/08 and spring 2011). The figures within Tabe 9 show the aggregated number of the data based on these trust-specific secondary sources: for exampe, we counted 1 for process/protoco innovations if the trust reported the introduction of a new IPC training scheme, as it fas into the category of process innovation. Simiary, we counted 1 for organisationa/administrative/programmatic innovations if the trust reported the Queen s Printer and Controer of HMSO 2014. 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. 55

ORGANISATIONAL CONTEXT: THE MACROCASES OF THE EIGHT NHS TRUSTS STUDIED TABLE 9 Innovations reported at each trust (reported 2007/08 spring 2011) Trust Organisationa/ administrative/ programmatic innovations Technica/ technoogica/ product innovations Process/ protoco innovations Tota number of innovations reported No. of staff (average between 2007/08 and 2010/11) Innovations reative to size (no. of innovations/ 100 staff) Rating based on Tota number of innovations reported (tota score) T1 86 46 90 101 9793 1.03 (1) T2 125 51 128 160 5690 2.81 (3) T3 100 46 109 125 6175 2.02 (2) T4 75 26 77 87 6407 a 1.36 (1) T5 84 29 76 86 8831 0.97 (1) T6 126 45 133 156 4133 3.77 (3) T7 145 50 134 165 12,356 1.34 (3) T9 69 26 72 84 7308 1.15 (1) a Average for 2007/08, 2008/09 and 2010/11. The figures within parentheses show the scores given based on the tabe beow. Key Tota number of innovations reported Rating based on tota number of innovations reported Scored 3 when the number was 139 165 Assigned when the score was 3: a greater number of innovations reported by the trust Scored 2 when the number was 111 138 Assigned when the score was 2: moderate number of innovations reported by the trust Scored 1 when the number was 84 110 Assigned when the score was 1: fewer innovations reported by the trust 56 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 appointment of new IPC staff (i.e. a medica IPC ead, antibiotic prescribing pharmacists, infection prevention ink nurses, etc.), as it fas into the category of organisationa/administrative innovation. Some innovations were identified as cross-cutting or mutifaceted innovations: for exampe, we considered a Bioque VHP RBDS (Bioque UK Ltd, Andover, UK) at T5 as a mutifaceted innovation within a three categories. It is a product technoogy; its evauation was initiated as part of the Department of Heath s Showcase Hospitas programme; and the innovation process invoved coaboration with the trust s domestic services partner. The number of innovations reported impies the openness or transparency of the organisation in terms of information sharing, and aso a desire to demonstrate to others a pro-innovation cuture. T2, T6 and T7 were stronger in this aspect, whereas T1, T4, T5 and T9 were weaker (Figure 5). In reation to the type of innovation, a trusts tended to focus on organisationa/administrative/ programmatic and process/protoco rather than technoogica/technica/product innovations (Figure 6). The data that incude termination foowing adoption decisions or impementation of an innovation are not often disseminated in the pubic domain. It is therefore difficut to assess the degree of sustainabe impementation of innovations from secondary sources. The resuts of the comparison concerning the number of innovations reative to size (no. of innovations reported/no. of staff) impied the importance of organisation size (Figure 7). As demonstrated by a U-shaped curve here, reativey extreme trusts, in terms of size (either smaer or arger), reported more innovations. On the other hand, moderate-sized trusts reported much fewer innovations during the observed period. Trust T9 T7 T6 T5 T4 T3 T2 T1 0 20 40 60 80 100 120 140 160 180 Number of innovations reported FIGURE 5 Tota number of innovations reported 2007/08 spring 2011. Organisationa/administrative/programmatic 150 100 50 0 Process/protoco Technica/technoogica/product T1 T2 T3 T4 T5 T6 T7 T9 FIGURE 6 Types of innovations reported by each trust 2007/08 spring 2011. Queen s Printer and Controer of HMSO 2014. 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. 57

ORGANISATIONAL CONTEXT: THE MACROCASES OF THE EIGHT NHS TRUSTS STUDIED Number of innovations reported (2007/08 spring 2011) 180 160 140 120 100 80 60 40 20 0 T6 T3 T4 T2 T9 0 2000 4000 6000 8000 10,000 12,000 14,000 T5 T1 Number of staff (average 2007/08 2010/11) T7 FIGURE 7 Reationship between number of staff (average 2007/08 2010/11) and number of innovations reported (2007/08 spring 2011). Communication: interna/externa We wi now assess the communication domain at each trust, based on secondary sources that were reported from 2007/08 to spring 2011. To examine this domain, we seected four aspects: (1) communication channes, incuding newsetters, magazines, events, briefings and eadership wak rounds; (2) patient and pubic invovement initiatives, and reated infrastructure; (3) inkage with regiona, nationa and internationa IPC/patient safety initiatives; and (4) IPC/patient safety training or awarenessraising events (Tabe 10). The figures in Tabe 10 show the aggregated number of data; for exampe, we counted 1 for communication channes if there was a reguar team brief within that organisation. Tabe 10 refects the extent to which interna and externa communication was reported by each trust during the observed period. Communication channes, [a], and IPC/patient safety training and awareness-raising events, [d], can be considered as interna communication, and the rest as externa. However, data within the tabe do not take account of the quaity of the communication channes or of informa communication channes. The overa ratings in Tabe 10 show that T1 and T5 seemed to score reativey ow on communication, whereas T3, T7 and T9 reported reativey high numbers of communication-reated channes and initiatives and high eves of communication-reated infrastructure. Notaby, T7 showed a significanty higher number of patient and pubic invovement initiatives and higher eves of reated infrastructure than the remaining trusts; this was aso demonstrated by the extremey high number of patients (approximatey 20,000) who were recruited to participate in research during 2009/10. A simiary research-strong organisation, T1, recruited approximatey 13,000 patients during the same period. In fact, T7 was one of the UK s first trusts to incorporate the pubic into research decision-making mechanisms. 58 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 TABLE 10 Communication (interna and externa) (reported 2007/08 spring 2011) Trust [a] [b] [c] [d] Overa rating (tota score) T1 7 5 14 18 (1+1+1+2=5) T2 7 6 39 17 (1+1+3+2=7) T3 12 15 35 24 (2+2+3+3=10) T4 6 12 25 13 (1+2+2+2=7) T5 4 2 19 12 (1 + 1+ 1+ 1 = 4) T6 10 8 30 19 (2+1+2+2=7) T7 13 28 32 8 (2+3+3+1=9) T9 19 18 30 14 (3+2+2+2=9) [a] No. of communication channes. [b] No. of patient and pubic invovement initiatives, and reated infrastructure. [c] No. of inkages with regiona, nationa and internationa IPC/patient safety initiatives. [d] No. of IPC/patient safety training or awareness-raising events. The figures (tota scores) within parentheses show the scores cacuated based on the tabe beow. Key [a] [b] [c] [d] Overa rating Scored 3 when the aggregated number was 15 19 Scored 3 when the aggregated number was 20 28 Scored 3 when the aggregated number was 32 39 Scored 3 when the aggregated number was 20 24 Assigned when the tota score was 9 10: higher eve of communication Scored 2 when the aggregated number was 9 14 Scored 2 when the aggregated number was 11 19 Scored 2 when the aggregated number was 22 31 Scored 2 when the aggregated number was 13 19 Assigned when the tota score was 6 8: moderate eve of communication Scored 1 when the aggregated number was 4 8 Scored 1 when the aggregated number was 2 10 Scored 1 when the aggregated number was 14 21 Scored 1 when the aggregated number was 8 12 Assigned when the tota score was 4 5: ower eve of communication Summary Tabe 11 shows overa ratings for each domain of contextua factors for the eight macrocases. To sum up, T7 obtained a better overa rating in a of the domains observed. A greater number of research activities were reported by T1, T5 and T7. Activities that refect oca innovation capacity and a pro-first cuture were more ikey to be seen among T1, T3 and T7. A higher number of interna/externa communication-reated channes/initiatives/infrastructures was reported by T3, T7 and T9. Being research-orientated, having a greater oca innovation capacity and a pro-first cuture, and/or a greater number of interna/externa communication-reated initiatives/channes did not seem to have payed an important roe in increasing the number of reported innovations. This was demonstrated in T6, where such attributes were at a ower eve than at other trusts. Reativey extreme trusts, in terms of size (either smaer, such as T6 and T2, or arger, such as T7), reported more innovations. Hence, in our organisationa sampe the trust size was a prominent factor in this regard. Limitations in the cassifications and custering of cases presented in this chapter reate to our reiance upon sef-reported data for a number of organisationa context dimensions, and the unavoidaby reductionist approach we used in anaysing and reporting on the arge data set at hand. Queen s Printer and Controer of HMSO 2014. 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. 59

ORGANISATIONAL CONTEXT: THE MACROCASES OF THE EIGHT NHS TRUSTS STUDIED TABLE 11 Overa summary of contextua data reported by the trust (based on secondary source) Trust Trust performance and patient experience Magnitude of shocks, crises and critica events (inner, outer) Research activity Communication (interna, externa) Innovation activity Loca innovation capacity and pro-first cuture Innovation reported by the trust Trust size/ resources (no. of staff average between 2007/08 and 2010/11) T1 9793 T2 5690 T3 6175 T4 6407 a T5 8831 T6 4133 T7 12,356 T9 7308 a Average for 2007/08, 2008/09 and 2010/11. Key Better overa rating in performance/activity/communication, or reativey ow eve of interna/externa shocks. Moderate eve of overa rating in performance/activity/communication, or moderate eve of interna/externa shocks. Worse overa rating in performance/activity/communication, or reativey high eve of interna/externa shocks. 60 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Chapter 7 Evidence in action: technoogy products overview and typoogy In this chapter we discuss the resuts of our forma investigation of 18 environmenta hygiene technoogy products. We do this by using interview data from phase 2 and compementary secondary data on product-supporting evidence for efficacy and cost. We start by presenting an overview of the seected products. We purposefuy samped for three technoogy product exampes in each of the eight trusts fufiing the foowing criteria: (1) one technoogy product currenty being considered for adoption, (2) one technoogy product successfuy adopted and impemented, and (3) one technoogy product rejected or discontinued after initia adoption. A products empiricay examined concerned the period 2007 2012. In this chapter we aso provide a typoogy of these 18 products, distinguishing among three important dimensions: (1) expected budgetary impact, (2) perceived impact on practice, and (3) evidence strength on efficacy. Technoogy products overview This section offers an overview and typoogy of the environmenta hygiene technoogy products studied in each of the trusts. Detaied accounts of their journeys in the eight trusts participating in phase 2 are incuded. Overa, 18 environmenta hygiene technoogy products based on 15 unique technoogies have been reviewed in a tota of 27 individua technoogy product journeys in the eight trusts. These 18 products constitute tracers for studying the use of evidence in support of the innovation adoption process in each organisation. These products were recommended by participating trusts staff to the research team as exampes of innovative technoogies considered for adoption since 2007, and can be categorised into: Liquid ceaning technoogy products (three): DIFFICIL-S (Cinimax Ltd, Bury St Edmunds, UK); Chor-Cean soube tabets (Guest Medica Ltd, Ayesford, UK); and Virusove+ (Amity Internationa, Barnsey, UK). Wipe ceaning technoogy products (four): cine universa sanitising wipes (non-sporicida, green wipes) (GAMA Heathcare Ltd, London); cine sporicida wipes (red wipes) (GAMA Heathcare); cine acohoic 2% chorhexidine wipes (GAMA Heathcare); and PDI Sani-Coth CHG 2% acohoic chorhexidine guconate wipes (PDI Inc., Orangeburg, NY, USA). Inspection technoogy products (four): 3M Cean-Trace NG uminometer (3M United Kingdom pc, Brackne, UK); Hygiena SystemSURE II adenosine triphosphate (ATP) hygiene monitoring system (Hygiena, Camario, CA, USA); UV (utravioet) ight inspection torch (UV Light Technoogy Ltd, Birmingham, UK); and DaRo UV ight inspection cabinet (DaRo UV Systems Ltd, Sudbury, UK). Decontamination technoogy products (five): Bioque VHP RBDS; Steris BioGenie VHP decontamination system (STERIS Corporation, Mentor, OH); Advanced Steriisation Products (ASP ) GLOSAIR 400 aerosoised hydrogen peroxide (ahp) system (ASP c/o Johnson & Johnson Medica Ltd, Wokingham, UK); JLA OTEX aundry system (JLA Ltd, Ripponden, West Yorkshire, UK); and Medixair and Medixair Meos UV air steriisation units (Pathogen Soutions Ltd, Soihu, UK). Other infection prevention products with no anti-infective agent (two): Design Bugs Out (DBO) commode (The Kirton Heathcare Group Ltd, Haverhi, UK); and disposabe sterie surgica site gowns. Tabe 12 shows the different technoogy products examined in each of the trusts. They have been isted in coumns representing the outcome for each at the time of data coection (Apri 2011 Juy 2012), with the number in parentheses denoting each individua technoogy product microcase. Ony one exampe, the Bioque VHP RBDS, features in a three coumns. Queen s Printer and Controer of HMSO 2014. 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. 61

EVIDENCE IN ACTION: TECHNOLOGY PRODUCTS OVERVIEW AND TYPOLOGY TABLE 12 Technoogy products seected for review by trusts Trust Products under consideration Successfuy impemented products Rejected products T1 (One) DBO commode (Two) cine universa sanitising wipes (2% chorhexidine, C 22 H 30 C 2 N 10, 70% ethano-based acoho) (Three) Bioque VHP RBDS (30% w/w aqueous hydrogen peroxide, H 2 O 2 ) T2 (Four) disposabe sterie surgica site gowns (Five) ASP GLOSAIR 400 ahp system (5 6% hydrogen peroxide soution, reeased in aeroso form) (Seven) UV Light Technoogy Ltd inspection torch (Six) 3M Cean-Trace NG uminometer (based on ATP measurement) T3 (Eight) Bioque VHP RBDS (30% w/w aqueous hydrogen peroxide, H 2 O 2 ) (Nine) cine sporicida wipes (peracetic acid, CH 3 CO 3 H) (10) Medixair and Medixair Meos UV air steriisation units T4 (11) Cinimax DIFFICIL-S (chorine dioxide, CO 2 ) (12) Bioque VHP RBDS Steris BioGenie VHP system (30% w/w aqueous hydrogen peroxide, H 2 O 2 ) (13) Virusove+ iquid (dodecyamine-based substances, biodegradabe detergent) T5 (14) Bioque VHP RBDS (30% w/w aqueous hydrogen peroxide, H 2 O 2 ) (15) Chor-Cean tabets (sodium dichoroisocyanurate, C 3 C 2 N 3 NaO 3 ) (16) 3M Cean-Trace NG uminometer, Hygiena SystemSURE II ATP hygiene monitoring system (based on ATP measurement) T6 (17) Bioque VHP RBDS (30% w/w aqueous hydrogen peroxide, H 2 O 2 ) (18) JLA OTEX aundry system (ozone, O 3 ) (19) Medixair and Medixair Meos UV air steriisation units T7 (20) Cinimax DIFFICIL-S (chorine dioxide, CO 2 ) (21) ASP GLOSAIR 400 ahp system (5 6% hydrogen peroxide soution, reeased in aeroso) (22) UV Light Technoogy Ltd inspection torch (23) UV Light Technoogy Ltd hand inspection unit T9 (24) cine acohoic wipes and PDI Sani-Coth wipes (2% chorhexidine, C 22 H 30 C 2 N 10, 70% ethano-based acoho) (25) cine sporicida wipes (red) (peracetic acid CH 3 CO 3 H) (26) JLA OTEX aundry system (ozone, O 3 ) (27) Bioque VHP RBDS (30% w/w aqueous hydrogen peroxide, H 2 O 2 ) Typoogy of technoogies This section offers a typoogy of the environmenta hygiene technoogy products in terms of (1) expected budgetary impact for trusts, (2) perceived impact on practice for trust staff, and (3) evidence strength on efficacy. The budget and practice impact cassifications have been based on trust staff perceptions of product attributes eicited during phase 2. This is in ine with quaitative methods used in heath technoogy assessment depoyed within the context of the heath-care organisation to rigorousy examine the objective materia conditions; the actors prior knowedge, vaues and experience; and the actors working definitions of what kind of event they were engaged in and the ways in which conditions, knowedge, vaues and experience were reevant (p. 46). 91 This approach connects seamessy with sensemaking theory, and incorporates the innovation studies concepts of compatibiity, which is refected in the perceived budget and practice impact, reative advantage, which is inked to budget impact and evidence strength on efficacy, and compexity, refected in practice impact. 62 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 In this typoogy, a specific technoogy product budget impact is cassified as high, medium or ow. These cassifications are based on trust staff perceptions of (1) the immediate budgetary impact of each product examined in their trust [unit cost price, financia support avaiabe for procurement, cost assumed by private finance initiative (PFI) partner], and (2) sustainabiity costs. Cassifications for the 18 products across the eight trusts are isted in Tabe 13. In addition, Appendix 7: Technoogy products unit cost price ist shows the technoogy products according to their ist unit cost price in descending order, from the most to the east expensive. As part of the Department of Heath and the former NHS PASA s HCAI Technoogy Innovation Programme Award for outstanding contributions to TABLE 13 Technoogy products expected budgetary impact in trusts Technoogy product Trust Budget impact ASP GLOSAIR 400 ahp system T2 Low T7 High Steris BioGenie VHP system T4 Low JLA OTEX aundry system (JLA 40 High Spin machine with OTEX system fitted) T6 Low T9 Low 3M Cean-Trace NG uminometer (with board and swab rods) T2 Medium T5 Medium Bioque VHP RBDS (one hospita room) T1 High T3 T5 T6 T9 Medium Medium Medium High Medixair and Medixair Meos UV air steriisation unit T3 Low T6 T7 Low Low UV LIGHT Technoogies inspection torch T2 Low Hygiena SystemSURE II ATP hygiene monitoring system (with swab rods) T5 Medium DBO commode T1 Medium DaRo UV ight inspection cabinet (with ge and accessories) T7 Low DIFFICIL-S disinfectant soution (with mixing vesse and four bottes) T4 Low T7 Low Virusove+ T4 Low Disposabe sterie surgica site gowns (box of 30) T2 Medium Cine universa sanitising wipes (non-sporicida, six 200-wipe packs) T1 Medium Cine sporicida (red) wipes (pack of 25) T3 Medium T9 Medium Cine acohoic wipes T9 Low Chor-Cean tabets T5 Low PDI Sani-Coth CHG 2% acohoic chorhexidine guconate wipes (pack of 200) T9 Low Queen s Printer and Controer of HMSO 2014. 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. 63

EVIDENCE IN ACTION: TECHNOLOGY PRODUCTS OVERVIEW AND TYPOLOGY fighting infections 2009, 150,000 was awarded to trusts T3, T4 and T7 and 50,000 to T2. The trusts were given free reign to use the sum to procure technoogies that coud hep reduce HCAIs (awarded in February 2009 and technoogies procured within the foowing year). The award funding was taken into account in the cassification of technoogies in terms of expected budgetary impact for these four trusts and for the specific technoogy products procured using this method. When this funding was reported by the respondents to have payed a significant roe in the adoption and impementation processes, this is discussed in the individua microcases in Chapter 8. For exampe, the technoogy product ASP GLOSAIR was perceived to have a ow -budget impact in T2 and a high budget impact in T7, as T2 used the award funding to procure the specific product. Tabe 14 groups technoogy products in terms of their associated impact on practice perceived by the trust staff interviewed. The cassification has been put together based on quaitative anaysis of phase 2 interviews, and incudes five casses: Very ow product or technoogy same or very simiar to existing, estabished products in the NHS. Low product has new features (e.g. active ingredient) and is used in the same manner as existing, estabished products in the NHS: imited staff training required. Medium product has new features and is used differenty from existing, estabished products in the NHS: staff training required. High new product or technoogy with precursor method, product or technoogy. Very high new product or technoogy without precursor. Evidence strength data on the efficacy of products have been coected through secondary research: Efficacy refers to the probabiity of benefit to individuas in a defined popuation from a medica technoogy appied for a given medica probem under idea conditions of use (p. 711). 92 Tabe 15 iustrates the strength of the evidence base for the efficacy of each product based on (1) a HPA RRP recommendation, (2) an evauation report pubished as part of the Department of Heath s HCAI Technoogy Innovation Programme, Showcase Hospitas programme, or other government-sponsored technoogy assessment or evauation programmes, and (3) scientific artices pubished in peer-reviewed journas. A product of RRP recommendation 1, pubished scientific artices, and technoogy assessment evauation reports where avaiabe is cassified as an estabished product having a high evidence strength on efficacy. Products of RRP recommendation 2 which aso feature in pubished scientific artices or technoogy assessment evauation reports are cassified as emergent products, having medium evidence TABLE 14 Practice impact of technoogy products Very ow Low Medium High Very high Disposabe sterie surgica site gowns DBO commode DIFFICIL-S ASP GLOSAIR 400 ahp system Medixair UV air steriisation unit Cine universa sanitising wipes (non-sporicida) Cine sporicida (red) wipes Chor-Cean tabets Steris BioGenie VHP system Medixair Meos UV air steriisation unit Cine acohoic wipes Virusove+ JLA OTEX aundry system 3M Cean-Trace NG uminometer PDI Sani-Coth wipes Bioque VHP RBDS UV LIGHT Technoogies inspection torch Hygiena SystemSURE II ATP hygiene monitoring system DaRo UV ight inspection cabinet 64 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 TABLE 15 Evidence strength on the efficacy of technoogy products Technoogy product HPA RRP recommendation Technoogy assessment evauation report (UK/internationa) Peer-reviewed journa scientific artices Evidence strength on efficacy (estabished/emergent) ASP GLOSAIR 400 ahp system RRP3 (2008) Medium, emergent Steris BioGenie VHP system JLA OTEX aundry system RRP2 (2005) RRP1 (2012) RRP2 (2008) Low, emergent High, estabished 3M Cean-Trace NG uminometer RRP1 (mutisite) High, estabished Bioque VHP RBDS RRP1 (2008) RRP2 (2004) High, estabished Medixair UV air steriisation unit UV LIGHT Technoogies inspection torch Hygiena SystemSURE II ATP hygiene monitoring system Medixair Meos UV air steriisation unit RRP2 Low, emergent Medium, emergent RRP1 (2010) High, estabished Low, emergent DBO commode Low, emergent DaRo UV ight inspection cabinet DIFFICIL-S RRP2 (2009) RRP3 (2008) Low, emergent Low, emergent Virusove+ RRP5 Low, emergent Disposabe sterie surgica site gowns Low, emergent Cine universa sanitising wipes Cine sporicida (red) wipes RRP2 Medium, emergent Low, emergent Chor-Cean tabets Low, emergent Cine acohoic wipes RRP2 Medium, emergent PDI Sani-Coth CHG 2% acohoic chorhexidine guconate wipes Low, emergent Queen s Printer and Controer of HMSO 2014. 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. 65

EVIDENCE IN ACTION: TECHNOLOGY PRODUCTS OVERVIEW AND TYPOLOGY strength on efficacy. A other combinations of (1) (3) resut in an emergent / ow cassification for the products concerned. The HPA RRP may pubish one of seven recommendation statements for each particuar technoogy product. Products that obtain RRP1 are understood as having a strong evidence base confirming their efficacy, and are normay considered for fast tracking and incusion in NHS Procurement and NICE work pans. RRP1 is issued as basic research and deveopment, vaidation and recent in use evauations [of the product] have shown benefits that shoud be avaiabe to NHS bodies to incude as appropriate in their ceaning, hygiene or infection contro protocos (p. 5). 73 A of the remaining six recommendations describe different eves of a product s emergent evidence base on efficacy. [Pease see the foowing page of the HPA porta for a fu expanation of the RRP recommendations: www.hpa.org.uk/productsservices/ MicrobioogyPathoogy/RapidReviewPane/rapRecommendations/ (accessed 12 November 2012).] 93 66 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Chapter 8 Evidence in action: product microcases in eight NHS trusts This chapter provides an in-depth presentation of the 27 technoogy product microcases across the eight NHS trusts that participated in phase 2. The reader is aerted to the ength of the chapter, which detais findings from a sizabe study with mutipe cases. A microcases foow a standardised format to faciitate cross-comparison. Tabes 16 41 ist the specific evidence types used in each microcase aongside the sources from where these were eicited. Figures 8 33 depict the stakehoders invoved and evidence types used in each of the innovation process substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for each of the technoogy products. Text in ight grey shows the evidence type(s) or stakehoder(s) who were not invoved in that substage. We ook at each technoogy product journey in detai aong the three key stages of the innovation process: initiation, adoption decision and impementation. We present the interpay among stakehoders invoved in each stage, the associated evidence types and sources debated, and how these were inked to organisationa adoption and impementation outcomes. What reevant evidence and knowedge bases have the diverse stakehoders in our case sites accessed, debated, used or rejected? What can be earnt from exporing the reationships among such diverse evidence forms? How does the espoused use of evidence by individua professionas reported in phase 1 compare with coective processes of accessing and using evidence for the adoption and impementation of specific products in the context of an organisation expored in phase 2 and outined in this chapter? Trust 1 technoogy microcases Microcase 1: Design Bugs Out commode Attributes perceived by stakehoders The specia design features of the DBO commode were perceived by informants as nove, suggesting that a ot of high-tech input went into its design and fabrication. It was perceived to be a ow-tech piece of equipment and one that comes with a process of how to cean it after use. At the time of its introduction, environmenta hygiene had sti been an area of concern for T1. However, informants suggest that it was viewed as an opportunity to aunch a next-generation product. Its main advantages are identified to be (1) its modern ook and fee; (2) staff time savings owing to ease and speed of ceaning its surfaces; (3) its capacity to save space by pacing commodes onto one stack easy to move and store; and (4) patient and staff safety in terms of reduced infection risk. Stakehoders, evidence and decision-making The Showcase Hospitas programme is understood to have provided the initia idea and support for the adoption of the DBO commode in T1. Evidence was aso sourced through seminars and presentations avaiabe through the Design Counci DBO project. The T1 showcase ead payed a championship roe by providing support to the oca tria at every stage. Key stakehoders invoved at the start of the DBO commode tria were the DIPC, senior and junior members of the IPC team, ward and domestic contractor staff (domestic services are outsourced in T1), heads of nursing and cinica eads. The oca tria was approved at the trust s infection prevention committee meeting. During the tria, patient feedback on its use was eicited. The strong interest and commitment shown by the DIPC, aong with effective communication of the tria intent and benefits by the IPC team to other stakehoders, are viewed as pivota in the successfu conduct of the tria. Senior nurses engaged positivey with the tria process, whie the cean, modern ook and fee of the product served to compement the IPC team communication with shop-foor stakehoder groups. Queen s Printer and Controer of HMSO 2014. 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. 67

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS Evidence sources accessed during the stages of initiation, adoption decision, and impementation incuded materia avaiabe through Showcase Hospitas and the DBO programme (Tabe 16, Figure 8). Senior IPC team members aso accessed evidence through their professiona networks in a three stages. Loca evidence, in the form of ongoing patient and ward staff feedback, was aso directy coected during the tria. Key decision-makers are aware of the importance of the perceived ceaniness of bedside products and care environment in enhancing patient confidence when seecting new products. One respondent highighted: I think you ve got to remember when you re in the patient environment how it ooks is very important to patients and visitors. So if you ve got different commodes and a ook tatty and uncean, or difficut to cean, and even you coud have the nicest ward but when you ve got kit around the bedside that doesn t match... Senior nurse TABLE 16 T1 DBO commode: evidence sources and types Evidence sources Showcase Hospitas programme DBO programme Professiona networks Trust care environment Evidence types Product documentation Product documentation inc. evauation report Professionas recommendations Loca tria inc. patient and staff feedback Initiation Adoption decision Product documentation Product documentation DBO evauation report DBO evauation report DIPC Professionas recommendations Professionas recommendations DIPC Heads of nursing Lead nurses IPC team Ward staff Loca tria, patient and staff feedback Loca tria, patient and staff feedback Heads of nursing Lead nurses IPC team Ward staff Domestic services partner staff Impementation Domestic services partner staff Product documentation Professionas recommendations DBO evauation report Loca tria, patient and staff feedback DIPC Heads of nursing Lead nurses IPC team Ward staff Domestic services partner staff Outcome Adopted in two of three sites, phased impementation in progress FIGURE 8 T1 DBO commode: professionas engagement and evidence types in decision-making. 68 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Training materias showing the ceaning process to foow after use of the commode were made avaiabe to users. Informants estimated the innovation adoption process to have asted a maximum of 2.5 years, incuding the eary suppier invovement phase faciitated by the Department of Heath invoving discussions among designers, manufacturers and NHS trusts. Outcome The outcome was that, foowing the tria, the DBO commode became avaiabe for genera purchase in T1 in December 2011. One incompatibiity identified prior to the tria was that the commode s portabe pan requires macerator discharge in suice rooms and ony two of the three arger T1 hospita sites have suice room macerators instaed. The product has otherwise generay been considered to be easy to use and in ine with the organisation s cuture and vaues. Key factors in the commode s adoption are perceived to be its ease of ceaning, patient comfort and cost neutraity. Sustainabiity was considered during its design and tria. A requirement shared among externa stakehoders and T1 was that the changeover to the new commode had to be cost neutra. Financia pressures have now ed the IPC team to coaborate with externa stakehoders in assessing product ife-cyce cost impications. Some minor damage has been reported to the commodes in the form of, for exampe, discoouration of the commode arms caused by extensive ceaning and use in the trust care environment. Microcase 2: cine universa sanitising wipes Attributes perceived by stakehoders This product is perceived as a ow-tech, we-estabished and vaidated product. It is aso understood as being compatibe with the systems, structures and processes underpinning care deivery in the ward environment, as we as with the infection-contro-reated vaues and cuture of the organisation. The product s specific advantage is considered to be the time saved compared with using other products and equipment. Its use is simpe: staff take it out of the packet, wipe the surface and then dispose of it. Before the introduction of wipes in T1, ceaning in wards was based on the use of a bucket, a mop and ceaning soution. This soution was harmfu to the ward environment and equipment: it was abrasive and woud wear down surfaces over time. This ceaning process was aso fraught with errors associated with diution, use of mops, etc. Using a wipe was thought to be a simper and more effective means of ceaning. Severa wipe products had been introduced in the trust. These were withdrawn when it was decided to standardise to and procure one product for use across the trust hospita sites. Stakehoders, evidence and decision-making Disinfectant wipes were first introduced in T1 at the start of 2009. Many wipe-based disinfectant products had appeared on the market as genera sanitisers or specific to infectious diseases such as C. difficie. As severa of these were used in T1 hospitas and the merger of T1 s constituents was progressing, product standardisation emerged as a priority. In this case, the initia focus was on the cine Sporicida Wipe. However, a senior IPC team member of nursing background suggested standardising to one universa sanitising wipe across the organisation, gathered the economic and other evidence, and produced a business case for this product. Visits to other trusts and the knowedge of IPC team members provided a basis for ideation and evidence gathering. Evidence was eicited from three main sources during the initiation, adoption decision and impementation stages: professiona networks of individua staff members; peers and coeagues in other trusts; and industry/suppiers (Tabe 17 and Figure 9). Evidence acted as a faciitator towards adopting this new, innovative ceaning product. Trust members interviewed suggested that their review of the evidence on use in other trusts created a peer pressure effect, as it made them reaise that they were behind the times. Queen s Printer and Controer of HMSO 2014. 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. 69

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS TABLE 17 T1 cine universa wipes: evidence sources and types Evidence sources Trust management Industry/suppiers Professiona networks Peers and coeagues Evidence types Business case Product documentation Conference presentations Peer recommendations Initiation Adoption decision Chief operating officer Medica director DIPC Heads of nursing Business case Product documentation Conference presentations Peer recommendations Business case Product documentation Conference presentations Peer recommendations Chief operating officer Medica director DIPC Heads of nursing IC physician IPC team E&F team Procurement Ward staff Impementation IC physician IPC team E&F team Procurement Ward staff Business case Product documentation Conference presentations Peer recommendations Chief operating officer Medica director DIPC Heads of nursing IC physician IPC team E&F team Procurement Ward staff Outcome Trust-wide impementation FIGURE 9 T1 cine universa wipes: professionas engagement and evidence types in decision-making. E&F, estates and faciities; IC, infection contro. Sustainabiity was considered in the decision-making process. The procurement department required this product standardisation to be cost neutra or ead to an overa cost reduction. Financia pressures during that time are understood to have been ess intense than more recenty. The IPC team woud ater be required to confirm any such change as cost-saving. The seection process itsef had a few weeks duration. Pressures and other contextua factors, incuding high C. difficie infection rates at that time, and the T1 hospitas merger circumstances, triggered a sense of urgency to sove these probems, and created favourabe ground for the adoption of a product with ow compexity and ow cost. One respondent suggested: I think just at the time of the merger there was just ots going on and this was a quick win and a quick decision reay. Senior nurse 70 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 More importanty, externa support, incuding the suppier providing wa mount fittings for the product, was another key faciitating factor in the trust-wide adoption decision across three main sites. One respondent said: [...] cine come with wa-dispensers which was a factor so the ony consutation with cine was whether they coud support us to physicay come round and fit them a. And so we needed to invove them because they need their maintenance staff to come round and fit it a. Senior nurse [...] there were points to negotiate and that reay came down to fixtures and fittings and did sight changes in areas, sight changes in practice not resistance. Senior nurse There was no specia project team set up. The product was approved through a committee whose members incuded a senior stakehoders understood to have a key roe by staff members: the DIPC, infection contro physician, medica director, chief operating officer. Fina approva was granted by the DIPC. No patient views were eicited as part of the process. The IPC team initiay worked with the procurement department to identify a range of products for consideration. Once the product choice was made, other stakehoder groups were invited to take part incuding the heads of nursing and ward staff. The groups invoved in impementation panning incuded IPC nurses, the heads of nursing, procurement, and estates & faciities department (E&F). The product champion roe is identified with the senior IPC nurse who suggested the product initiay. IPC nurses were invoved in the day-to-day, ward-to-ward impementation of the new ceaning product, working with procurement to streamine suppies, and with E&F to mount new wa racks in wards where wipes are stored and accessed. Outcome Some chaenges were often heard during eary impementation, especiay around issues of compatibiity with certain equipment and poor engagement with predictabe hot spot users (i.e. theatres staff), or status quo supporters, who often chaenge new practices, processes and/or products as a resut of a ack of effective communication. Two respondents commented: There aways is a group of individuas who is saying they ve done it in this way, this many years, why are we changing? Senior non-cinica manager When you make an executive decision about changing products, you coud have 99.9% of key stakehoders that are happy and 1% wi not be happy. I think most of the peope were concerned about it post-impementation. Because as I said what we did was we removed a of the other products that were avaiabe through to order and it was kind of an anxiety from particuar sets of cinicians and paces ike theatres that they fet that ought to have acoho based products to cean their surfaces. They didn t understand the technoogy behind it. I suppose on refection we probaby shoud have communicated that a bit better. Senior nurse Nevertheess, a product champion (senior IPC nurse) utiised effective communication channes with senior nurses, incuding a weeky Back to the Foor Fridays meeting, to inform their adoption decision, faciitating a smooth transition from one product to another. Other members of the IPC team foowed this paradigm and championed the new product across hospita areas of the trust: I think to be fair, cine [wipes] was something that we a fet very strongy about. We knew it woud make ife easier on the wards, and we knew that we woud make things happen. So I think Queen s Printer and Controer of HMSO 2014. 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. 71

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS that is one thing that we can say is that as a team we were probaby a championing, and sti do when we are doing our audits. Senior nurse Standardisation to the new cine sanitising wipe product was competed in T1 in ate 2009. One measure of success identified was ward staff productivity gains in terms of ess time needed to cean surfaces. The trust C. difficie rate reduction is perceived by some trust members to be associated with the use of this wipe. However, there has been no forma evauation to measure and substantiate these caims. Stakehoder groups invoved in the innovation adoption decision incuded IPC nurses, heads of nursing, procurement and ward staff. Microcase 3: Bioque vapour hydrogen peroxide Room Bio-Decontamination Service Attributes perceived by stakehoders Informants perceive the main attributes of the service to be its efficacy in eiminating pathogens via disinfection and decontamination of the environment. The service is understood to invove a piece of equipment, a device and a process operating procedure and be part of the Showcase Hospitas programme. The technoogy is considered to have been nove, high-tech, at the time of its introduction to the market in 2008/2009. The cear reative advantage, understood as reevant to patients, staff, the trust and the NHS, is the high eve of decontamination and hygiene assurance it offers. However, it is thought that it cannot be a substitute for a deep-cean process; it is perceived as a compement offering additiona assurance, as it aso prompts ward staff to conduct a deep cean and de-cutter the ward environment prior to use. The service itsef, its operation and its merits are understood as reativey easy to expain to others. However, deivery of the service (portabe machine operation, area seaing, etc.) is thought to be quite compex. Stakehoders, evidence and decision-making The trust had sporadicay used the service during infection outbreaks and viewed the Showcase Hospitas programme as an opportunity to tria a promising environmenta hygiene technoogy. There was aso an incentive for the trust to urgenty improve C. difficie infection rates at that time. Initiay, itte resistance was noted by respondents. The tria was supported by the Showcase Hospitas programme and was ed by the trust Showcase Hospitas programme team, comprising a project manager and assistant (Tabe 18 and Figure 10). Stakehoder groups invoved incuded the IPC team, E&F, domestic staff, heads of nursing, procurement and cinica eads in areas where the service was triaed. The tria was aso on the agenda of two trust C. difficie task force group meetings, which incude the medica director and chief operating officer. The showcase ead acted as a champion and promoted use of the technoogy with enthusiasm. TABLE 18 T1 Bioque VHP RBDS: evidence sources and types Evidence sources Trust management Industry/suppiers Showcase Hospitas programme Professiona networks Trust care environment Evidence types Business case Product, service documentation Technoogy documentation Conference presentations Loca tria; staff feedback 72 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Initiation Adoption decision Chief operating officer Medica director DIPC Heads of nursing IC physician IPC team Business case Product, service documentation Technoogy documentation Conference presentations Loca tria; staff feedback Business case Product service documentation Technoogy documentation Conference presentations Loca tria; staff feedback Chief operating officer Medica director DIPC Heads of nursing IC physician IPC team E&F team E&F team Procurement Ward staff Impementation Procurement Ward staff Business case Product, service documentation Technoogy documentation Conference presentations Loca tria; staff feedback Chief operating officer Medica director DIPC Heads of nursing IC physician IPC team E&F team Procurement Ward staff Outcome Rejected FIGURE 10 T1 Bioque VHP RBDS: professionas engagement and evidence types in decision-making. IC, infection contro. The service was initiay considered as compatibe with care structures and systems, as we with T1 vaues. During the tria the service began to be understood as a compement to other means of infection contro, and as a ast resort too of ensuring effective decontamination. This change in perception, couped with its high cost, resuted in a difference of opinion between cinicians and managers; the former were in favour of its adoption as an effective decontamination means, whereas the atter fet that its routine use came with a high cost. The service was aso understood by some to introduce a time ag between care systems and processes that had to be run concurrenty. For exampe, bays and rooms were becoming avaiabe ater than anticipated. One respondent highighted awareness of the compexity of this technoogy s use in terms of space and cost (i.e. patient fows, reated hidden cost), which seems to have triggered a negative perspective on adoption among the IPC team: The business case was written but the cost was quite substantia for the organisation. [...] when organisations had funding that they coud spend but as time went on we thought actuay it s not a good use of funding. So even though the business case was written, amost approved, infection contro [team] strongy disagreed with funding a product that they strongy beieved woud have an impact. [...] The C. diff[icie] task force accepted that and party because actuay the use of that product was so compex in terms that you woud have to move patients off. Then actuay just the cost of a that woud have been more than using a piece of equipment. So they were happy with that decision. Senior non-cinica manager Queen s Printer and Controer of HMSO 2014. 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. 73

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS As the service tria progressed, the two main types of evidence featuring in the decision-making of whether to adopt or reject were (1) the business case prepared by the IPC team, and (2) feedback eicited by stakehoder groups whie the tria was ongoing. The business case confirmed the high cost arising from reguar use of the service. The E&F department anticipated additiona workoad to be generated as a resut of using this technoogy in terms of preparing cinica areas for its use. There were some reports of intensive-care cinicians suggesting bed management to have been somewhat adversey affected during the tria. The stakehoder groups aso considered the possibiity of ad hoc use. During a engthy adoption decision-making stage, the decine of infection rates through other initiatives was witnessed: [...] there was a ot of discussion for about 6 months afterwards, as to whether we woud bring them in on an ad hoc basis and use them. We got as far as having a business case. And we then decided infection rates were going down regardess and we fet it was something that wasn t reay needed but we know it s there if we do need it. Senior nurse Outcome The fina decision not to mainstream use of this service at the present time was reached at trust board eve. The tria report suggested that, generay, the service was positivey perceived. A business case was put together by the IPC team, the showcase team, managers and procurement. It was presented to the trust s infection prevention committee group and was then recommended to the trust board. Overa, a key factor faciitating the tria was that the technoogy became avaiabe as a managed service. However, the cost of mainstreaming the use of this particuar service across the trust is understood to have payed a key part in the decision taken, aong with any disruptive effects anecdotay reported during the tria. Trust 2 technoogy product microcases Microcase 1: standardisation of disposabe sterie gowns Attributes perceived by stakehoders Disposabe sterie gowns were understood by T2 informants to be a product that is easy to use, and one that has been avaiabe in the NHS for a ong time. The objectives behind standardising gowns used in T2 to one gown product, namey to ensure quaity and generate savings for T2, were highighted by informants as important. Severa different gowns used in T2 theatres have been found to aow strike-through, thatis,fuid seepage from their exterior into their interior surface, posing a risk to theatre staff. Gown standardisation was understood to be compatibe with care deivery structures and systems, T2 vaues and the service quaity cuture. It has been approached through an integrated care perspective that examines the use of gowns in care pathways invoving different surgica procedures. It has aimed at seecting one gown product that provides adequate protection against strike-through for severa hours, ease of use in any procedure and cost savings. Benefits to patients and staff incude ess risk of having to stop a procedure for a gown change and a more comfortabe working routine for staff. Stakehoders, evidence and decision-making The need for standardisation was highighted by T2 senior theatre staff. The procurement speciaist nurse then sourced further information and evidence through NHS procurement, professiona networks and suppiers (Tabe 19 and Figure 11). Suppiers were then approached individuay with requests for product demonstrations. A specia focus group was formed to ook at the evidence, as part of the wider T2 cost-saving ean transformation programme. Focus group members were senior nurses, procurement speciaists, senior surgery staff and a T2 ean service improvement team member. 74 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 TABLE 19 T2 standardisation of disposabe sterie gowns: evidence sources and types Evidence sources Professiona networks Industry/suppiers Peers and coeagues Trust care environment Evidence types Suppier and product information Product documentation; product demonstration Feedback on current products Loca tria; current usage data Initiation Adoption decision Space group Senior nurses IPC team Service improvement team Procurement speciaist nurse Suppier and product information Product documentation Product demonstration Feedback on current products Loca tria; usage data Suppier and product information Product documentation Product demonstration Feedback on current products Loca tria; usage data Space group Senior Nurses IPC team Service improvement team Procurement speciaist nurse Theatre staff Theatre staff Impementation Suppier and product information Product documentation Product demonstration Feedback on current products Loca tria; usage data Space group Senior nurses IPC team Service improvement team Procurement speciaist nurse Theatre staff Outcome Ongoing decision-making FIGURE 11 T2 standardisation of disposabe sterie gowns: professionas engagement and evidence types in decision-making. Five products of different suppiers were shortisted by the focus group within 2 weeks. An evauation pan was then put together to assess the reative merits of each product regarding highest quaity offered for a price acceptabe to the trust. The procurement speciaist nurse acted as a champion, supported shortisting and ed the evauation process. The evauation of the five gown products was organised in eary 2012. It was based on a singe data entry form agreed a priori with manufacturers. Each of the gowns was evauated on a particuar day within 1 week. Resuts were coected and fed back to the focus group by the procurement speciaist nurse. Queen s Printer and Controer of HMSO 2014. 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. 75

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS Outcome The resuts of the tria were fed back to the focus group and the T2 innovations or space group. However, the decision process was deayed in the second quarter of 2012, as one of the companies participating in the tria raised a forma compaint against T2. Microcase 2: 3M Cean-Trace NG uminometer Attributes perceived by stakehoders This system was understood by T2 informants to be a medium- to high-technoogy soution for assessing whether cinica areas and surfaces are ceaned effectivey. Prior to its introduction, there were no means of testing whether a previousy ceaned surface had been decontaminated of microorganisms and residues. This system was viewed as having a key benefit for patients, staff, the trust and the NHS. T2 staff members suggested patients were reported as feeing more secure when observing use of the device, whie eves of staff responsibiity vis-à-vis effective ceaning aso were raised. It is generay perceived to be compatibe with care structures and systems and T2 s cuture and vaues. Stakehoders, evidence and decision-making Ideation about the system came through the Showcase Hospitas programme and the T2 DIPC Executive Nurse. The DIPC put the system forward at the T2 space group. It was then foowed up by the IPC nurse consutant, who iaised with ward staff for training and triaing purposes. Stakehoder groups invoved incuded the IPC team and ward staff. Championship roes are identified with the nurse consutant and individua matrons in wards where the device was first triaed. In addition to the Showcase Hospitas programme, further information and evidence became avaiabe through the companies invoved and other trusts in the region (Tabe 20 and Figure 12). Additiona evidence featuring in the decision-making process incuded peer-reviewed journa artices on environmenta assessment based on ATP, reviewed by T2 s microbioogy department. A oca evauation was funded by the Department of Heath through coaboration with the Smart Soutions programme. This supported an evauation of the Cean-Trace system and the UV ight torch equipment at the same time, as it was thought that an aternative method of assessing surface ceaniness was needed. Outcome Foowing the tria, the system has continued to be used in seected wards in the main T2 hospita site. Funding and support to sustain its use has been provided by the DIPC. Athough a reduction in C. difficie cases was noted in wards where it was used, a forma evauation was not carried out to estabish a ink. The main outcomes identified have been raising staff (incuding matrons ) interest in and motivation for effective ceaning, and improved communication among staff and patients. TABLE 20 T2 3M Cean-Trace NG uminometer: evidence sources and types Evidence sources Showcase Hospitas programme Industry/suppiers Peer-reviewed academic iterature Other trusts Trust care environment Evidence types Product documentation Product demonstrations and training Scientific artices Loca trias feedback Loca tria data 76 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Initiation Adoption decision Product documentation Product documentation Space group DIPC/executive nurse Microbioogy Product demonstrations and training Scientific artices Loca trias feedback Product demonstrations and training Scientific artices Loca trias feedback Space group DIPC/executive nurse Microbioogy IPC team Loca tria data Loca tria data IPC team Ward staff Ward staff Domestic staff Impementation Domestic staff Product documentation Product demonstrations and training Scientific artices Loca trias feedback Loca tria data Space group DIPC/executive nurse Microbioogy IPC team Ward staff Domestic staff Outcome Adopted and used in seected wards FIGURE 12 T2 3M Cean-Trace NG uminometer: professionas engagement and evidence types in decision-making. The innovation adoption process in this case asted 6 months. The system s main advantageous feature is understood to be the direct, onine feedback provided to midde and senior management on surface ceaniness in wards. New domestic staff members were appointed for the impementation of this technoogy, and their cuture of coaborative teamwork was aso witnessed as eading to successfu impementation. Ownership of the swabbing process by domestic staff is thought to have been another key faciitating factor, as it heped generate enthused and interested users among them. An aternative scenario woud see IPC team members visiting wards and obtaining sampes. This has been viewed as potentiay intrusive to care deivery in wards. One respondent commented: [...] a practicaity. Something that can actuay transate down to ward eve. Because that was a bit of a chaenge because I think some ways of impementing that this woud be given to infection contro and then they just pop out and do swabbing. But you then go into an area as a stranger and with [domestic staff] using it there was a bit of ownership and you don t actuay get that if you do something and you give somebody feedback that s fine but you re very much an inspector. If peope can take part in it and do something about getting the readings for themseves and you ve got somebody who knows the area reay we and knows what they are doing, I think you get more invovement. Senior nurse Queen s Printer and Controer of HMSO 2014. 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. 77

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS Microcase 3: ASP GLOSAIR 400 ahp system Attributes perceived by stakehoders The system s perceived attributes incude its decontamination and disinfection capabiity and its versatiity regarding room size. The system is used by the trust s Deep Cean Team as part of their ceaning regime once patients and staff have been removed from cinica areas before having them seaed. Its use is compementary to and foows the deep cean, genera or termina ceaning methods practised before its adoption. It is most often used during E. coi, C. difficie and norovirus outbreaks. Athough there has been no forma review of its effectiveness and use conducted after adoption, its introduction is considered successfu. As one T2 adopter suggested, it seems to be working for us. Adopters further suggested that a positive communication dividend has been reaped in terms of higher assurance of patients and the pubic that infection contro is a top priority at T2. One respondent said: [...] even patients ask as we now, what s this machine in a roundabout way. Non-cinica manager [...] we have had feedback from patients. And we have done that by a variety of surveys and actuay patients fee very assured when they see us doing that and actuay taking ceaning very seriousy. And actuay we have had a coupe of compaints in winter that patients had been in our trust previousy. And they had seen the HPV vapour being used on the ward and during the foowing admission they had not seen it, so they wrote in to say are you sti not doing that? I think it does assure patients around the standard of ceaning when they see things ike that happening. Senior nurse The system is perceived as compex to utiise by senior trust members. Staff members working more cosey with the Deep Cean Team suggest that it is reativey easy to use. However, operators need to be trained appropriatey, and ceaning prior to its operation is viewed a prerequisite. Bed management issues arising from its use were reported. However, respondents suggested that staff members work together to minimise impact, and that this system is considered quicker to use than reated services. The innovation is considered to be in ine with the vaues and cuture of T2, as one organisation in which IPC and patient safety are high priority areas. Stakehoders, evidence and decision-making Senior trust members first heard about the system at a company presentation in a neighbouring trust. A decision was subsequenty taken to tria the system in T2. Tria and purchase were supported through the Department of Heath s Deep Cean programme. The system s purchasing cost was viewed as prohibitive. A workshop and demonstration were organised by the T2 Hote Services Team. Stakehoders invoved in the process incuded the T2 IPC team, microbioogy department, hote services and domestic staff. Key individuas with a eading roe were the IPC Team Leader, the Consutant Medica Microbioogist (Infection Prevention Doctor) and the DIPC. Microbioogy assessed the evidence and highighted the system s reative merits to other stakehoders. Some informa chaenges towards the evidence gathered by microbioogy were witnessed, and the company s promotion efforts were perceived as insistent by some stakehoders: I think there was a itte bit of [something] about the resuts of the information, I think there was a bit of resistance, we not resistance, sighty chaenged. [...] I think it was Microbioogy. Non-cinica manager [...] I think not formay, there have been some reservations because as I said not a huge amount of evidence that this works. Primariy it was the company that was pushing it forward and so there has been some kind of disquiet around is this actuay making a difference or is it generay raising the awareness of you know, ceaning and things. It s never been formay chaenged as such. Senior nurse 78 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Nevertheess, the decision to adopt the system was made at senior management eve and was greaty supported by the DIPC. A respondent commented: It was agreed at a committee an infection contro group committee but I think the decision to go with it sat with the DIPC the Director of Infection Prevention, I think the utimate decision was [theirs]. Senior nurse Tabe 21 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Figure 13 depicts the stakehoders invoved and evidence types used in each of the innovation process substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. TABLE 21 T2 ASP GLOSAIR 400 ahp system: evidence sources and types Evidence sources Mass media Industry/suppiers Peer-reviewed academic iterature Trust care environment Evidence types Speciaist periodica reports Product documentation; product demonstration Scientific artices Product workshop; oca tria Initiation Adoption decision Trust board DIPC/executive nurse Speciaist periodica reports Product documentation Product demonstration Speciaist periodica reports Product documentation Product demonstration Trust board DIPC/executive nurse Microbioogy Scientific artices Scientific artices Microbioogy IPC team Hote services Product workshop; oca tria Product workshop; oca tria IPC team Hote services Domestic staff Impementation Domestic staff Speciaist periodica reports Product documentation Product demonstration Scientific artices Product workshop; oca tria Trust board DIPC/executive nurse Microbioogy IPC team Hote services Domestic staff Outcome Trust-wide impementation FIGURE 13 T2 ASP GLOSAIR 400 ahp system: professionas engagement and evidence types in decision-making. Queen s Printer and Controer of HMSO 2014. 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. 79

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS Outcome The system became avaiabe for use across T2 in ate 2007. The evidence featuring during the process and mutidiscipinary teamwork during impementation part of T2 s organisationa cuture are understood to have faciitated adoption. The technoogy has been considered an opportunity during a chaenging cimate of persistenty high C. difficie and MRSA bacteraemia case incidence at T2. However, since adoption the system has mosty been used to combat C. difficie and norovirus. Protocos were deveoped to support its use. The innovation adoption process is understood to have concuded fairy quicky. The company provided training and a new group was formed as part of the T2 Deep Cean Team, the Rapid Response Cean Team; the respondents considered these to have been key enabers. In T2, use of the system was reported to take 3 hours for a bay or room. A fu deep-cean process, incuding use of this system, was reported to take a maximum of 6 8 hours. Space to host patients becomes avaiabe after the deep cean and/or rapid vapour-based cean take pace. This is considered very important in aeviating bed management pressures. The system s adoption is understood to be a success as part of the measures heping T2 report ower infection rates. Based on T2 interviews from phase 1, this technoogy product is currenty in the re-evauation process to buid up its oca evidence base. This was driven by an organisationa need for justification of its ongoing use, and a need for evidence fet by stakehoders based on microbioogists critica appraisa of the existing evidence avaiabe. Microcase 4: UV LIGHT Technoogies inspection torch Attributes perceived by stakehoders Staff members of T2 understand the torch to be buky and heavy when carried within the care environment. The risks of eye damage when directing or refecting ight towards others, and of skin burn when touching the front gass once the torch has been in operation for some time, were aso identified by respondents. The torch is viewed as a high-tech item that was recenty introduced in the NHS and that is usefu in reveaing stains and other surface residues that are not readiy discernibe. However, further training is required for observers to identify the type and content of stains or residues reveaed. Its main benefit was thus understood to be that it enabes staff to visuay assess surface ceaniness rapidy. It was perceived as rather impractica for use in wards, but usefu in occasiona inspections, and generay as bringing imited benefit to T2 s IPC practice. Stakehoders, evidence and decision-making The UV ight torch was initiay considered as an opportunity at T2 during a time of high C. difficie incidence in 2007 8. Subsequenty, the opportunity for a tria came in the form of an evauation of the UV ight torch in tandem with the 3M Cean-Trace uminometer, funded by the Department of Heath and Smart Soutions. One respondent expressed some concerns about the suitabiity of this evauation method to assess genuine outcomes: I think if you have a go with something quite a ot of spin-offs, we didn t know at the time what kind of spin-offs there was going to be. But a big benefit to us was being abe to try the ATP out at the same time. So actuay we ended up with two technoogies and at the end of it I was actuay thinking to mysef that maybe we shoudn t, aways be viewing the technoogies in isoation because quite often some of these things are compementary. Senior nurse Once the risks associated with its use became apparent, a detaied protoco was deveoped to guide the use of torches, uminometers and rod swabs. A items were paced on a troey for easier transfer, access, use and reposition by T2 staff members during the tria. 80 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Tabe 22 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Figure 14 depicts the stakehoders invoved and evidence types used in each of the innovation process substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. TABLE 22 T2 UV LIGHT inspection torch: evidence sources and types Evidence sources Industry/suppiers Peers and coeagues Trust care environment Evidence types Product documentation; product demonstration Feedback on use Loca tria data Initiation Adoption decision Product documentation Product documentation Product demonstration Product demonstration DIPC/executive nurse Feedback on use Feedback on use DIPC/executive nurse Microbioogy Loca tria data Loca tria data Microbioogy IPC team IPC team Domestic staff Domestic staff Impementation Product documentation Feedback on use Product demonstration Loca tria data DIPC/executive nurse Microbioogy IPC team Domestic staff Outcome Adopted and ad hoc use trust wide FIGURE 14 T2 UV LIGHT inspection torch: professionas engagement and evidence types in decision-making. Queen s Printer and Controer of HMSO 2014. 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. 81

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS Outcome Foowing the tria, consensus among staff centred on not recommending the system for trust-wide impementation, but keeping the unit for use in occasiona inspections. A faciitating factor to this end is considered to be the avaiabiity of the torch at a reduced price by the suppier. A respondent commented: [...] it woud have been better to ook at the UV ight and its usefuness in moving equipment, for exampe, into a darker room and examining how cean it was. Rather than try to do it in broad day ight at the bed-side. It is usefu in the operating theatre. Senior nurse Trust 3 technoogy product microcases Microcase 1: Bioque vapour hydrogen peroxide Room Bio-Decontamination Service Attributes perceived by stakehoders The Bioque VHP RBDS was perceived by T3 informants as an effective means of disinfection and decontamination. It is understood that hydrogen peroxide vapour can access those areas that may not be readiy accessibe by manua ceaning, and that it is more efficacious than its aerosoised variant. It is viewed as a new, high-tech system that is a compement to deep ceaning. Its efficacy in eradicating C. difficie spores has been a particuary attractive feature. The main benefits arising from its use are understood to be a safer care environment for patients, reduced risk of cross-infection and a reduced workoad for staff. Opinion seems to differ on whether there woud be financia savings to be had from its use, and whether the time taken to use the service amounts to more or ess the overa time required to deep-cean care areas to the same effect. Respondents suggested that there is a substantia cost eement in using this service and VHP technoogy more generay. Nonetheess, they woud generay recommend the service and technoogy be taken up more widey in the NHS. Stakehoders, evidence and decision-making The technoogy was reviewed as part of T3 s efforts to mitigate C. difficie incidences. A senior member of the trust IPC team acted as the evidence broker, forming a project team to coect and review evidence in the first instance, and bringing the evidence to other trust fora. These incuded working groups on C. difficie reduction and meetings with the trust CEO. The technoogy was aso discussed by the trust Investment and Purchasing Group. After a review of the evidence, the trust CEO aowed site surveys to be carried out in the trust. Patient groups aso informay demonstrated their interest in this technoogy. The trust s medica microbioogist was invoved in the adoption decision. The foowing respondent suggested that he was exercising expert power as a microbioogist over the other stakehoders when reviewing the evidence: The microbioogist, not chaenged it but are you sure that it s doing, that was amost the thing. Because I woud take the evidence to him and go through it with him so that is his nature. If you are going to sit in a meeting with him I need you to be with me. Not then be against me and start chaenging. So I was very cear to pick out a the things that I thought were reevant and I think he was reading himsef. But actuay he eft it up to me to do a ot of the stuff and he woud actuay chaenge a ot. Senior nurse 82 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Moreover, the key decision-makers became confident in making a more concrete decision through a site visit to another trust, where they directy observed this technoogy in action. One respondent suggested: Ony after we had the practica demonstration in [the other trust] we were cautious before that. They provided us with the evidence when they gave us the seminar here. But we were cautious unti we had actuay seen exacty what was the process invoved. How they seaed a the rooms up, how they controed it whie they gas. It was ony after we had actuay seen it and had it demonstrated to us, and we had spoken to the operatives, [that we] did we fee competey safe that it was a being controed in the proper manner. Senior non-cinica manager Sustainabiity has been a factor in the decision-making process, as reguar use of the service has been understood to represent a significant outay for the trust. Tabe 23 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Figure 15 depicts the stakehoders invoved and evidence types used in each of the innovation process substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. Outcome Informants from T3 suggest that the technoogy is positivey viewed in the trust. A decision on it is pending owing to perceived costs associated with its use, and aso because it cannot be widey used across a of the trust s sites. The suppier s engagement with the process, with particuar regard to the organisation of oca site surveys and deivery of evidence on the service, is considered as a key faciitator of the decision to tria the service and wiingness to deveop its use further as an active component in the trust s decontamination approach, particuary when a new panned hospita site is buit. The evidence on the technoogy s efficacy is aso thought to have payed a supporting roe. Microcase 2: cine sporicida wipes Attributes perceived by stakehoders The cine Sporicida Wipe is understood by T3 informants as a ow-tech, nove product combining sporicida action with wipe use. They suggested that the product was introduced as another measure to hep reduce infection rates further. Trust members suggested that they were aready famiiar with using wipes in the trust care environment and wecomed use of this product. The product s perceived benefits incuded ease of use, efficacy and a safer care environment for patients and staff. Before its adoption, a spray-based sporicida product was used. Its use by staff was fraught with probems despite reguar training, and its efficacy was understood to be rather ow. TABLE 23 T3 Bioque VHP RBDS: evidence sources and types Evidence sources Heath agencies Showcase Hospitas programme Peer-reviewed academic iterature Professiona networks Industry/suppiers Other trusts Trust care environment Evidence types HPA RRP recommendation Showcase tria report Scientific artices Conference presentations Product documentation and research Site visits; feedback on use Site surveys; feedback on use Queen s Printer and Controer of HMSO 2014. 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. 83

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS Initiation Adoption decision Trust CEO Deputy DIPC Head of decontamination IC physician Medica microbioogist H&S IPC team E&F team Risk management Purchasing Operations staff RRP recommendation RRP recommendation Showcase tria report Showcase tria report Scientific artices Scientific artices Conference presentations Conference presentations Product documentation Product documentation Site visits; use feedback Site visits; use feedback Site surveys; use feedback Site surveys; use feedback Impementation Trust CEO Deputy DIPC Head of decontamination IC physician Medica microbioogist H&S IPC team E&F team Risk management Purchasing Operations staff RRP recommendation Showcase tria report Scientific artices Conference presentations Product documentation Site visits; use feedback Site surveys; use feedback Trust CEO Deputy DIPC Head of decontamination IC physician Medica microbioogist H&S IPC team E&F team Risk management Purchasing Operations staff Outcome Ongoing decision-making FIGURE 15 T3 Bioque VHP RBDS: professionas engagement and evidence types in decision-making. H&S, heath and safety; IC, infection contro. Stakehoders, evidence and decision-making The cine sporicida wipes were introduced at a time when the incumbent sporicida product was understood to be faiing. Ideation came from a presentation in a professiona conference attended by IPC team members. In a short space of time, sma oca trias were hed in a few hospita areas, where ward staff were given the product to try it out. The decision was channeed through the trust s product seection committee, whose membership incudes care speciaists, divisiona representatives and matrons. Minutes from forma meetings hed were reviewed by trust directors, incuding finance directors. The trust s Heath and Safety Team were aso consuted. The product s cost was considered favouraby during the decision-making process, as the product was proven to be ess expensive than the incumbent product, generating sma savings for the team and the trust. Tabe 24 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Figure 16 depicts the stakehoders invoved and evidence types used in each of the innovation process substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. Outcome The decision to adopt the product was taken by the IPC team, and was approved by the product seection committee. A key factor was the review of the evidence on the product s cost neutraity. After the decision was made, IPC team members communicated with ward managers via e-mai and visits to wards. 84 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 TABLE 24 T3 cine sporicida wipes: evidence sources and types Evidence sources Industry/suppiers Peer-reviewed academic iterature Professiona networks Other trusts Trust care environment Evidence types Product documentation Scientific artices Infection Prevention Society conference presentations Feedback on use Staff feedback Initiation Adoption decision Product documentation Product documentation Product seection committee IPC team H&S Scientific artices IPS conference presentations Feedback on use Staff feedback Scientific artices IPS conference presentations Feedback on use Staff feedback Product seection committee IPC team H&S Procurement Procurement Domestic staff Domestic staff Ward staff Ward staff Impementation Product documentation Scientific artices IPS conference presentations Feedback on use Staff feedback Product seection committee IPC team H&S Procurement Domestic staff Ward staff Outcome Trust-wide impementation FIGURE 16 T3 cine sporicida wipes: professionas engagement and evidence types in decision-making. H&S, heath and safety; IPS, Infection Prevention Society. The company s active engagement during product depoyment, in terms of product support and trust staff training, is understood to have faciitated impementation. One respondent described this as foows: [...] the company had been very supportive in roing out to an organisation. But they went round and saw a the staff you know we ooked at a the posters and that, these are the sort of measures that we need to give our staff. They did a of that and went round and heped us and the company came round and put a the dispensers up and everything, so I think it s important. Senior nurse Queen s Printer and Controer of HMSO 2014. 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. 85

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS No resistance was reported during the impementation stage; this was party a resut of the nursing staff s experiences with the previous simiar products. One respondent commented: [...] we ve had negative stuff with previous products but I think because that is so negative, the fact that something that woud just so easy to use I think they just grasped it so I think they were very happy with it. I think perhaps that heped it. The negative experience heped it to be a positive yeah. Senior nurse Cine sporicida wipes have been used in the suice rooms of the trust s hospita wards since their introduction. The product is understood to be successfu because of trust members satisfaction, wide adoption by staff, a decrease in cost and the substitution of the earier probematic product. There is a perception among staff that use of the wipes is associated with a reduction of infection rates and outbreak duration. Microcase 3: Medixair UV Light Air Steriisation Unit Attributes perceived by stakehoders Informants understand the Medixair systems to caim to eradicate air-borne pathogens by producing pathogen-free air in cinica areas. A coatera effect of keeping environmenta surfaces ceaner is understood to be caimed aso. They are aso understood as a high-tech product and quite new to the NHS, but not compatibe with existing trust care systems and structures. Benefits anticipated incuded a reduction in cross-infection, a ceaner care environment, better patient outcomes, a perception of activey improving care for patients and reated benefits for the trust. Stakehoders, evidence and decision-making The IPC team was presented with grant funds to procure and use new technoogy to combat HCAIs. Use of the devices was triaed in two hospita wards (thought to be hot spots ), in which air sampes were coected. Evidence was gathered, reviewed by the IPC team and presented at the trust s product seection committee. IPC team members noted that the evidence presented on the technoogy was conficting. Those IPC team members who had a microbioogy background understood the tria resuts to be inconcusive in proving the efficacy of the technoogy and devices themseves. The devices were understood by some staff members to be disruptive whie in operation in cinica areas. IPC members found it difficut to source spare parts when required. Knowedge about such maintenance requirements and ongoing cost was neither readiy identified by the trust from the start nor provided by the suppier: [...] we did piot again and they were on renta because we started reaising there were a ot of issues with the maintenance of them and the ongoing maintenance, and that was going to be a probem, and the ongoing cost reay. It wasn t as it appeared when we first started out with it. So things started to change we weren t confident in the resuts. We did air samping and we weren t confident with those resuts either. Senior nurse This resuted in staff members osing confidence in making this technoogy work in reaity. Tabe 25 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Figure 17 depicts the stakehoders invoved and evidence types used in each of the innovation process substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. 86 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 TABLE 25 T3 Medixair UV Light Air Steriisation Units: evidence sources and types Evidence sources Professiona networks Industry/suppier Showcase Hospitas programme Other trusts Heath agencies Trust care environment Evidence types Conference presentations Product documentation, case study reports Product documentation Feedback on use HPA RRP recommendation Loca tria; staff and patient feedback Initiation Adoption decision Conference presentations Conference presentations Product documentation Product documentation DIPC and medica Case study reports Case study reports DIPC and medica director Feedback on use Feedback on use director IPC team RRP recommendation RRP recommendation IPC team IC physician Loca tria; staff and Loca tria; staff and IC physician Medica microbioogist patient feedback patient feedback Medica microbioogist E&F team E&F team Procurement Procurement Decontamination Decontamination manager Impementation manager Ward staff Ward staff Conference presentations Product documentation Case study reports Feedback on use RRP recommendation Loca tria; staff and patient feedback DIPC and medica director IPC team IC physician Medica microbioogist E&F team Procurement Decontamination manager Ward staff Outcome Rejected FIGURE 17 T3 Medixair UV Light Air Steriisation Units: professionas engagement and evidence types in decision-making. IC, infection contro. Outcome The outcome of the evidence review and decision-making process was a rejection of the system s continued use in the trust. The decision was taken by the IPC team. Loca tria resuts were not suggestive of a high eve of efficacy of the product in terms of air purification. Patient and staff feedback incuded comments on the product being obtrusive as part of the ward environment and noisy at times. T3 informants fet that, overa, the evidence was not robust enough to warrant their further engagement with this technoogy. Queen s Printer and Controer of HMSO 2014. 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. 87

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS Trust 4 technoogy product microcases Microcase 1: DIFFICIL-S disinfectant iquid detergent Attributes perceived by stakehoders DIFFICIL-S is understood by T4 informants to be a next-generation ceaning and disinfection product based on chorine dioxide, which is produced upon mixing. It is considered a step forward from hypochorite products used, which are understood to cause surface corrosion. Currenty, the hypochorite disinfectant used at T4 is ActiChor Pus (ECOLAB, Swindon, UK) tabets. DIFFICIL-S is thought to be highy effective, as it achieves a very high bacteria oad reduction in a short time, and aso because of its ow risk Contro of Substances Hazardous to Heath profie. These aspects are considered as key advantages over chorine dioxide and hypochorite products aike. Products with chorine dioxide as their active ingredient have been avaiabe on the market for some time, but their use in the NHS seems reativey new. The fact that the product deivers the required chorine dioxide concentration means that it is viewed by senior staff members as high tech, whereas the product appication generay is viewed as ow tech. The product is considered to be in ine with existing ceaning practice, care deivery processes and the trust s cuture. However, it is perceived as a product that is ess easy to use than detergent wipes, and one for which variabe ceaning efficacy due to errors in preparation might sti be an issue. Infection rate reduction is suggested as the main benefit. Further benefits for the trust incude a onger ife of surfaces and equipment and pubic confidence owing to ower infection rates. Stakehoders, evidence and decision-making Members of the IPC team found out about the product at the Infection Prevention Society annua conference. Subsequenty, they contacted the HPA for further input, and consuted a scientific paper that reported research resuts about the product in a speciaist peer-reviewed journa. The recent C. difficie rates and trust management support for efforts mitigating C. difficie incidences were aso thought of as favourabe conditions for seecting the product as we as aunching its oca tria. The foowing respondent noted the externa pressure appied from the strategic heath authority in reation to trust s C. difficie performance. The aforementioned scientific paper was pubished during the period when trust members were activey searching for soutions: [...] our rates haven t come down as quick as the SHA (Strategic Heath Authority) woud have iked them to do. [...] we sti had ess cases than ast year but they wanted ess [than that...] we were activey ooking for anything that woud hep us with C. difficie, otherwise it, with new products it s whether you hear about them through professiona networks, you see them at conferences, or a rep etterboxes you and gives you some iterature, or in our case it was a mix of we were ooking at the time that this was avaiabe, so we were thinking what can we do and this paper came out. Senior nurse Key stakehoders invoved incuded the IPC team, the medica director and director of nursing, heads of nursing from the oncoogy hospita areas where the product was triaed, T4 s domestic services partner staff, the finance department and the mutiprofessiona infection prevention monitoring committee. As T4 is a PFI trust, the decision has invoved negotiations between the IPC team and the trust domestic services partner on costing, staff training and PFI contractua aspects. The tria had an approximate duration of 2 months. It was organised in the oncoogy areas of the T4 main hospita site, because of their stabe patient fow patterns that do not typicay incude transfers to and stays in other hospita areas. Any effect on infection rates was, thus, thought to have been contained within, and be reevant to, those areas ony. 88 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Evidence featuring in the initiation, adoption decision and impementation stages incuded feedback from peers and coeagues in T4 and other trusts, expert advice from the HPA, suppier product documentation, peer-reviewed journa artices and oca data coected during the tria. Tabe 26 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Figure 18 depicts the stakehoders invoved and evidence types used in each of the innovation process substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. TABLE 26 T4 DIFFICIL-S disinfectant iquid detergent: evidence sources and types Evidence sources Peers and Coeagues Heath agencies Industry/suppiers Peer-reviewed academic iterature Other trusts Trust care environment Evidence types Feedback on use HPA expert advice Product, service documentation Journa of Hospita Infection scientific artice Loca trias feedback Loca tria data Initiation Adoption decision IPM committee Medica director/ DIPC Director of nursing Heads of nursing IPC team E&F team Theatre staff Ward staff Domestic services partner staff Feedback on use HPA expert advice Product, service documentation J Hosp Infect scientific artice Loca trias feedback Loca tria data Impementation Feedback on use HPA expert advice Product, service documentation J Hosp Infect scientific artice Loca trias feedback Loca tria data IPM committee Medica director/ DIPC Director of nursing Heads of nursing IPC team E&F team Theatre staff Ward staff Domestic services partner staff Feedback on use HPA expert advice Product, service documentation J Hosp Infect scientific artice Loca trias feedback Loca tria data IPM committee Medica director/dipc Director of nursing Heads of nursing IPC team E&F team Theatre staff Ward staff Domestic services partner staff Outcome Ongoing decision-making FIGURE 18 T4 DIFFICIL-S disinfectant iquid detergent: professionas engagement and evidence types in decision-making. IPM, infection prevention monitoring. Queen s Printer and Controer of HMSO 2014. 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. 89

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS Outcome The technoogy was viewed positivey by T4 informants. The IPC team took a eading roe in organising the tria. A champion roe is identified with the manner in which a senior IPC team member has ed the process. The tria took pace in the first quarter of 2012 and data were coected. This ocay produced evidence was reviewed in Apri 2012. A decision is pending regarding adoption of DIFFICIL-S in T4. Microcase 2: Bioque vapour hydrogen peroxide Room Bio-Decontamination Service and Steris BioGenie Attributes perceived by stakehoders Informants understood this technoogy to be appropriate for use once manua surface ceaning has been competed by staff. The vapour reeased is thought to permeate and decontaminate areas not easiy accessibe by manua ceaning, with the same efficacy each time it is used, unike manua ceaning. The technoogy is understood to have been utiised in other industries for many years, and has ony recenty been made avaiabe in heath care. It is thus viewed as a ow-tech principe whose appication in this manner in T4 is understood to be high-tech. This may refect the attributes of the newer VHP machines bought in T4, which can perform both vapour generation and aeration based on programing that takes into account the voume of the room where the device wi operate. The main benefits perceived to be stemming from the use of this technoogy are (1) a high degree of decontamination and ow infection rates for patients, (2) reassurance and a reduced workoad for staff to manage, and (3) a good pubic perception of the trust. Stakehoders, evidence and decision-making Initiay, T4 had used Bioque VHP RBDS to effectivey eradicate mutipe MRSA bacteraemia strains in its neonata intensive-care unit. It was aso used to decontaminate areas after an incident with sanitation pipeines. One respondent described this as foows: We had a massive sewage eak in the eye department or an air con faiure [...], so when the eye department came in on a Monday morning there was water just iteray running down the was and off the ceiing ties, and in their three operating theatres, and it was ike going into a tropica rainforest. But we were then worried about pseudomonas and things ike that, so we decided then that we woud just peroxide the whoe ot, cean it up and peroxide it, so we d used it a coupe of times, we iked it. Senior nurse Persisting issues with environmenta hygiene at T4 ed the IPC team to consider soutions. The team attended a Showcase Hospitas programme conference where they were presented with evidence on VHP technoogy. The technoogy was considered easy to use and manage by the IPC team themseves, and very effective in raising environmenta hygiene standards. Decision-making was confined to senior members of the IPC team. The stakehoders at the initiation stage did not go through a tender process. A quick decision was taken to purchase this particuar product, mainy based on financia incentives and previous positive experience with the technoogy. This resuted in severa probems, diemmas and interna frictions, and was exacerbated by a ack of ongoing support from the company. Tabe 27 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Figure 19 depicts the stakehoders invoved and evidence types used in each of the innovation process substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. 90 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 TABLE 27 T4 Bioque VHP RBDS & Steris BioGenie: evidence sources and types Evidence sources Showcase Hospitas programme Heath agencies Peer-reviewed academic iterature Other trusts Peers and coeagues Trust care environment Evidence types Product documentation HPA RRP recommendation Scientific artices Loca trias and feedback on use Feedback on use Bioque VHP RBDS oca tria Initiation Adoption decision Trust IPC ead Heads of nursing Product documentation RRP recommendation Scientific artices Product documentation RRP recommendation Scientific artices Trust IPC ead Heads of nursing Fow managers IPC team Theatre staff Ward staff Loca trias and use feedback Feedback on use Bioque VHP RBDS oca tria Loca trias and use feedback Feedback on use Bioque VHP RBDS oca tria Fow managers IPC team Theatre staff Ward staff Domestic services partner staff Impementation Domestic services partner staff Product documentation RRP recommendation Scientific artices Loca trias and use feedback Feedback on use Bioque VHP RBDS oca tria Trust IPC ead Heads of nursing Fow managers IPC team Theatre staff Ward staff Domestic services partner staff Outcome Adopted and ad hoc use trust wide FIGURE 19 T4 Bioque VHP RBDS and Steris BioGenie: professionas engagement and evidence types in decision-making. Outcome Based on these positive experiences and on avaiabe externa funding [ 150,000 was given to T4 as part of the first HCAI Technoogy Innovation Programme Awards, which is a joint initiative by the Department of Heath and the former NHS PASA, which was expected to be used for new technoogy aimed at further tacking HCAIs (source: trust s annua report 2008/09)], a decision was made by the trust IPC team to buy four VHP machines, now marketed by Steris BioGenie for use in T4 hospitas as and when required. This decision was impemented through direct contact with the suppier. The product was chosen on the basis of its perceived ease of use, its combined operating modes of vapour generation and aeration/ Queen s Printer and Controer of HMSO 2014. 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. 91

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS dehumidification, its residua antibacteria efficacy through incusion of 6 parts per miion (ppm) siver iron in the vapour mix and the discount offered by the suppier on the purchase of four machines. Subsequenty, T4 procurement highighted forma procurement channes and aternative providers offering products with identica attributes. Issues with the after-saes service and support of the suppier, before Steris BioGenie, ed the IPC team to seek VHP machine maintenance through the T4 cinica engineering team. Members of the IPC team are caed on by other hospita groups to operate the machines. The IPC members conduct a seaing required within a room, incuding doors, windows, air vents, etc., and they then operate the machines themseves. Since its introduction, a further hospita unit, the neonata intensive-care unit, chose to use the machines. IPC team members have provided training to neonata intensive-care-unit staff. Two of the machines now reside in the neonata intensive-care unit for immediate use upon incidence of an infection. Wider use has been met with difficuties. Despite interest from theatre staff in the machines, theatre rooms have been confirmed to require more time and speciaist input in order to be prepared for VHP, and, as the IPC team has had a higher than expected staff turnover, it has been unabe to provide this additiona support. As some bed management and staff working time issues have been reported in this trust of high bed occupancy, it is thought that a dedicated team woud hep expand service use, but that comes with its own cost impications. It has aso been suggested that domestic services partner staff undertake this task; however, a training and cost dimension has been identified that has merited discussion. The IPC team s intention of estabishing a roing VHP programme across the trust has thus not been reaised to date. Microcase 3: Virusove+ Attributes perceived by stakehoders The suggestion to adopt this product came from a theatre infection contro ead staff member (IPC theatre ink nurse). The product was understood to be very effective against a types of bacteria, incuding bood-borne pathogens. Its ease of use resuted from it needing to be prepared ony once for frequent use thereafter. This was perceived to be a reative advantage over the current disinfectant needing to be made up before each use. The product s cost was viewed as acceptabe to the trust. Virusove+ is understood by IPC team members to have been used in other trusts, and adopted reativey quicky in T4, without fu recourse to and examination of the evidence avaiabe. Stakehoders, evidence and decision-making Shorty after the product began to be used, the IPC team asked to see the product data sheets and reated information. This occurred as part of a wider discussion and evidence review exercise among IPC team members on new disinfectant products, prompted by corrosion effects observed on surfaces, attributed to the currenty used, incumbent, product. It resuted in doubts being raised about the active ingredient of the product, its chemica composition and its ceaning efficacy. Theatre staff feedback suggested that the product was deposing a thin ayer of substance on equipment, which needed extra rinsing to remove and whose odour was rather unpeasant. Further IPC team members communication with the suppier did not produce satisfactory resuts. The decision to withdraw the product was taken by the T4 infection contro ead. Tabe 28 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Figure 20 depicts the stakehoders invoved and evidence types used in each of the innovation process substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. 92 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 TABLE 28 T4 Virusove+: evidence sources and types Evidence sources Professiona networks Industry/suppiers Peer-reviewed practitioner journas Heath agencies Evidence types Conference presentations; Infection Prevention Society artice Product documentation TOPIX artice HPA artice; HPA staff members feedback Initiation Adoption decision Conference presentations Conference presentations IPS artice IPS artice Product documentation TOPIX artice Product documentation TOPIX artice Theatre managers, staff IPC team IPC theatre ink nurse HPA artice HPA staff members feedback HPA artice HPA staff members feedback Teathre managers, staff IPC team IPC theatre ink nures Impementation Conference presentations IPS artice Documentation Product Theatre managers, staff IPC team IPC theatre ink nurse Outcome Rejected FIGURE 20 T4 Virusove+: professionas engagement and evidence types in decision-making. IPS, Infection Prevention Society. Outcome During its short time of use, the product was depoyed in theatres. T4 staff members are reported to have had a positive view of the product. However, doubts about its efficacy, resuting from a reative ack of evidence and transparency on the product operating principes, have been the main reason for its withdrawa. There were some concerns about a major change in ceaning products impacting on a high number of domestic staff, couped with an ambiguous evidence base around the advantages of Virusove+. One respondent commented: [...] ogisticay there are 600 domestics in this trust, they have a been trained to use hypochorite, [...] that is quite a task, and my ot, especiay XXX, she came in nights, she came in weekends [...]. And to change over to another product is a big undertaking, and whie it s not a cear picture to me Queen s Printer and Controer of HMSO 2014. 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. 93

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS as to whether we shoud change the Virusove+, or we shoud even question about our hypochorite, I m not going to change, I m not in a position to change because my numbers for C. diff[icie] are just hovering above or on the trajectory, and I cannot rock the boat in anyway. So unti I have a good body of evidence that there is superior product, whether it s Virusove+, or chorine dioxide, or something ese, I m not going to change. Senior nurse This risk averse attitude towards the introduction of HCAI technoogies can be party expained by the fact that T4 is the ony trust among the participating trusts that achieved a good performance on both MRSA bacteraemia and C. difficie infection rates during the whoe period observed (see Chapter 6). Trust 5 technoogy product microcases Microcase 1: Bioque vapour hydrogen peroxide Room Bio-Decontamination Service Attributes perceived by stakehoders The service was understood by T5 informants to invove a piece of equipment, a device and a process or operating procedure. It became avaiabe to the trust through the Showcase Hospitas programme in 2008. It is considered to be a high-tech soution. Informants perceive the main attributes of the service to be its efficacy in eiminating pathogens via disinfection and decontamination of the environment. The equipment itsef is considered easy to use; however, there was imited understanding of its principes and review of any evidence, especiay among ward staff. Perceived caveats incude that it is time-consuming, costy and cumbersome in the form it was offered, that is, a service deivered by an externa party rather than by trust operators. The service s cear reative advantage is perceived to be the high eve of decontamination assurance it offers. Severa informants suggest its use seems to coincide with fas in infection rates in wards. However, it is thought that it is not a substitute for ceaning, but rather a compement to standard cinica area ceaning practice. The service and equipment operation are understood to be reativey easy to understand and expain to others. However, deivery of the service (portabe machine operation, area seaing, etc.) is thought to be compex and requiring speciaist hep. Stakehoders, evidence and decision-making Key stakehoders invoved were the IPC team, incuding the DIPC, who is the chief nurse, nurse consutant and medica microbioogist, heads of nursing and ead nurses from the surgery, medicine, cinica and scientific hospita divisions, domestic services staff and the T5 domestic services partner. The tria had an approximate duration of 3 months. Types of evidence featuring in the initiation, adoption decision and impementation stages incuded product documentation from the Showcase Hospitas programme, feedback on use via professiona networks, peers and coeagues in other trusts, the Department of Heath s HCAI Technoogy Innovation Programme evauation reports, suppier product documentation, peer-reviewed journa artices and oca data coected during the tria (Tabe 29 and Figure 21). Outcome The technoogy was viewed positivey by T5 informants. Users support during the piot was evident, in part faciitated through awareness of the Showcase Hospitas programme, and by showcase ead acting as a boundary spanner. One respondent said: [...] we had a showcase ead nurse so they were, she was the one, or he was the one at the time who was invoved in about six different projects around the showcase hospitas. And he was sort of iaising with the different teams so [...] it was discussed as a division, if you needed it then come 94 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 TABLE 29 T5 Bioque VHP RBDS: evidence sources and types Evidence sources Showcase Hospitas programme Professiona networks/peers and coeagues Heath agencies Industry/suppiers Peer-reviewed academic iterature Other trusts Trust care environment Evidence types Product documentation Feedback on use Department of Heath s HCAI Technoogy Programme evauation reports Product, service documentation Scientific artices Loca trias feedback Loca tria data Initiation Adoption decision Product documentation Product documentation Feedback on use Feedback on use Scientific artices Scientific artices DIPC/chief nurse HCAI Tech Programme evauation Product, service doc HCAI Tech Programme evauation Product, service doc DIPC/chief nurse Showcase ead Scientific artices Scientific artices Showcase ead Heads of nursing Loca trias feedback Loca trias feedback Heads of nursing Lead nurses Loca tria data Loca tria data Lead nurses IPC team IPC team Domestic services partner staff Impementation Domestic services partner staff Product documentation Feedback on use HCAI Tech Programme evauation Product, service doc Scientific artices Loca trias feedback Loca trias data DIPC/chief nurse Showcase ead Heads of nursing Lead nurses IPC team Domestic services partner staff Outcome Adopted and ad hoc use trust wide FIGURE 21 T5 Bioque VHP RBDS: professionas engagement and evidence types in decision-making. down from infection contro because they d get the resuts, and then it woud come to use and say right, where do you want Bioqueing? or whatever the need was. Senior nurse In addition, anecdota feedback was suggestive of a positive reception by T5 staff and patients. The service was understood to improve on the inconsistent efficacy of manua ceaning, reduce the ceaning workoad for nursing staff and reieve training needs for domestic staff associated with a high turnover. A ess Queen s Printer and Controer of HMSO 2014. 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. 95

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS positive aspect is identified in the waiting times for rooms to become avaiabe for occupancy and bed management issues associated with them. The sustainabiity dimension was aso discussed during decision-making. The service was again used successfuy during the 2011 12 winter months in wards reporting a higher than usua pathogen incidence. The trust has been ooking at different options for adopting HPV technoogy in tandem with its ceaning regime and staffing requirements, in cose coaboration with its domestic services partner. This has invoved the preparation of a business case for a further HPV evauation, which has been ed by the IPC team in coaboration with hospita divisions. Overa, a key factor in faciitating the tria has been that the technoogy became avaiabe as a managed service. However, the disruptive effects that emerged during the tria, reated to patient fow, staff depoyment and bed management, are understood to have payed a key part in the decision taken. Microcase 2: Chor-Cean tabets Attributes perceived by stakehoders Chor-Cean is perceived to be a ow-tech, innovative product which fas within the nationa guideines on effective sporicida ceaning. It is understood to be easy to use. However, attention is required to use it correcty: that is, the tabet has to be diuted in water to achieve the concentration recommended by guideines. Prior to adopting Chor-Cean, Haz-Tabs (Guest Medica Ltd, Ayesford, UK) were used comprehensivey at T5, aong with detergent wipes where appropriate. Haz-Tabs are now used ony in cases in which a higher-chorine-concentration agent is required, for exampe in cases of bodiy fuid spiage. Detergent wipes are used when ceaning with a esser chorine concentration is considered appropriate. Stakehoders, evidence and decision-making Senior IPC team members coaborated with the manufacturer to deveop a protoco detaiing how to use Chor-Cean in cinica areas. The adoption decision was taken by the IPC team. Subsequenty, the product was introduced across the trust on the basis of active eectronic, verba communication and a teaching schedue. Ward ink nurses iaised with the IPC team members and ward staff with regards to the product on a reguar basis. Evidence was shared with other hospita groups via the intranet IPC team website; however, the exact types and sources of evidence distributed have not been determined. Ward staff seemed unaware of the product s specific reative advantage, as we as of its cost and sustainabiity aspects. They seemed to pace trust in the work of the IPC team preparing the product s impementation. Impementation centred on the use of posters in wards and cascade teaching as part of T5 s routine teaching programme. This aso incuded demonstrations about how to diute tabets in water to achieve the required concentration, and how to conduct ceaning using the product. Instructions have aso been incuded on the containers and tabet tubes themseves. Tabe 30 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Figure 22 depicts the stakehoders invoved and evidence types used in each of the innovation process substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. Outcome Since its introduction, the product has been adopted and widey used by ward staff and domestic staff. The product has been successfuy mainstreamed across T5 and used extensivey in the ast 5 years. Informants suggest that staff are generay happy with using the product and seem incined to associate it 96 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 TABLE 30 T5 Chor-Cean tabets: evidence sources and types Evidence sources Professiona networks Heath agencies Industry/suppiers Peer-reviewed academic iterature Other trusts Peers and coeagues Evidence types Conference presentations Department of Heath s sporicida ceaning guideines Product, service documentation Scientific artices Loca trias feedback Product feedback Initiation Adoption decision Conference presentations Conference presentations Sporicida guideines Sporicida guideines IPC team Ward staff Domestic staff Product, service documentation Scientific artices Loca trias feedback Product feedback Product, service documentation Scientific artices Loca trias feedback Product feedback IPC team Ward staff Domestic staff Impementation Conference presentations Sporicida guideines Product, service documentation Scientific artices Loca trias feedback Product feedback IPC team Ward staff Domestic staff Outcome Trust-wide impementation FIGURE 22 T5 Chor-Cean tabets: professionas engagement and evidence types in decision-making. with a reduction in infection rates. Two probems with its use were reported as part of this research. One concerns the undesirabe effect on surfaces observed after repeated use: many surfaces start to show signs of breaking down once repeatedy ceaned with Chor-Cean. A simiar concern was raised with regard to using probes for oxygen saturation in areas recenty ceaned with the product. Soap and water continue to be used for soft, for exampe fabric, surfaces, such as mattresses. Queen s Printer and Controer of HMSO 2014. 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. 97

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS Microcase 3: 3M CeanTrace and Hygiena SystemSURE II ATP hygiene monitoring system Attributes perceived by stakehoders Informants from T5 understand both systems to be ow-tech products, new to the NHS and reativey easy to use; the 3M product is viewed as somewhat easier to hande. Storing resuts on a server for ater viewing is considered a high-tech feature; however, respondents suggested that the graphs and tabes generated through the software are not aways easy to make sense of. Before their tria, there was no means of determining the efficacy of surface ceaning other than visua inspection. The systems are thought to be in ine with T5 s vaues and cuture, emphasising infection prevention and environmenta hygiene. However, their introduction was met with some difficuty vis-à-vis systems and structures supporting care deivery at T5. Stakehoders, evidence and decision-making The Showcase Hospitas programme provided ideation about this technoogy. Three oca trias supported by the programme were conducted in specific hospita areas of high patient throughput, such as the medica assessment unit, neonata and paediatric intensive-care units, and rena and gastroenteroogy wards. Specific surfaces were seected that represented areas of high frequency of use by ward staff. In one ward, patient feedback was sought through questionnaires about their confidence eves. These patients were presented with ATP data coected from their bedside surfaces. In other wards, managers and matrons presented data as they became avaiabe. The trias were supported by academic staff based at Loughborough University, who visited wards to coect data through swabbing. One respondent described this as foows: [...] what we agreed was that every week that the ward managers woud get feedback from Loughborough University, from the professor. [...] Every week, every Monday morning, OK. And it came to me, and it came to the ward managers because obviousy that s their immediate area, OK. And he actuay woud highight for them, this may need a itte bit more attention or whatever, but overa the resuts were very, very good, very good. Senior nurse Additiona staff members were aso hired to work with the system and sampe certain surfaces, which were agreed upon beforehand between ward staff and the IPC team. Resuts, in the form of tabes and graphs, were fed back to T5 s staff of those wards and cinica areas where trias took pace. Stakehoder groups invoved incuded the IPC team, ward staff, domestic staff (housekeepers), heads of nursing and the trust s infection contro committee. The T5 showcase ead has been identified as a champion, as a resut of him or her enacting communications about the trias among staff groups, advocating the added vaue of the systems and the tria to the trust and organising data coection. One respondent commented: I e-maied the matrons, the ward managers and the heads of nursing for them areas and said, we re going to be given the opportunity to do this, I see it as a very positive step forward, I invoved peope ike [...] and a these peope from Sodexo, and I said if we use it as a positive thing it s going to be a very good guideine for as to how we we re doing our ceaning. And as we a know cean hospitas are something that s very high on the agenda for the Department of Heath. So I kind of sod it to them in a very positive way. Senior nurse The types of evidence featuring in the adoption process as suggested by informants (Tabe 31) incuded product documentation avaiabe through Showcase Hospitas, presentations at professiona network conferences, RRP recommendation reports, feedback from other trusts, data generated through oca trias. Figure 23 depicts the stakehoders invoved and evidence types used in each of the innovation process 98 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 TABLE 31 T5 3M CeanTrace and Hygiena SystemSURE II ATP hygiene monitoring system: evidence sources and types Evidence sources Showcase Hospitas programme Professiona networks Heath agencies Other trusts Trust care environment Evidence types Product documentation Conference presentations Department of Heath s HCAI Technoogy Programme evauation reports; HPA RRP recommendations Loca trias feedback Loca tria data Initiation Adoption decision Product documentation Product documentation Conference presentations Conference presentations IC committee IPC team Ward staff Domestic staff HCAI Tech Programme evauation RRP recommendations Loca trias feedback Loca tria data HCAI Tech Programme evauation RRP recommendations Loca trias feedback Loca tria data IC committee IPC team Ward staff Domestic staff Impementation Product documentation Conference presentations HCAI Tech Programme evauation RRP recommendations Loca trias feedback Loca tria data IC committee IPC team Ward staff Domestic staff Outcome Rejected FIGURE 23 T5 3M CeanTrace and Hygiena SystemSURE II ATP hygiene monitoring system: professionas engagement and evidence types in decision-making. IC, infection contro. substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. Outcome The resuts of the tria suggested to T5 s staff members that the trust s ceaning regime and practices were generay quite effective. Both systems were viewed positivey by most professionas and hospita groups invoved in the trias. Domestic and nursing staff members in wards where trias took pace were reportedy Queen s Printer and Controer of HMSO 2014. 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. 99

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS enthusiastic about the systems; however, information or training does not seem to have been provided systematicay. Foowing the trias, use of the two systems was discontinued, as there was no interest shown by T5 s senior staff. One incompatibiity was identified between the use of Chor-Cean tabets and ATP swabbing: a particuar ingredient of Chor-Cean atered ATP measurements. Cost impications had become apparent during the trias. In addition, no particuar hospita group or team was identified that woud utiise the system without adding to the existing workoad of staff and disrupting existing care deivery systems and processes. Use of the two systems was thus discontinued. Trust 6 technoogy product microcases Microcase 1: Bioque vapour hydrogen peroxide Room Bio-Decontamination Service Attributes perceived by stakehoders This technoogy is understood by T6 informants to be an effective means of decontamination, and more effective than manua ceaning, as hydrogen peroxide vapour can access those areas that may not be readiy accessibe by manua ceaning. It is viewed as a new, high-tech system, a departure from the traditiona means and methods of ceaning. Prior to its introduction, manua deep cean and steam ceaning were practised. It is, otherwise, thought to be reativey straightforward to expain and train staff members in the use of. However, the time taken to carry out the procedure is understood to be a disadvantage regarding its use in the trust and the NHS more widey. Benefits arising from its use may incude a safer care environment for patients and staff, a reduced workoad for staff, a higher throughput and better financia position for the trust, and improved quaity of care in the NHS. Stakehoders, evidence and decision-making The technoogy was introduced in the trust as an environmenta ceaning measure to hep aeviate the impact of a proonged outbreak that caused significant disruption. Since then, it has been used one more time for the same purpose. A respondent discussed how evidence is sourced: We ve, oh right OK, obviousy from your training. If you re a microbioogist you woud have gone through the contamination training and things ike that. You woud have gone through conferences, you woud have seen it with hydrogen peroxide. The pressure to use it woud have come from the outbreak contro meetings.... So there s a ot of things that converges through, focus you. And sometimes the drug reps or the manufacturers, if they re present they might come and tak to you. Senior doctor Trust staff members were approached by companies offering VHP-based products. The RRP recommendation of 1 awarded to the service was a key reason for deciding to introduce the technoogy to the trust. The IPC and E&F teams took part in the evidence review and decision-making, whereas the DIPC ed the process. The decision to bring in the Bioque service was taken by the DIPC and director of E&F. The incidence of outbreaks, the introduction of this technoogy in other trusts and trust members awareness of that were the other factors eading to this decision. As one respondent commented: So I think your need, and what s going on in your organisation at the time aso directy infuences your wiingness to go out there and seek the new innovation and technoogies. Senior nurse 100 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Another respondent said: There was good consensus, we bought it in after a coupe of outbreaks. We were not meeting the objectives and the targets that we were getting from [the Strategic Heath Authority], so it was fet that athough this was over and above what is recommended nationay, it woud be a good decision for the trust to undertake. Senior nurse Tabe 32 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Figure 24 depicts the stakehoders invoved and evidence types used in each of the TABLE 32 T6 Bioque VHP RBDS: evidence sources and types Evidence sources Heath agencies Practitioner journas Professiona networks Industry/suppiers Other trusts Trust care environment Evidence types HPA RRP recommendation Scientific artices via MEDLINE Conference presentations Product documentation Feedback on use Use experience; staff feedback Initiation Adoption decision DIPC/director of nursing Deputy DIPC IC physician IPC team E&F team Procurement Ward staff Domestic staff RRP recommendation Scientific artices Conference presentations Product documentation Feedback on use Use experience; staff feedback Impementation RRP recommendation Scientific artices Conference presentations Product documentation Feedback on use Use experience; staff feedback DIPC/director of nursing Deputy DIPC IC physician IPC team E&F team Procurement Ward staff Domestic staff RRP recommendation Product documentation Scientific artices Conference presentations Feedback on use Use experience; staff feedback DIPC/director of nursing Deputy DIPC IC physician IPC team E&F team Procurement Ward staff Domestic staff Outcome Ongoing decision-making FIGURE 24 T6 Bioque VHP RBDS: professionas engagement and evidence types in decision-making. IC, infection contro. Queen s Printer and Controer of HMSO 2014. 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. 101

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS innovation process substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. Outcome Decision-making was channeed through the trust s outbreak management committee. The fina decision to introduce the technoogy was taken by the DIPC. The DIPC is understood by some respondents to have championed the introduction of VHP technoogy in the trust. One respondent commented: So [the DIPC], I woud think [the DIPC] was obviousy a champion. [the DIPC], not because of the evidence and things, there s a ot of pressure that comes to the DIPC and the DIPC thinks differenty in terms of management. Senior doctor The experience of having used the service is thought to be a positive one by the trust s staff members, with particuar regard to the support offered by the suppier. Some reservations have been expressed regarding its use, as it introduces a time ag before bays become avaiabe after decontamination. A respondent suggested: I think the main thing I said they were a barrier is the patient fow and the activities, yeah, disruption to that. That s the one nobody can swaow. Senior doctor Senior trust members wish to estabish whether the evidence is strong enough to confirm its efficacy against other methods of ceaning. If it is to be mainstreamed, it shoud be better ony than current ceaning methods such that it can deiver better patient outcomes in tandem with other measures. Microcase 2: JLA OTEX system Attributes perceived by stakehoders OTEX is understood by T6 informants to be a nove way of machine washing fabric-based care and hospita equipment, not by traditiona means of water and detergent, but through the reease of ozone. Respondents suggest that there is substantia evidence to support the efficacy of this technoogy, in particuar its abiity to reease dirt from fabric. It is understood as a fairy we-estabished and vaidated technoogy, viewed as simpe to expain and quite compatibe with T6 s vaues and cuture. Informants opinions seemed to differ on whether there is added vaue from this technoogy and benefits to patients, staff, the trust and the NHS more widey. Stakehoders, evidence and decision-making The depoyment of OTEX coincided with the introduction of microfibre mops and coths in the trust. Foowing a suggestion to use the product by the trust domestic services partner, a business case was prepared. This was reviewed first by the IPC team and then by the trust s IPC Committee, whose membership incudes the trust s directors of operations, other senior trust board members and senior domestic services partner staff. The business case was reviewed in tandem with other evidence types, which are shown in Figure 25, with a view to the new system featuring in the trust PFI contract. As one respondent commented: I don t think cost has been an issue, I think the ony probem there might have been is [the hospita] being a PFI and getting the agreement of the PFI Group to agree the instaation of the machines. Senior nurse Tabe 33 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. 102 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Initiation Adoption decision RRP recommendation RRP recommendation Product documentation Product documentation IPCC DIPC/director of nursing Deputy DIPC SH report of T9 Tria Business case Staff feedback SH report of T9 Tria Business case Staff feedback IPCC DIPC/director of nursing Deputy DIPC IPC team IPC team Domestic services partner staff Impementation Domestic services partner staff RRP recommendation Product documentation SH report of T9 Tria Business case Staff feedback IPCC DIPC/director of nursing Deputy DIPC IPC team Domestic services partner staff Outcome Mainstreamed use in the trust FIGURE 25 T6 JLA OTEX system: professionas engagement and evidence types in decision-making. IPCC, infection prevention and contro committee; SH, Showcase Hospitas. TABLE 33 T6 JLA OTEX system: evidence sources and types Evidence sources Heath agencies Industry/suppiers Showcase Hospitas programme Trust care environment Evidence types HPA RRP recommendation Product documentation Showcase Hospitas report of T9 tria Business case; staff feedback Outcome The technoogy has been mainstreamed in the trust and has become part of the trust s PFI contract. This is monitored through meetings between T6 s board members and senior staff of the domestic services partner. T6 s domestic services partner has assigned championship responsibiities to their staff members depoyed in the trust, who perform a tasks reated to the system s operation in coaboration with the trust s ward staff. This aspect is viewed as important vis-à-vis adoption and continuous use. One respondent commented: [Domestic service partner staff] works, once they re on the ward we have what we ca devoution, where they become part, they are part of the ward team... they re [domestic service partner] empoyees, but once they work on the ward they wi take a ead from the sister [on that ward]. Senior non-cinica manager Queen s Printer and Controer of HMSO 2014. 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. 103

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS The trust s domestic services partner aso offers courses and product-based training, demonstrations and training sessions with trust members. Microcase 3: Medixair UV air steriisation units Attributes perceived by stakehoders Informants from T6 understand Medixair to eradicate air-borne bacteria and be appropriate for use in cinica areas. They are viewed as high-tech, radicay new pieces of equipment whose efficacy has yet to be supported by robust evidence. They are aso understood to be compatibe with existing trust care systems and structures. Benefits anticipated incuded a reduction in cross-infection, a ceaner care environment and a perception of activey improving care on behaf of patients. Stakehoders, evidence and decision-making The technoogy was considered for introduction in the trust care environment both as an opportunity in itsef and as part of a suite of measures to hep reduce MRSA bacteraemia coonisation through air-borne bacteria in bays. Ideation began through a communication by the suppier to the CEO at T6. The suppier forwarded product documentation, a report on the equipment s scientific principes of operation and case studies of the equipment s use in other trusts. These were then forwarded to the IPC team for consideration. The HPA RRP recommendation on the product was sourced during the adoption decision stage. The entire evidence review and decision-making process asted for approximatey 1 month. The Deputy DIPC coected a evidence types and information, and distributed it to the other stakehoders. Tabe 34 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Figure 26 depicts the stakehoders invoved and evidence types used in each of the innovation process substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. Outcome The outcome of the evidence review and decision-making process was a rejection of the systems. The trust s infection contro physician and decontamination manager scrutinised the evidence and suggested that the aeged efficacy coud not be sustained on the basis of the product s principes of operation. Informants suggested that this scrutiny and derived concusion was accepted on the basis of the speciaist training of their two senior coeagues. Informants aso fet that, overa, the evidence wasn t robust enough to warrant their further engagement with this technoogy. A respondent commented: So we a basicay sat round the tabe, having ooked at the information that we d been given, and came up, had a discussion around whether we fet this was worth pursuing. The outcome was that the evidence reay wasn t very strong, and we probaby woudn t pursue it. Senior nurse TABLE 34 T6 Medixair UV air steriisation units: evidence sources and types Evidence sources Professiona networks Industry/suppier Heath agencies Evidence types Conference presentations Product documentation; case studies; scientific basis report HPA RRP recommendation 104 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Initiation Adoption decision Conference presentations Conference presentations Product documentation Product documentation CEO Decontamination manager IPC team Case studies Scientific basis report RRP recommendation Case studies Scientific basis report RRP recommendation CEO Decontamination manager IPC team E&F team E&F team Procurement Procurement Impementation Conference presentations Product documentation Case studies Scientific basis report RRP recommendation CEO Decontamination manager IPC team E&F team Procurement Outcome Rejected FIGURE 26 T6 Medixair UV air steriisation units: professionas engagement and evidence types in decision-making. Trust 7 technoogy product microcases Microcase 1: DIFFICIL-S disinfectant iquid detergent Attributes perceived by stakehoders DIFFICIL-S is understood by T7 informants to be a new ceaning and disinfection product based on chorine dioxide, which is produced upon mixing. It is considered to be particuary effective against C. difficie vis-à-vis other disinfectant products, resuting in a higher eve of decontamination and cross-infection mitigation. It is understood to have been evauated by other trusts and sti not widey adopted. It is viewed as a product that is ony somewhat compicated to prepare owing to its mixing requirement. Chor-Cean, the earier disinfectant used in T7, aso requires mixing with water in a container. Hence, DIFFICIL-S has been viewed to be compatibe with ceaning practice and easiy adoptabe by T7 staff based on their experience with Chor-Cean. It is aso thought to be in ine with T7 s vaues and cuture, incuding a focus on impementing innovative technoogies that add vaue to care deivery. Anticipated benefits are a ower C. difficie incidence, a safer care environment for patients and staff and a shorter patient ength of stay. Further positive effects are expected vis-à-vis the trust s reputation with the pubic and heath-care reguators. Queen s Printer and Controer of HMSO 2014. 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. 105

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS Stakehoders, evidence and decision-making The tria and use of DIFFICIL-S featured in an action pan towards mitigating C. difficie incidence, which was reguary reviewed by the IPC team and senior managers. This action pan was put together as part of a business continuity risks management suite of measures designed by T7 s senior staff:... the decision to tria it was in response to the increase in C. difficie and there were reguar meetings with the Chief Executive. Senior nurse A tria was organised on the basis of the product viewed as an opportunity to improve care deivery. The decision to tria the product was taken among the DIPC, ead infection contro nurse and the head of domestic services. The tria was organised in four areas of one T7 hospita site and two wards in the T7 main site, and asted for 10 weeks. The ead infection contro nurse organised the tria and ed the process, which invoved ward visits and meetings with domestic and ward staff and monitoring of progress at the IPC team meeting. Senior nursing staff were informed of the tria at a specia meeting. Ward staff, incuding ink IPC nurses, were briefed on the product by a company representative. Domestic services staff appied the product during the tria, incuding using swab equipment to check ceaning efficacy. There was no patient invovement. Junior IPC team members attended a demonstration in one ward where the tria was taking pace. Company representatives expained the process of producing and then using the product, and responded to questions. During the tria, compaints were made of a rather unpeasant scent in bays and throat irritation after product use. Other concerns put forward incuded the somewhat onger time for disinfection to take effect and increased usage of ceaning coths. In addition, the product came at a significanty higher cost than the incumbent product. Cost, staff and training impications, arising from frequency of use, mainstreaming the product across the trust or introducing the product in areas where the C. difficie incidence was higher than others, were reviewed in the meetings of T7 s infection contro committee, which incuded stakehoders such as patient groups, the oca primary care trust and the HPA. Evidence types featuring at the initiation stage incuded presentations at professiona network conferences, product test data obtained from the Birmingham-based Hospita Infection Research Laboratory, product documentation and demonstrations organised by suppiers (Tabe 35 and Figure 27). Product principes were examined by recourse to the foowing types: a peer-reviewed journa artice, feedback on use sourced from other trusts, and data and staff feedback from T7 s oca tria. TABLE 35 T7 DIFFICIL-S disinfectant iquid detergent: evidence sources and types Evidence sources Professiona networks Heath agencies Industry/suppiers Peer-reviewed academic iterature Other trusts Peers and coeagues Trust care environment Evidence types Conference presentations HCAI research aboratory data Product documentation and demonstrations Journa of Hospita Infection scientific artice Loca trias and feedback on use Loca tria feedback Loca tria; patient and staff feedback 106 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Initiation Adoption decision CEO IC committee DIPC/consutant microbioogist Senior nurses IPC team Ward staff Head of domestic services Domestic services team Wider stakehoders Conference presentations HCAI research ab data Product documentation and demos J Hosp Infect scientific artice Loca trias and use feedback Feedback on tria Loca tria Impementation Conference presentations HCAI research ab data Product documentation and demos J Hosp Infect scientific artice Loca trias and use feedback Feedback on tria Loca tria CEO IC committee DIPC/consutant microbioogist Senior nurses IPC team Ward staff Head of domestic services Domestic services team Wider stakehoders Conference presentations HCAI research ab data Product documentation and demos J Hosp Infect scientific artice Loca trias and use feedback Feedback on tria Loca tria CEO IC committee DIPC/consutant microbioogist Senior nurses IPC team Ward staff Head of domestic services Domestic services team Wider stakehoders Outcome Trust-wide impementation FIGURE 27 T7 DIFFICIL-S disinfectant iquid detergent: professionas engagement and evidence types in decision-making. IC, infection contro. Outcome The outcome of the tria was positive. A somewhat ower ceaning aesthetic was identified on ceramic and stainess stee surfaces. The use of additiona ceaning agents was thought to be required in those cases. The tria and reated evidence were reviewed by the T7 Trust Executive Group: [...] the purpose of that group is to do that chaenging, it s to make sure that there is robustness to the decisions that you make. Usuay with the things that we ve done there has been enough evidence to suggest that this is we worth doing and therefore the dissent is essened. Senior nurse Foowing the tria, DIFFICIL-S was adopted by the trust in December 2011. As part of T7 s C. difficie Action Pan for 2012/13, it is now used in the T7 main hospita s medica assessment units, surgica assessment centre and haematoogy unit as we as in another trust hospita. It is aso used foowing any individua cases of C. difficie and in any risk areas identified. Microcase 2: ASP GLOSAIR 400 ahp system Attributes perceived by stakehoders The promise of this particuar technoogy, the C. difficie incidence at the trust and funding avaiabiity provided the impetus for the decision to review and tria this product. The choice of technoogy for the Queen s Printer and Controer of HMSO 2014. 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. 107

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS tria was the Bioque VHP system. Locay generated evidence appeared to be important to trust members of different seniority and professiona background. A respondent noted: Anything that we do, I think we try, we usuay do an audit on and give feedback. Sometimes it may just be the infection ink nurses that wi do it with them. But normay we tria quite a few things on our ward. Senior nurse Severa issues regarding room cosure, hospita air conditioning systems, fire aarm systems, bed management and Contro of Substances Hazardous to Heath were identified and reviewed by T7 s senior managers. A significant financia impact is reportedy associated with the purchase of the machines and staff training costs. A respondent commented: Certainy in terms of this technoogy there is an ongoing cost but within the terms of disposabes, in terms of the hydrogen peroxide canisters. But equay... maintenance costs for the machines themseves... are not inconsiderabe. So this wi have been considered at a high eve within the trust. Agreement has been made about how that s funded and it is being funded. We wi need to review because these things won t ast forever and, but it woud not be conceivabe [that] the trust woud go forward without this technoogy. Senior nurse Stakehoders, evidence and decision-making The chief nurse, deputy chief nurse and ead IPC nurse are viewed as trust members who championed the technoogy. Use of ahp was understood to invove a trade-off between bed avaiabiity and staff workoad, and enhancing patient care. The senior team supporting the adoption of this technoogy worked through issues identified with coeagues from other hospita groups. A respondent commented on the approach towards evidence: We became aware [of trias] across the country and we then began to ook at those products from our own perspective and to see and test whether the evidence was there. There was some manufacturer evidence, research studies and... a rapid review assessment suggested, same as before that these things seemed to have got the science base to use them. By which stage we d aready got nine of them because ocay we perceived that there was enough evidence to suggest that they were going to be effective in the way that we wanted to use them. Senior nurse Ten machines were then purchased, foowed by another 10 after a few months. The two purchases represented a arge capita outay earmarked for adopting this technoogy. Overa, senior team members commitment is understood to have faciitated adoption. A respondent noted: [...] some organisations wi have different priorities, the speed of adoption is often about oca factors as much as it is about evidence. We were taking a very, I d ca, forthright view at that time, we needed to do something different to get on top of things. Senior nurse Tabe 36 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Figure 28 depicts the stakehoders invoved and evidence types used in each of the innovation process substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. Members of the IPC team were trained to use the machines and initiay operated these across the trust, with no impications arising for other hospita groups. Subsequenty, the trust appointed infection contro 108 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 TABLE 36 T7 ASP GLOSAIR 400 ahp system: evidence sources and types Evidence sources Heath agencies Industry/suppiers Peer-reviewed academic iterature Other trusts Peers and coeagues Trust care environment Evidence types HPA RRP recommendation Product documentation Scientific artices Loca trias and feedback on use Loca tria feedback Bioque VHP RBDS oca tria Initiation Adoption decision IC committee DIPC/consutant microbioogist Senior nurses IC physician IPC team E&F Ward staff Domestic services staff Wider stakehoders RRP recommendation Product documentation Scientific artices Loca trias and use feedback Loca tria feedback Bioque VHP RBDS oca tria Impementation RRP recommendation Product documentation Scientific artices Loca trias and use feedback Loca tria feedback Bioque VHP RBDS oca tria IC committee DIPC/consutant microbioogist Senior nurses IC physician IPC team E&F Ward staff Domestic services staff Wider stakehoders RRP recommendation Product documentation Scientific artices Loca trias and use feedback Loca tria feedback Bioque VHP RBDS oca tria IC committee IPC team DIPC/consutant microbioogist Senior nurses IC physician E&F Ward staff Domestic services staff Wider stakehoders Outcome Adopted and ad hoc use trust wide FIGURE 28 T7 ASP GLOSAIR 400 ahp system: professionas engagement and evidence types in decision-making. IC, infection contro. assistants as new members of the T7 IPC team, who were trained in how to use the ahp machines for a period of 4 weeks unti they became competent. As an additiona measure towards mitigating C. difficie incidence in the trust, domestic services and other hospita group staff members were trained and took on use of the machines. Bed management issues have been worked around successfuy through iaison among IPC team members, bed managers and ward staff. Effective coaboration was aso reported between domestic services and the IPC team. Despite some reuctance to taking on additiona workoad, the number of users and trained staff has expanded across the trust. Queen s Printer and Controer of HMSO 2014. 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. 109

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS Outcome Foowing the introduction of ahp and other measures to mitigate C. difficie at the trust, infection rates were faing throughout the post-impementation period. On this basis, and because of its wider utiisation, incuding norovirus cases and other pathogens, ahp is understood to be a successfu technoogy, and remains centra to the trust IPC strategy. One respondent commented: I think what was reay hepfu was, shorty after they got introduced, there was a dramatic fa in the number of cases of C. difficie and so whether it was or not associated with this it woud amost be impossibe to say directy. But, having achieved such a high eve of improvement, I think there woud then be a reuctance to take away something which woud be seen as an effective too in the armour. Senior nurse Microcase 3: Medixair UV air steriisation units Attributes perceived by stakehoders The Medixair UV air steriisation units are understood by T7 informants to be new, high-tech products avaiabe on the market and to the NHS. Benefits associated with their use incude a reduction in cross-infections from air-borne viruses such as norovirus. Air-borne viruses may spread quicky and cause a major operationa impact on emergency, panned or eective care, incuding cosure of bays and wards for decontamination purposes, as we as adversey affect trust reputation. Stakehoders, evidence and decision-making In their efforts to reduce infection rates further and imit the impact of outbreaks, senior T7 staff members ooked at technoogies capabe of steriising the air in rooms and stopping cross-contamination of air-borne bacteria and viruses. One respondent noted: A coupe of years ago the hospita was hit by a proonged, disruptive [outbreak].... It affected mutipe wards, ots of bed cosures, operationa difficuties, a ot of disharmony in the hospita about how we were deaing with it and a frustration that it appeared that there was very itte we coud do to prevent the spread of this, perhaps. So a number of issues were ooked at, one of them was for the potentia for these units to, if you ike, cean the air. Senior nurse The medica assessment units of T7 were identified as areas to depoy the Medixair units, because of the possibe onward transmission of vira infections from these units to other hospita areas. During the initiation stage, there were aso some tests in the ward environment of using portabe UV ight inspection devices in tandem with ATP swabbing. This has been viewed as a compement to ceaning conducted by domestic services, and an aid for them to check the efficacy of their ceaning process. Consutant microbioogists ed on evidence gathering and review in coaboration with T7 s deputy chief nurse, IPC team members and T7 s E&F at a subsequent stage. The suppier suggested a cinica tria shoud be organised; however, a consensus was reached among staff members that the evidence did not seem to support this. A smaer piot, in the form of a case study on the product devices, was competed: It was quite a sma group reay and it argey centred around infection contro doctors, DIPC, ead infection contro nurse, deputy chief nurse, the chief operating officer. Senior nurse The evidence suggested that the air intake and reease rates of these particuar products were a ot ower than those of simiar systems used in theatres. On this basis, their use in busy medica wards proved to be ineffective. The initia and ongoing maintenance costs of these products were aso understood to be high. The evidence base put together is understood to have acted as a barrier to adoption. The evidence base was reviewed and a decision to reject adoption was taken by the staff members mentioned above. 110 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Tabe 37 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Figure 29 depicts the stakehoders invoved and evidence types used in each of the innovation process substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. Outcome Foowing review and deiberation of the evidence, it was fet that the efficacy of the Medixair units did not match the procurement and maintenance costs invoved. The evidence, its examination and the decision to reject the product, which was taken by the group of staff members who ooked at the evidence, were TABLE 37 T7 Medixair UV air steriisation units: evidence sources and types Evidence sources Professiona networks Industry/suppiers Trust care environment Evidence types Conference presentations Product documentation Loca case study incuding patient and staff feedback Initiation Adoption decision Conference presentations Conference presentations Product documentation Product documentation Deputy chief nurse Case study data Case study data Deputy chief nurse Microbioogy Microbioogy IPC team IPC team E&F team E&F team Impementation Conference presentations Product documentation Case study data Deputy chief nurse Microbioogy IPC team E&F team Outcome Rejected FIGURE 29 T7 Medixair UV air steriisation units: professionas engagement and evidence types in decision-making. Queen s Printer and Controer of HMSO 2014. 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. 111

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS documented in a paper presented to the Trust Executive Group. The decision to reject its adoption in the trust was approved by the Trust Executive Group. One respondent noted: Essentiay, the infection contro doctors ooked very cosey at this equipment and they did not concur with the manufacturer s findings in terms of efficacy. And they did not fee that they coud substantiate their caims. Senior nurse Microcase 4: DaRo UV ight inspection cabinet Attributes perceived by stakehoders The UV ight inspection cabinet marketed by DaRo UV Systems Ltd has aso been triaed at T7. Informants understand this technoogy product to be based on organic materia uminescence becoming visibe with UV radiation. The technoogy is understood to originate from the food industry, and to have ony recenty been appied in heath care. Stakehoders, evidence and decision-making DaRo UV ight inspection cabinets were aso introduced by the IPC team in wards, in coaboration with senior nurses and ward staff, as a compement to the trust s hand-washing campaign. The product was first viewed at a conference by IPC team members, and was then discussed at a meeting with senior nurses. The decision to buy the product was reached swifty, and the product was then activey promoted by hand hygiene eads in wards. Outcome The UV ight inspection cabinet has been viewed as a too to train staff in hand-washing techniques, to examine the efficacy of these techniques and to prevent cross-infection from inadequatey sanitised hands. IPC nurses ran demonstrations of the cabinet for ward staff. The cabinets remain in reguar use, incuding as part of the induction for a new trust staff. Trust 9 technoogy product microcases Microcase 1: cine and PDI Sani-Coth CHG 2% acohoic chorhexidine guconate wipes for skin preparation Attributes perceived by stakehoders Informants at T9 understand these two wipe products to have been designated to be suitabe for use on medica devices, for decontamination and device preparation. The wipes, viewed as ow-tech products, are required to be used with the technique termed scrub the hub, requiring friction to be appied whie the hand is used to hande the wipe. They have not been icensed for skin preparation. The product currenty used for skin preparation in the trust and esewhere in the NHS is an ampoue-based product that contains a soution with a chemica composition and specification and chemica properties very simiar to those of the two wipe products. This is the ChoraPrep (CareFusion Corp., San Diego, CA, USA) preoperative skin preparation antiseptic of 2% chorhexidine guconate and 70% isopropy acoho. Use of the ampoue aso requires an appropriate topica massage routine that generates friction and heps with skin substance absorption. This technique, akin to the aseptic non-touch technique, aows the heath-care worker to appropriatey use the ampoue to decontaminate the skin before any procedure, whie not coming into contact with the patient. 112 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Use of the wipes in this innovative manner is understood to reate to earier practice, before the introduction of chorhexidine and ChoraPrep, when acoho- or iodine-based wipes and soutions were used. The innovation is understood to be in ine with the cost-saving cuture at the trust. One respondent said: No one to my knowedge has chaenged it because it seems to make sense. We re in difficut financia times and this is a cassic exampe of what we ca a QIPP [QIPP refers to Quaity, Innovation, Productivity and Prevention, which is a Department-of-Heath-ed programme to transform NHS services to make efficiency savings of 20 biion. 94 ] quaity improvement, innovation, innovation productivity, and prevention where we see something that achieves the same outcomes but for much ess financia outay, so. Senior pharmacist Stakehoders, evidence and decision-making The ideation for using wipe products in this manner originated from the trust s Chid Heath Division. It searched for evidence to confirm that the use of ChoraPrep reduces infection rates. Such evidence was not identified; hence, the recommendation to use wipe products was made. Senior managers reportedy understand ChoraPrep to be more expensive than the wipes, which are viewed as the same product but in a different format. The wipes have been highy efficacious in the trust in disinfecting intravenous devices, resuting in rates of MRSA bacteraemia, and other boodstream infections reated to centra or periphera devices, being cose to zero. However, IPC team members aso saw a risk in using the wipes in a patient context, as skin may be contaminated or recontaminated through wipe contact. Moreover, the friction required when using a wipe is understood to be consideraby arger and appied during a onger time interva, entaiing some risk of physica damage, particuary for frai patients. Therefore, an audit in the form of a oca tria was decided as a means to coect evidence on this aternative use of the wipes and reated staff training requirements. A sma working group was formed to organise two trias in paediatrics and genera surgery. One respondent commented on cinica engagement during the oca trias, and identified surgica areas as hot spots : They must have got quite a ot of consensus because as I said, some of the doctors have been a itte bit difficut to change, that s why it s not fuy roed out in some, in a of the surgica areas. Senior nurse The trust s infection contro physician is understood to have ed on evidence gathering and evauation. A paediatrics ead nurse has acted as a oca champion, eading the audit in that division and reporting on it. One respondent commented: It s very difficut when you re impementing a change that everybody has to compy with and they don t have achoice. So utimatey it is the ward nurses who are impementing this, they have to do it, they don t have a choice, but you have to get them on side. I woud imagine that the benefits of it were expained in that we re reducing the MRSA, we re saving the trust money, we re promoting patient safety, patient care, which is utimatey, ike I say, we a signed up to be nurses because we want to care for peope. Senior nurse The way in which the evidence was communicated by senior nurses to the ward nurses, who were the impementers of the innovation, was beieved to be rationa sensegiving aigned with the ward nurses vaues and sensitivity to certain forms of evidence. Tabe 38 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Figure 30 depicts the stakehoders invoved and evidence types used in each of the innovation process substages (initiation, adoption decision and impementation), and the reated Queen s Printer and Controer of HMSO 2014. 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. 113

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS TABLE 38 T9 cine and PDI Sani-Coth CHG 2% acohoic chorhexidine guconate wipes for skin preparation: evidence sources and types Evidence sources Industry/suppiers Peers and coeagues Trust care environment Evidence types Product documentation and demonstrations Views and opinions Loca economic and tria data Initiation Adoption decision Trust IPC committee Product documentation and demonstrations Product documentation and demonstrations Trust IPC committee Trust governors committee Medica director DIPC/DoN Views and opinions Loca economic and tria data Views and opinions Loca economic and tria data Trust governors committee Medica director DIPC/DoN Deputy DIPC Deputy DIPC Divisiona directors/ heads of nursing IPC team Stores department Ward staff Impementation Divisiona directors/ heads of nursing IPC team Stores department Ward staff Product documentation and demonstrations Views and opinions Loca economic and tria data ongoing divisiona oca trias Trust IPC committeetrust governors committee Medica director DIPC/DoN Deputy DIPC Divisiona directors/heads of nursing IPC team Stores department Ward staff Outcome Ongoing decision-making 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. DoN, director of nursing. organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. Outcome The outcome is anticipated foowing concusion and evauation of the trust s oca trias. Microcase 2: cine sporicida wipes (red) Attributes perceived by stakehoders Informants from T9 understand this product to be effective against C. difficie spores, which prove hard to remove with ceaning based on soap and water, and cause cross-infection among patients. The wipe s active ingredient is activated by using tap water to wet the wipe, which then becomes ready for appication. The product is understood to have been radicay new when it was introduced, because of its 114 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 specia C. difficie sporicida focus. Before its adoption in the trust, ActiChor Pus tabets and water were used to produce a chorine-based soution and cean commodes and other surfaces, causing surface deterioration and damage. The product is understood to be high tech because of the perceived high eve of research that was required to deveop it; its uses are thought of as ow tech. Informants associate it with quicker ceaning practice; a reduction in C. difficie rates; and raising the importance of efficacious commode ceaning in the trust. It is viewed as befitting the trust s vaues and cuture. Stakehoders, evidence and decision-making Cine sporicida wipes were introduced at a time of reativey high C. difficie incidence for the trust. Before its introduction, processes were in pace to ensure a high eve of hygiene, such as ceaning practice audits and spot checks by senior staff. The product was introduced to the trust by the IPC team. Ward staff were informed about it through the infection contro ink nurses meetings. The avaiabiity of evidence on its sporicida efficacy is understood to have faciitated its adoption. The product comes with a reativey high cost of approximatey 7.65 per pack of 25 (see Appendix 7: Technoogy Products Unit Cost Price List); however, this was weighted against the high costs of persistent C. difficie incidence. It was then decided that it woud be used to cean ony the trust s commodes and bed pans. Whie the product was being roed out, it was championed by an IPC team member. Appropriate communication during training provided by the suppier, by interna e-mai and posters, is understood to have payed a key roe in the product s adoption by ward staff. Carefuy worded posters were prepared with specific instructions on how to hande and use the wipe. Tabe 39 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Figure 31 depicts the stakehoders invoved and evidence types used in each of the innovation process substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. Outcome Cine sporicida wipes have been used in a hospita areas of the trust in the ast 2 3 years. The product is understood to be one successfu part of a suite of measures introduced to substantiay reduce infection rates across T9. Microcase 3: JLA OTEX system Attributes perceived by stakehoders OTEX is understood by T9 informants to be a very effective product for washing and disinfecting fabric-based domestic services equipment (mops, coths), as we as hote services equipment (curtains, inen, etc.). Its environmenta benefits, using ozone rather than chemica disinfectants and energy and carbon emissions savings, are aso recognised. It is viewed as a new concept for the NHS and its environmenta benefits, in particuar, are thought to be of reevance. It is aso viewed as compicated to expain, in part because of the ong-standing use of disinfectant-based washing in the NHS. The system is thought of as fuy compatibe with care deivery systems and processes, as we as with T9 s cuture and vaues. TABLE 39 T9 cine sporicida wipes (red): evidence sources and types Evidence sources Industry/suppiers Peer-reviewed academic iterature Professiona networks Trust care environment Evidence types Training on product use; ab tests documentation Scientific artices Conference presentations Staff feedback Queen s Printer and Controer of HMSO 2014. 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. 115

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS Initiation Adoption decision Product use training Product use training Lab tests documentation Lab tests documentation Scientific artices Scientific artices DIPC/DoN Conference presentations Conference presentations DIPC/DoN Heads of nursing Staff feedback Staff feedback Heads of nursing IPC team IPC team Ward staff Ward staff Impementation Product use training Lab tests documentation Scientific artices Conference presentations Staff feedback DIPC/DoN Heads of nursing IPC team Ward staff Outcome Trust-wide impementation FIGURE 31 T9 cine sporicida wipes (red): professionas engagement and evidence types in decision-making. DoN, director of nursing. Stakehoders, evidence and decision-making The trust was asked to tria OTEX as part of the Showcase Hospitas programme. The trust s domestic services partner team had been interested in the system for a few years before support for its evauation became avaiabe through the programme. It was invoved in a stages (initiation, adoption decision and impementation), as iustrated in Figure 32. Such user invovement from the initiation stage, together with the partner team s pre-existing positive perception of the system, payed a catayst roe for consensus decision-making among stakehoders. One respondent commented: I think, because the contract, domestic contractor wanted it anyway, we didn t, it was a reay easy task because we agreed, I think we were asked to evauate it, we knew that our domestic service were interested in it, so I think that s party why we agreed, because actuay they, it was something they wanted to do and we d been asked to do, so that was a, I think that, we came to our consensus of opinion very quicky that we d go and evauate it, because we woudn t have too many hurdes to cross by trying to persuade someone it was a good idea. Senior nurse The trust was ooking at further environmenta hygiene measures at the time, so the tria of OTEX was viewed as a timey opportunity. The tria was managed by the trust IPC team. Choices were carefuy made on both the hospita groups to engage with, and of how to engage with them. These incuded the trust s domestic services partner, the trust s ceaning operationa group, incuding the patient services manager, and the cinica environmenta 116 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Initiation Adoption decision DIPC/DoN Deputy DIPC Showcase ead Heads of nursing IPC team E&F team Site management team Ward staff Domestic services partner staff RRP recommendation Product documentation Feedback on use Loca tria data; staff feedback Impementation RRP recommendation Product documentation Feedback on use Loca tria data; staff feedback DIPC/DoN Deputy DIPC Showcase ead Heads of nursing IPC team E&F team Site management team Ward staff Domestic services partner staff RRP recommendation Product documentation Feedback on use Loca tria data; staff feedback DIPC/DoN Deputy DIPC Showcase ead E&F team Site management team Ward staff Heads of nursing IPC team Domestic services partner staff Outcome Trust-wide impementation FIGURE 32 T9 JLA OTEX system: professionas engagement and evidence types in decision-making. DoN, director of nursing. monitoring ead. A cose coaboration is reported between the IPC team and the domestic services contractor. The tria asted for a period of 3 months. The evidence generated from the tria was discussed in the IPC team s weeky operationa meetings. No separate project structures, for exampe meetings, etc., were put together. Progress was reported at the trust s infection prevention committee meetings, which occurred every 2 months. Tabe 40 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Outcome The tria evidence is understood to have demonstrated that the technoogy had no adverse effects and proved efficacious in eradicating germs and pathogens. Cost savings resuting from using ess water, ess TABLE 40 T9 JLA OTEX system: evidence sources and types Evidence sources Heath agencies Industry/suppiers Other trusts Trust care environment Evidence types HPA RRP recommendation Product documentation Feedback on use Loca tria data; staff feedback Queen s Printer and Controer of HMSO 2014. 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. 117

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS energy and ess detergent were aso documented. The change in practice and transition to a new technoogy aso had no adverse effects. Such positive oca resuts changed the views of this technoogy among IPC team members. One respondent said: The ony resistant was from Infection Contro, because they didn t reay, actuay I don t know, they just were very negative against it. But once they saw the resuts [i.e. onsite infection cases drop], and saw what it offered, they were a for it. Non-cinica manager Foowing the tria, the trust s IPC team approved further use of the system in the trust. The domestic service partner confirmed that it woud be abe and wiing to continue using the technoogy. Its use has, thus, now been mainstreamed as part of the trust s ceaning regime. Use of OTEX was incuded in the domestic services contract, with no further financia impications for the trust. Adoption was faciitated through coaboration among the showcase ead, domestic services and the suppier s after-saes staff. The domestic services partner s motivation, support from the Showcase Hospitas programme and cost neutraity are understood to be the main factors supporting adoption. Moreover, the suppier is viewed as having a very supportive after-saes service. Microcase 4: Bioque vapour hydrogen peroxide Room Bio-Decontamination Service Attributes perceived by stakehoders During the tria of the service, patients and staff perceived the service to be highy efficacious, resuting in high eves of disinfection and creating a safe care environment at the trust. Patient and staff opinions were formay documented as part of the service evauation. Stakehoders, evidence and decision-making The Showcase Hospitas programme provided the opportunity to the IPC team to tria the service without cost impications for the trust. The programme supported the avaiabiity of Bioque staff and equipment on-site. These woud be requested by trust members who wished to use the equipment for decontamination in specific hospita areas. Trust members were reportedy encouraged to use the service. The Showcase Hospitas programme ead introduced the service throughout T9. The trust had mutipe measures in pace to combat HCAIs, and infection rates started to come down. At the same time, use of the service was more often than not exacerbating deays associated with bed avaiabiity and waiting times. There was time pressure, arising from competing priorities, and this was exacerbated by the trust s poor isoation capacity. One respondent commented as foows: [...] you ve got your competing demands of patients not being abe to wait in A&E (accident & emergency) for more than four hours and that, the constant pressure. We have interna targets around how quicky patients need to be isoated, so the turnover of those, so that was I think the biggest hurde was the whoe timeframe. Senior nurse After the end of the tria, C. difficie infection rates remained ow and continued to fa. This ed the trust to take a more cautious approach to adoption. The same respondent described this as foows: [...] We did then get it back in again for a short period when our C. difficie rates went up, [...] and we d managed to secure some funding to do that. C. difficie rates went down but again we d refocused a our energies within the organisation on the C. difficie so a the practice improved as we. So again it was difficut to see the impact and the rates sti have gone down since we stopped using it again. [...] we evauated it in 2008/9 I think it was, and the ast two, three years we ve often had conversations about Bioque because it s quoted so much, the evidence is there. However, I think 118 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 now where our C. difficie numbers have radicay reduced quite significanty, [...] from a cost justification perspective. Senior nurse On this basis of evidence reated to infection rates and operationa issues, it was considered that the service may not actuay make a difference as part of the trust s suite of measures mitigating HCAI incidence. Nonetheess, the technoogy was viewed in a positive ight by senior trust members, incuding the DIPC/director of nursing. Tabe 41 ists the specific evidence types used in this microcase aongside the sources from where these were eicited. Figure 33 depicts the stakehoders invoved and evidence types used in each of the TABLE 41 T9 Bioque VHP RBDS: evidence sources and types Evidence sources Heath agencies Showcase Hospitas programme Professiona networks Industry/suppiers Trust care environment Evidence types HPA RRP recommendation Product information Conference presentations Product documentation Loca tria data; staff feedback Initiation Adoption decision DIPC/DoN Deputy DIPC Showcase ead Heads of nursing IPC team Heath and safety E&F team Site management team Ward staff Domestic services partner staff RRP recommendation Product information Conference presentations Product documentation Loca tria data; staff feedback Impementation RRP recommendation Product information Conference presentations DIPC/DoN Deputy DIPC Showcase ead Heads of nursing Product documentation IPC team Loca tria data; staff Heath and safety feedback E&F team Site management team Ward staff Domestic services partner staff RRP recommendation Product documentation Conference presentations Product documentation Loca tria data; staff feedback DIPC/DoN Deputy DIPC Showcase ead Heads of nursing IPC team Heath and safety E&F team Site management team Ward staff Domestic services partner staff Outcome Rejected FIGURE 33 T9 Bioque VHP RBDS: professionas engagement and evidence types in decision-making. DoN, director of nursing. Queen s Printer and Controer of HMSO 2014. 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. 119

EVIDENCE IN ACTION: PRODUCT MICROCASES IN EIGHT NHS TRUSTS innovation process substages (initiation, adoption decision and impementation), and the reated organisationa adoption and impementation outcomes for the technoogy product. Text in ight grey shows the evidence types or stakehoders who were not invoved in that substage. Outcome The IPC team documented the tria and its outcomes and the evidence was presented to the trust board. The CEO made further enquiries and a consensus deveoped with regard to the costs reated to its permanent adoption and operationa use, which outweighed the benefits obtained. One respondent commented: We then had some quite big discussions around whether we woud continue using it and obviousy Bioque as a company were very keen. We coud see the advantages in terms of the concept and the technoogy. The biggest stumbing bock for us was cost and the operationa issues. So I think we sort of put a provisiona case together and it was sat on the shef in terms of, the chief executive and the trust board were very much, OK, that s great but what are the benefits? And obviousy we then see, or they wanted to know the benefits because it was such a huge cost to the existing service, the existing process. Senior nurse A decision was, thus, taken at that eve to reject adoption of this technoogy at the trust. 120 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Chapter 9 Cross-case anaysis This chapter outines key themes from the cross-case anaysis [ooking at reevant patterns across the macro- (eight trusts) and microcases (27 technoogy product journeys)]. Overview of technoogy microcase outcomes across trusts In Tabe 42 the adoption and impementation outcomes for the technoogy microcases are compared aong the dimensions of expected budgetary impact, perceived impact on practice and strength of evidence base on efficacy (discussed in Chapter 7). Themes from this comparative anaysis are summarised by decision outcome and adoption/impementation processes. The patterns observed are refective of the eight trusts samped for this study; they provide important insights into the reevance of perceived technoogy attributes to this process. Decontamination and inspection products were mosty put forward by trusts to be studied as microcases and most of these aso resuted in adoption and trust-wide impementation. Decontamination products, such as iquid ceaning and wipe ceaning, were generay associated with a ower expected budgetary impact and a ow to medium perceived impact on practice. The evidence associated with these products was generay of ow strength. The adoption and impementation outcomes for these products varied consideraby across the trusts, from trust-wide impementation, adoption by the trusts and avaiabiity for ad hoc use to rejection. By ongoing decision-making we refer to those technoogy products under consideration at the time of the study. The next section examines the decision-making processes and outcomes across these technoogies by considering the three dimensions of our typoogy, namey perceived budgetary impact, practice impact and strength of the evidence base on efficacy. Decision outcome themes Evidence strength on efficacy themes There is no cear observabe pattern when we ook at outcomes and evidence strength on efficacy Tabe 42 incudes products whose evidence base on efficacy ranges from ow to high and is emergent or estabished. Within these cassifications, decision outcomes vary between rejection and trust-wide impementation. For those technoogies impemented trust-wide, the evidence base on efficacy spans the range of ow, emergent, to medium. Ony two microcases, both of the JLA OTEX aundry system, with a high, estabished, evidence base on efficacy resuted in trust-wide impementation, which occurred in both T6 and T9. High evidence strength on the efficacy of a technoogy product did not aways ead to its adoption and fu-scae impementation (as initiay panned) There were four technoogies in our sampe with a high, estabished, evidence base on efficacy, and these featured in 10 of the microcases. Decision outcomes across these 10 microcases incuded rejection, adoption and use in seected wards, adoption and ad-hoc use trust-wide, and trust-wide impementation. Two exampes of these are Bioque VHP RBDS, which was adopted for ad-hoc use trust-wide in T5, but rejected in T1 and T9, and the 3M CeanTrace and Hygiena SystemSURE II ATP hygiene monitoring system, which were both rejected in T5. Queen s Printer and Controer of HMSO 2014. 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. 121

CROSS-CASE ANALYSIS TABLE 42 Product attributes and outcomes Technoogy product Budget impact Practice impact Evidence strength on efficacy Trusts Adoption and impementation outcome ASP GLOSAIR 400 ahp system DIFFICIL-S disinfectant soution Low High Medium, emergent T2 Trust-wide impementation Low Medium Low, emergent T7 Trust-wide impementation Chor-Cean Low Medium Low, emergent T5 Trust-wide impementation Cine universa sanitising wipes Medium Very ow Medium, emergent T1 Trust-wide impementation JLA OTEX aundry system Cine sporicida (red) wipes ASP GLOSAIR 400 ahp system Steris BioGenie VHP system Low Medium High, estabished T6, T9 Trust-wide impementation Medium Low Low, emergent T3, T9 Trust-wide impementation High High Medium, emergent T7 Adopted and ad-hoc use trust-wide Low High Low, emergent T4 Adopted and ad-hoc use trust-wide DBO commode Medium Low Low, emergent T1 Adopted in two of three sites; phased impementation in progress DaRo UV ight inspection cabinet Low High Low, emergent T7 Adopted and ad-hoc use trust-wide Bioque VHP RBDS Medium High High, estabished T5 Adopted and ad-hoc use trust-wide 3M Cean-Trace NG uminometer UV ight inspection torch DIFFICIL-S disinfectant soution Medium High High, estabished T2 Adopted and used in seected wards Low High Medium, emergent T2 Adopted and ad-hoc use trust-wide Low Medium Low, emergent T4 Ongoing decision-making Disposabe sterie surgica site gowns Medium Very ow Low, emergent T2 Ongoing decision-making Cine acohoic wipes Low Low Medium, emergent T9 Ongoing decision-making PDI Sani-Coth CHG 2% acohoic chorhexidine guconate wipes Low Low Low, emergent T9 Ongoing decision-making Bioque VHP RBDS Medium High High, estabished T3, T6 Ongoing decision-making Bioque VHP RBDS High High High, estabished T1, T9 Rejected Medixair UV air steriisation unit Low Very high Low, emergent T3, T6, T7 Rejected Medixair Meos UV air steriisation unit Low Very high Low, emergent T3, T6, T7 Rejected Virusove+ Low Low Low, emergent T4 Rejected 3M Cean-Trace NG uminometer Hygiena SystemSURE II ATP hygiene monitoring system Medium High High, estabished T5 Rejected Medium High High, estabished T5 Rejected 122 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Low evidence strength on the efficacy of a technoogy product did not precude adoption and trust-wide impementation or adoption and ad-hoc use trust-wide There were 10 technoogy products cassified as having a ow, emergent, evidence base on efficacy. These were perceived as having variabe budget and practice impacts. Three of these products were adopted and impemented trust-wide in four trusts, whereas three more have been adopted for ad-hoc use across three trusts. Specificay, the technoogies impemented trust-wide were as foows: DIFFICIL-S in T7; Chor-Cean in T5; and cine sporicida wipes in T3 and T9. Those adopted and used ad hoc incude Steris BioGenie VHP system in T4; the DBO commode in T1; and the DaRo UV inspection cabinet in T7. Perceived impact on practice themes Technoogy products associated with a ow or medium perceived impact on practice were ess ikey to be rejected In our sampe, 10 technoogy products considered for adoption were perceived as having a very ow, ow or medium impact on practice. The majority of decisions concerning these products across the trusts (8 out of 13 decisions) ed to trust-wide or phased impementation: for exampe, DIFFICIL-S in T7; Chor-Cean in T5; cine universa wipes in T1; JLA OTEX aundry system in T6 and T9; cine sporicida wipes in T3 and T9; and the DBO commode in T1. Technoogy products associated with a high perceived impact on practice were more ikey to be rejected Eight technoogy products with a high or very high practice impact were considered for adoption in eight trusts. Out of these 16 decisions, there were 7 rejections reported. These incuded Bioque VHP RBDS in T1 and T9; Medixair in T3, T6 and T7; and the 3M CeanTrace and Hygiena SystemSURE II ATP hygiene monitoring system in T5. Seven decisions ed to products being adopted and impemented trust-wide or used ad hoc, namey the ASP GLOSAIR ahp system in T2 and T7; the Steris BioGenie VHP system in T4; the DaRo UV Inspection Cabinet in T7; Bioque VHP RBDS in T5; and the 3M CeanTrace uminometer and the UV inspection torch in T2. Technoogy products associated with a ow or medium practice impact were more ikey to be adopted and impemented trust-wide In our sampe, 10 technoogy products perceived to invove a very ow, ow or medium impact on practice were reviewed in 13 technoogy decisions across the eight trusts. In seven cases, these products were fuy impemented. These cases were as foows: DIFFICIL-S in T7; Chor-Cean in T5; cine universa wipes in T1; JLA OTEX aundry system in T6 and T9; and cine sporicida wipes in T3 and T9. In four cases, the decision to adopt was sti pending at the cose of the study: these were DIFFICIL-S in T4; disposabe gowns in T2; and PDI Sani-Coth and cine acohoic wipes in T9. In T4, Virusove+ was rejected. Rejection decisions on technoogy products with a perceived high impact on practice consistenty used oca sources of evidence (data generated within trusts) Our technoogy sampe featured four technoogy products with a very high or high practice impact that were rejected in seven of the microcases. These were as foows: Bioque VHP RBDS in T1 and T9; the Medixair units in T3, T6 and T7; and the 3M CeanTrace and Hygiena SystemSURE II ATP hygiene monitoring system in T5. In a seven cases, these rejections were based on staff feedback and oca tria or product case study data generated from within the trust care environment. In the Bioque RBDS case, in T1, the IPC team conducted a oca tria and coected and anaysed data on staff experiences during and after the tria, which was reviewed by senior executives and other stakehoders from within the trust incuding E&F and procurement. In T5, the IPC team conducted a oca tria and compared the resuts with feedback from oca trias undertaken in other trusts. In T7, the microbioogy team and IPC team conducted a sma case study of Medixair units in the ward environment. Queen s Printer and Controer of HMSO 2014. 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. 123

CROSS-CASE ANALYSIS Simiary, T3 s IPC team conducted a oca tria and eicited staff and patient feedback on the use of Medixair devices in wards. Budget impact theme There is no cear observabe pattern when we ook at outcomes and budget impact In tota, 11 technoogy products with a ow perceived budgetary impact were considered for adoption in seven trusts. Out of these 15 decisions, there were 4 rejections reported: Virusove+ in T4 and the Medixair units in T3, T6 and T7. Five decisions ed to trust-wide impementation: the ASP GLOSAIR ahp system in T2, the DIFFICIL-S in T7, the Chor-Cean in T5 and the JLA OTEX in T6 and T9. Another three technoogy products were adopted and used ad hoc trust-wide, whie for three more the adoption decision was ongoing. Two technoogy products with a high perceived budgetary impact were considered by three trusts: the ASP GLOSAIR ahp system was adopted and used ad hoc trust-wide in T7, whie the Bioque VHP was rejected in T1 and T9. The former technoogy product, ASP GLOSAIR, was perceived as having a ow budget impact in T2 (T2 had used externay awarded funding to procure the product) and was adopted for trust-wide impementation, whie in T7 it was perceived as having a high budget impact, eading aso to adoption but with ad hoc use trust-wide. Technoogy product microcase themes A comparative review of the 27 technoogy product microcases enabes the foowing observations to be made regarding stakehoder invovement and evidence use in the decision-making process. Nurses were invoved in a stages across the trusts for a technoogy products. Out of the 27 product cases, 10 featured the invovement of nursing staff and at east one interdiscipinary hospita group incuding senior trust members beyond the IPC team (trust innovations groups, IPC committees, product seection groups, risk management groups and the trust board). The IPC team was excusivey invoved in three microcases. These were Virusove+ in T4, Chor-Cean in T5 and cine sporicida in T9, and these cases were characterised by a ow or medium budget impact, a ow practice impact and a ow evidence strength on efficacy. Nursing staff, doctors and non-cinica speciaists were invoved in tandem in a three stages in four microcases, namey, DIFFICIL-S in T4 and T7; Bioque in T3; and the DBO commode in T1. Non-cinica staff were invoved in a three stages of 11 microcases, and in at east one stage in 25 microcases. In the initiation stage, non-cinica staff, for exampe from domestic services or procurement, were invoved in 12 cases of mosty medium budget impact; these invoved high practice impact products whose evidence strength on efficacy varied. Doctors were invoved in the initiation stage in 10 cases of medium or high budget impact and high practice impact products of variabe evidence strength on efficacy. A three professiona groups were invoved in the initiation stage for eight products associated with medium or high budget impact, medium to very high practice impact and ow, medium or high evidence strength on efficacy. Doctors participated in adoption decisions in 14 cases (amost haf of the tota cases). These were primariy the DIPCs and in some cases the medica director and infection contro doctor. They fufied a strategic roe of endorsement and support to the newy adopted product with regard to its cost and practice impications. This was refected in the sma sampe of doctor respondents in phase 2 (i.e. those activey invoved in the decision-making process).there were 10 microcases for which senior members of a three professiona groups were represented in the adoption decision stage. Non-cinica staff participated in the adoption decision stage in 21 journeys, making them the professiona group with the second strongest presence after nurses. 124 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Doctors were aso invoved in eary or fu impementation in nine microcases. Non-cinica staff were invoved in the impementation stage in 22 cases, again being the second most prevaent group after nurses. The types and sources of evidence used seemed to vary ony sighty depending on whether ony one or mutipe professiona groups were invoved. Technoogy product journeys can be grouped into 14 cases in which a three professiona groups were invoved in at east one stage and 13 in which this did not happen. The types of evidence used most frequenty within the former microcases were product information and demonstrations, sourced from industry and product suppiers, foowed by oca tria data, scientific artices and conference presentations. In the atter case, the evidence types most often used by those professionas invoved typicay nurses, and ward, domestic or procurement staff were product information and demonstrations provided by industry and suppiers, recommendations by heath agencies, oca tria data and staff feedback from the trust care environment, scientific artices and conference presentations. The invovement of medica microbioogists in 13 product journeys ed to the production of ocay generated evidence through eary impementation in the form of a oca evauation tria or case study. The data generated from these studies compemented peer-reviewed academic iterature regarding the proposed technoogies. This approach supported decisions concerning products with a medium, high or very high practice impact in 11 cases. Research-active trusts with a substantia research capacity, as defined by our categorisation in Chapter 6, generated evidence in their oca care environment: exampes incude T1, T5 and T7. In a cases of high practice impact and high evidence strength on the efficacy of products, senior organisationa executives were invoved in adoption decisions. Senior organisationa executives were invoved in 14 microcases of products of considerabe practice impact and otherwise variabe expected budget impact and evidence strength on efficacy. This senior invovement was in the form of a number of organisationa roes, incuding medica director, chief operating officer, director of nursing, deputy chief nurse, DIPC and deputy DIPC, head of nursing, decontamination manager, and senior consutant microbioogist. Senior executives aso contributed directy to decisions regarding products of ow budget impact and medium practice impact, such as DIFFICIL-S (ow evidence strength on efficacy) in T4 and T7 or OTEX (high evidence strength on efficacy) in T6 and T9. The roe of the director of infection prevention and contro Trust DIPCs were invoved in at east one stage of the adoption process of 17 technoogy products, whose expected budget impacts varied from ow to very high. Of these product microcases, 11 featured products of medium, or high practice impact. One-third of the decisions in which DIPCs were invoved (10 microcases) concerned products with a medium or high budget impact and products with a ow or medium evidence strength on efficacy. In 11 cases in which DIPCs were invoved, products were either impemented trust-wide (six cases) or adopted and made avaiabe for ad hoc use in the trust either in seected wards or trust-wide (five cases). Three decontamination products of high or very high practice impact were rejected. Trust DIPCs were invoved in the adoption decision stage of 15 product microcases. Ony five of these products were cassified as ow for evidence strength on efficacy, whereas seven were identified as having a high evidence strength on efficacy. Of these 15 decisions, 10 invoved products with a medium or high budget impact for trusts, and 9 were on products of medium, high or very high practice impact. The invovement of the DIPC at this stage of the process was associated with a positive outcome: 10 decisions resuted in trust-wide impementation, whereas one decontamination product was rejected in two trusts, and, in three cases, decision-making was ongoing. In addition, six of decontamination and inspection products with a medium, high or very high practice impact were adopted, two were rejected and one decision was yet to be made. Queen s Printer and Controer of HMSO 2014. 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. 125

CROSS-CASE ANALYSIS In nine technoogy microcases, the DIPC was invoved in a three stages. Six of these microcases invoved products with a ow or medium evidence strength on efficacy: the DBO commode in T1; cine sporicida wipes in T9; ASP GLOSAIR in T2 and T7; and DIFFICIL-S in T4 and T7. Eight of these microcases reated to products of medium or high practice impact, namey Bioque VHP RBDS in T5; OTEX in T6; ASP GLOSAIR in T2 and T7; DBO commode in T1; cine sporicida wipes in T9; and the 3M Cean-Trace and Hygiena SystemSURE II ATP hygiene monitoring system in T2. In our trust sampe, the DIPC was invoved in the initiation stage of 11 innovation journeys, and the impementation stage of 12 journeys. Product adoption and impementation were faciitated by the identification of an appropriate hospita team or group to act as the prime user of the new product. For exampe, OTEX is operated by the trust domestic services partner in T6 and T9, which took ownership of the practice. InT7,invovementofdomesticstaffin the decision concerning the ahp system ed to improved understanding of the workoad impications for domesticstaff,whichinturnresutedinhiring additiona staff to optimise the product s use.int2,the3m Cean-Trace and Hygiena SystemSURE II ATP hygiene monitoring system were successfuy adopted for use by domestic staff, and, by contrast, in T5 there was no group identified that coud potentiay incorporate the routine use of the uminometers into its daiy practice. Ownership of the swabbing and data recording process by domestic staff in T5 was widey viewed as a key faciitating factor in the product s successfu adoption and impementation, as it generated enthused and interested users among domestic staff. In T9, the fit of products with the trust s care systems and processes was reviewed in a oca tria, and emerged as a key determinant of successfu adoption and impementation. In T3, active suppier engagement during the product or service tria and impementation aso emerged as a factor conducive to products being positivey perceived and considered for adoption by staff. Mobiising sources and types of evidence and innovation stakehoders Our phase 1 findings show that severa types and diverse sources of evidence were variaby reported to be accessed and used by non-cinica or cinica hybrid managers. Access to and use of evidence was reported to vary significanty among professiona groups. Further, synthesis of phase 1 and 2 anayses aowed the exporation of what managers say they do as individua decision-makers and what managers reported to do in cases of coective organisationa decisions concerning the use of research-based and other forms of evidence. Our anaysis reveaed the compex interpay between diverse stakehoders, in terms of their professiona background and organisationa roe, and the evoving mix of evidence types accessed from different sources. At each stage of the product innovation journeys, coection, assessment and presentation of mutipe types and sources of evidence by different stakehoders to address various audiences and for different purposes were observed. We found that what managers caimed that they do as individua decision-makers (phase 1 data) was not foowed through in the context of coective decision-making processes (phase 2 data). Specificay, in phase 1 three nationa or centra sources of evidence, the NICE, the NPSA and NHS Nationa Service Frameworks, were reported as being used across the professiona groups when adopting innovations (see Figure 3). An additiona source, The Cochrane Library, was aso consistenty reported as being accessed and used by a cinica staff respondents, but not by those in the non-cinica group. However, respondents aso noted that evidence types associated with these sources, such as research-based evidence guideines or scientific artices, do not immediatey or seamessy reate to the deivery of heath care or innovation adoption in their own care environment. Our phase 2 data reveaed that, across the technoogy journeys in a the microcases, none of these sources was actuay used when evidence was sourced and reviewed to inform decisions; nor were journas cassified as heath services research and management, or mainstream organisation and management, used. 126 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Loca types of evidence, for exampe data generated through oca evauation trias, were more ikey to be mentioned by informants in phase 1 interviews when non-adoption or rejection decisions were made than other evidence from other trusts, the suppier, and nationa or internationa sources. Our phase 2 data iustrate that ocay generated evidence was usuay produced in order to criticay appraise other evidence types, and confirm the innovation s compatibiity, or otherwise, with the oca care environment. Our phase 2 data further suggest that research-engaged organisations in our sampe (T1, T5 and T7) tended to conduct oca tria evauations to inform adoption decisions, particuary in cases in which cost and practice impact were perceived to be substantia. This is in contrast to non-research-engaged trusts, for which suppier-sourced product documentation and peer-reviewed scientific artices tended to feature most frequenty across the stages of the innovation journeys. University-affiiated organisations showed a pattern of a somewhat wider range of evidence types utiised, frequenty drawing on exchanges with other trusts, professiona conferences and the HPA. In phase 1, suppier marketing materias were reported to be of ow importance in innovation adoption decisions by respondents across the trusts. However, in our phase 2 technoogy microcases, product documentation sourced by suppiers featured very frequenty in each of the stages of the innovation journeys across our macrocases of eight trusts. There appeared to be a more pronounced reationship with suppiers in ess-research-orientated organisations (i.e. T4, T6) than in university-affiiated trusts (i.e. T1, T5, T7), where suppier-sourced evidence was reconcied with other types in the evoving evidence mix. Overa, research-engaged organisations emerged as those wishing to quaify externa evidence vis-à-vis the adoption of innovative technoogy products by: i. generating and drawing on oca evidence on these products ii. engaging a high number of stakehoders from different professiona groups invoved in order to support this process of evidence review and customisation. In ess-research-engaged organisations, ocay generated data took a minima roe reative to externa evidence types, which were research-based and sourced from suppiers, professiona networks and other heath-care organisations. Severa saient aspects of these different evidence types featuring in each of the innovation journey stages in trusts were interwoven in discourses shared among members of different professiona groups. In these discourses, ocay generated evidence, research-based evidence, professiona experience, subject-matter knowedge, suppier-sourced materias and other evidence were other mediating factors. These discourses were again principay framed, and emerged from, within the professiona background of stakehoders. This underies the importance of professiona background vis-à-vis evidence pausibiity to sef and others in coective decisions. As reported earier (see Chapter 4), what counted as evidence for doctors and non-cinica managers differed, but what mattered most was that they themseves (doctors and non-cinica managers) were satisfied with the evidence. For the nurses, what counted as evidence to others mattered equay and sometimes more than own satisfaction with the evidence. This shaped the types and sources of evidence used by nurses at each stage of the innovation journey. When professionas came together as stakehoders to review evidence and enact decision-making, the professiona background and organisationa roe of the evidence presenters, and those of members of their audience, were of prime importance. Members of a professiona groups recognised that doctors have a unique position, either as presenters or as the audience, when evidence is being considered (Tabe 43). This, couped with the reative ack of invovement of this group in the product innovation journeys Queen s Printer and Controer of HMSO 2014. 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. 127

CROSS-CASE ANALYSIS TABLE 43 The presenter and audience matter Theme Cinician as presenter Exempar quote I aways find certain individuas within the team to present it, then it is istened to more. Again this is my own persona experiences, I can say the same thing as a cinica member of the team, but what I say is not accepted because I am not cinica. The cinica person can say exacty the same thing, same words, and they woud think it is wonderfu. The right peope. That is a chaenge of being a manager in a cinica setting. Non-cinica manager Athough it gas me to say it but I think the medica coeagues within the team are better at accessing [evidence] and they may come to a meeting and say I have had a ook at the evidence. I don t think it coud necessariy have been a systematic review of the evidence. Stating quite confidenty a particuar position and that coud be quite infuentia so that is something they are more ikey to do than nursing members of the team. Non-cinica manager Cinician as audience Cinicians seem to be the most powerfu group. And if you can get them on-board or at east some of them on-board then generay it makes things a ot easier because the nature of their training they wi ask for hard and fast data. Nurse expored in phase 2, partiay expains the sow adoption of innovations, particuary in IPC, as the fied is dominated by defaut by the nursing group: The infection contro agenda was amost entirey run through the nursing staff. So it was the nursing staff who knew that if an infection occurred on their ward they were going to be hod up in front of the senior nurse and have to account why it might have happened. The medica staff we are not subject to that sort of view at a [...]. Why are the medica staff not part of the anaysis of why these things happen? And it was reay party because, [...] there was a eve of hostiity amongst consutant staff towards changes. And I think even the senior nurses in the trust fet it woud be counterproductive dragging consutants into these meetings. And the resut of that was that the infection contro agenda became perceived as a nursing agenda. And the consutants were abe to stand back from it even more and say, It s nothing to do with us, it s a to do with the nurses, it s nothing we have to be invoved in, and that sort of you coud see the impementation of a ot of infection contro stuff fatering on that basis. Doctor There is the added compexity of organisationa roe versus professiona roe. For exampe, non-cinica managers as an organisationa group have a diverse professiona background incuding, for exampe, engineers and accountants; hence, the organisationa roe dominates in evidence-use practices. Nurses focused in our study on experientia and biomedica forms of evidence based on their professiona background. However, the organisationa roe of nurses in IPC appeared to override the professiona tempate as the primary frame of rationaity in decisions and was reported to shift according to the audience. In Chapter 4 we detaied the concepts of pausibiity for sef and others and how the atter was reported to be of greater concern to the nursing group. This variance in reported motivation mediated the span of evidence sourcing aong a continuum from narrow to wide (Tabe 44). TABLE 44 Motivation and span of evidence sourcing Behaviour: span of evidence sourcing Motivation Narrow Wide Pausibiity to sef dominates Medica hybrid manager Non-cinica manager Pausibiity to others dominates Nurse hybrid manager 128 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Chapter 10 Synthesis and inferences In this chapter we refect on and synthesise our empirica findings as to how the individua and coective sensemaking processes of heath-care managers evoved in practice as regards the use of evidence. Through our comparison of mutipe empirica cases, we provide insights into how managers sensemaking payed out within the mutiayered domains of infuence: uniprofessiona groups; mutiprofessiona groups; heath-care organisations; the fied of IPC and the heath-care sector. First, we return to our research questions to summarise key earning from our empiricay grounded work. We then refect with some impications for reevant theory. Refecting on our research questions Considering our origina research questions, we note that the process of managers making sense of evidence was found, not surprisingy, to be a situated socia process of individua and coective cognition in context. There was retrospective, ongoing interpretation of different types of evidence variaby sourced and assessed by a arge group of stakehoders with diverse professiona identities. Organisationa roes further infuenced this individua and coective sensemaking by shaping the focus of attention on the evidence debate. We found that organisationa members, through ongoing socia interactions with both immediate peers and seniors and distant comembers of the organisation, iterativey coconstructed pausibe accounts of reevance and credibiity to sef. In addition, this process invoved sensemaking for others. Notaby, the processes of decision-making invoved tacit and expicit and sometimes poitica or tactica sensemaking for others. Captured in this study is the more expicit sensemaking whereby making the case, for or against, at the different stages of the innovation process was payed out by diverse organisationa members. Reguation and poicy mandates, perceived decision urgency and service need, externa payers, such as the commercia suppiers of technoogies, and critica events, such as infection outbreaks, a infuenced these socia, situated processes of coective cognition. Here we summarise our findings as regards our origina research questions. How do managers (non-cinica and cinica hybrid managers) make sense of evidence? Managers encountered chaenges and constraints in accessing and making sense of evidence reevant to the decision at hand. Managers made sense of evidence by overcoming the conceptua constraints inherent in the nature of evidence as being mutifaceted, diffuse, ongoing and constanty updated (or in need of updating). By being mindfu of the tempora nature of evidence, particuary in the context of innovations, high strength and estabished scientific evidence about the efficacy of technoogies did not override other forms of evidence, such as cost and experientia knowedge about ease of use. Equay, ow evidence strength on efficacy for a product with an emergent scientific evidence base did not precude these technoogies from being adopted trust-wide (e.g. DIFFICIL-S or Chor-Cean in T7 and T5, respectivey). Managers were faced with and negotiated the map of an incompete evidence base in terms of missing evidence or poor-quaity evidence. The definition of quaity varied to some degree according to professiona background. Managers made sense of evidence in innovation decisions by sourcing evidence which was pausibe and accurate to sef but aso for significant others, that is to convince other members of the organisation for the case at hand. This function fe within the remit of some organisationa members (e.g. nurse hybrid managers in the context of IPC) more than others. At the same time the managers justified their own credibiity in the decision-making discourse as presenters of this evidence. Queen s Printer and Controer of HMSO 2014. 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. 129

SYNTHESIS AND INFERENCES What roe does evidence pay in management decision-making when adopting and impementing innovations in heath care? The articuation and discourse around evidence payed a major roe in decision-making when adopting innovations given the newness and risk inherent in innovations. Decision-makers fet the urgency for sourcing evidence to reduce the uncertainty and ambiguity associated with the introduction of innovations. Innovation evidence was often perceived as emergent, iterative and changing. In the eary stages of initiation and adoption, those invoved drew on a variety of types of evidence, many of which were avaiabe from centra sources; managers reported that in eary technoogy considerations they were not aways cear about what types of evidence they needed. Evidence payed a different roe in the stage of impementation, as respondents often cited missing evidence at this ater stage of the innovation process. Credibe and reevant evidence generated from systematic research on the topics of impementation and management was identified by the majority of respondents as currenty missing from the NHS evidence base. This is despite the fact that a significant body of such research evidence exists in heath services research journas [e.g. Impementation Science, BMJ Quaity and Safety, Heath Services Research & Poicy, Heathcare Management Review, NIHR Heath Services and Deivery Research (HS&DR) research reports] and mainstream management journas (e.g. Organization Studies, Academy of Management Journa, Organization Science). When probed, most respondents were not aware of these journas, and did not report reading them. As a resut, decision-makers often drew on more oca evidence, such as evidence from other trusts, or instigated the generation of oca trias. Stakehoder consteations evoved aong the innovation stages, shaping the mix of evidence types reviewed and taken forward at each stage. There was consistency in respondents accounts that different professiona groups accessed different sources of evidence because of dissimiar needs for evidence. How do wider contextua conditions and intraorganisationa capacity infuence research use and appication by heath-care managers? The presence of standardised evidence from centra sources affected a stakehoders invoved in decisions in the context of heath care. In addition, pressures of patient safety and performance infuenced the use of evidence in different ways. In the context of IPC, externa pressures, in the form of performance targets, media scrutiny, patient expectations and fear, were reported as incentives for sourcing evidence on innovations that woud deiver resuts in specific organisationa contexts. Severa decontamination technoogies were introduced as a resut of these pressures in our trusts sampe. These same pressures, however, were seen as a barrier to estabishing a we-informed and rigorous process of evidence consideration because of the pressure to act. Under such intense contextua pressures decision-makers often embarked on a quest for pausibe rather than accurate evidence. The consequent pace of decision-making necessitated a focus on pausibiity to others. Conversey, sometimes the pace infuenced the excusion of key stakehoders to avoid protracted decision-making processes with wider invovement deayed to the impementation stage. In this study, trust infrastructure redeveopment projects, a strong emphasis on patient safety, and strong and trustfu coaboration (especiay between IPC teams and other organisationa departments) appeared to widen the scope for the search, and use, of evidence in decision-making. In neary a phase 2 microcases, the number of evidence types and individuas invoved grew as the innovation process progressed from initiation to eary tria use, adoption decision and impementation. These evidence types were diverse and came from severa sources irrespective of whether one or many professiona groups came to be invoved. 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 shaped decision-making outcomes. 130 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Our findings aso suggest that research-engaged organisations in our sampe were more ikey to generate their own evidence, for exampe conduct oca evauation trias to inform adoption decisions. Research-engaged trusts tended to assess innovations by drawing on a wider range of evidence types, and engaging a high number of stakehoders from different professiona groups. Looking across professiona groups, what counted as evidence for doctors and non-cinica managers was different, but what counted most was that they themseves (doctors and non-cinica managers) were satisfied with the evidence. For the nurses, what counted as evidence to others mattered equay and sometimes more than own satisfaction with evidence. This shaped the types and sources of evidence used by nurses. Engagement with evidence unfoded over time through interaction and negotiation. There were diverse, but cosey interinked, evidence tempates in circuation and in use, namey biomedica-scientific, practice-based experientia and rationa-poicy (see Sensemaking in organisations beow). These tempates served as frames of reference for the managers and defined what constituted acceptabe and credibe evidence in the decision-making process. Informants variaby drew on those tempates to make sense of the evidence and of the organisationa probems identified and this is where micro and macro contextua infuences shaped this process. Impications for theory In this section, we suggest some theoretica impications that emerge from our empirica findings in reation to the reativey i-exposed iterature we identified in the concuding section of Chapter 2. We briefy outine some of the impications to the reevant theoretica debate in three iterature streams, namey, evidence-based heath care, organisationa innovation and sensemaking in organisations. The first two are considered conjointy as our study focused on the use of evidence in the context of organisationa innovation adoption and impementation decisions. Evidence-based heath care and organisationa innovation processes Much of the current empirica research on innovation adoption and diffusion in heath care has generay been imited to a singe eve of anaysis. Our study expored the innovation adoption process foowing a mutiayered anaysis at micro (individua managers sensemaking), meso (coective sensemaking of evidence in organisationa innovation decisions) and macro (interorganisationa professiona and poicy infuences, evidence tempates) eves to provide a hoistic understanding of socia processes in context. 95 In organisationa innovation iterature, there is aso insufficient exporation of how puraist evidence bases (and the associated diverse epistemoogica bases) might be reconcied (or not) in practice to make the case for or against particuar innovations. 96 Throughout our empirica cases, we consistenty observed that organisationa contexts, and especiay the organisationa cuture and eve of research engagement, poicy mandates, perceived urgency of issues, physica infrastructure, socia interactions and stakehoder engagement, and professiona identities, exerted a mediating infuence on how decision-makers accessed and used evidence for non-cinica organisationa decisions impacting on cinica-care deivery. We expored the roe and expressed motives of actors and the infuence of context, which mediated the socia construction of evidence in practice. Nature of innovation evidence The nature of evidence was conceptuaised aong a continuum of hard to soft. Hard evidence comprised cost and efficacy, whereas evidence on practice impact, usabiity and patient experience was more often perceived as soft. An emphasis on organisationa productivity outcomes was aso viewed as inked with hard and tangibe evidence and such caims were prevaent in the evidence discourse of managers with non-cinica backgrounds. Queen s Printer and Controer of HMSO 2014. 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. 131

SYNTHESIS AND INFERENCES The tempora nature of evidence served as both a motivator to seek and generate new evidence and a constraint. Sourcing evidence for the most up-to-date deveopments was viewed as part of the innovation process and a means to improve patient outcomes. At the same time, the deay in avaiabiity of high-quaity evidence was seen as a barrier, with decisions being put on hod in the absence of such evidence. The tempora dimension aso emerged as an externa pressure generated by performance measures and targets, particuary in the area of IPC, whereby the necessity or perceived urgency to act precuded decision-makers having sufficient time to review evidence in a robust manner. Many organisations in our study sampe (especiay research-engaged NHS trusts) sought opportunities to add to the evidence base through oca trias, and this may be expained by the high majority of senior managers interviewed in phase 1 who found it difficut to reate evidence from centra sources to oca practice. We identified no cear observabe pattern between adoption or impementation outcomes and the evidence strength on efficacy or expected budget impact of the studied technoogies when considered in isoation. A ow perceived practice impact was more ikey to be inked to 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. These empirica findings hep innovation researchers to better map the perceived attributes of innovations (e.g. reative advantage, compatibiity, compexity, triaabiity, observabiity) and innovation knowedge types (e.g. awareness, principes and how-to innovation knowedge) 24 aong these additiona three domains for improved understanding of innovation uptake within organisations. Situated evidence If technoogy adoption were to foow a purey evidence-based approach, then organisationa adoption decision-making woud be an entirey rationa process. Our findings suggest that individua interests, certain critica shocks, externa pressures and the trust s organisationa cuture and vaues had a strong impact on the use of evidence in the decision-making processes. This was often inked to a sense of urgency to sove perceived probems, eading to organisationa priority shifts in favour of such acute probem soving. For exampe, outbreaks, financia pressures, performance targets and trusts reationships with commercia suppiers often ed to reactive or fire-fighting attitudes towards probem soving, or a ess scrutinised approach to evidence use: decision-makers often reied upon an emergent evidence base adopting a pragmatic approach and sourced sensibe and credibe evidence; in other cases, a poitica and imperative approach dominated the evidence review process. Extrinsic motivation, such as organisationa image and the reated pressures (i.e. meeting the expectations of patients and the pubic, must-have innovations, organisationa reputation and being seen as NHS eaders in IPC or NHS eaders in quaity and innovation), exerted a significant infuence on decision-making and was reinforced by certain frames of reference among key decision-makers. Redeveopment projects, patient-centred organisationa vaues, and reationships of coaboration and teamwork were inked to a broader range of sources and types of evidence accessed, reviewed and used by decision-makers. A narrower span in accessing and using sources and types of evidence was often observed when there was a sudden and drastic change in the magnitude of pressures on the studied trusts especiay performance-reated pressures. In other words, the use or non-use of diverse forms of evidence became wider or narrower, depending on mutieve contextua infuences. Innovation adoption decision-making occurs within dynamic and compex contexts (both micro and macro). Our study found that this has had an effect on how actors perceived evidence (i.e. acute/urgent, credibe, reevant), and whether they actuay utiised it in their decision-making. The tempora nature of evidence per se as we as the diversity of actors identities (i.e. professiona background, organisationa roe) can add further compexity. This is because such evidence requires continuous (re)construction, 132 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 trianguation and interpretation by use of one s own cognitive tempate(s), which transate evidence to be deemed pausibe to sef and/or others. Within our studied cases the nature of the probems being addressed drove the quest for evidence and the amount of resources (time, manpower and expertise) expended. The externa forces that have been discussed previousy featured as inhibitors or faciitators when considering innovation and supporting evidence. In addition, the nature of the probem as technica and product based or more processua and concerned with service deivery and organisation aso impacted on the types and sources of evidence used. For probems of high perceived technica compexity, harder evidence was more readiy avaiabe. Furthermore, athough rated as of ow importance by cinicians and managers interviewed in phase 1, information from suppiers was often the point of first ca in the eary stages of technoogy assessments by the trusts in phase 2. Forms of evidence and sources of infuence on decisions Our findings suggest that there were six main sources of infuence on organisationa decision-makers use of evidence during the various stages of the innovation process, and these are summarised in Figure 34. The various sources of evidence were used at different times depending on the nature of the organisationa probem identified, but aso depending on who was invoved in the various stages of the innovation process. The size of each hexagon-ike box and hence the strength of the source of infuence varied with each decision. In some circumstances, evidence from a oca tria or the preferences of stakehoders (e.g. patient expectations and safety assurance for the use of the hydrogen peroxide vapour system) were judged by the decision-makers to be more important and reevant than research-generated evidence and, thus, were given much greater emphasis in specific decisions. In other situations, itte evidence was avaiabe from centra sources, and thus their infuence on manageria decisions was reativey imited. Practitioner expertise inked to professiona training and education Practitioner experience and persona knowedge Perspectives and preferences of key stakehoders Decision Evidence from oca context Poicy endorsement and evidence from centra sources Researchgenerated evidence FIGURE 34 Main sources of infuence on sourcing evidence in organisationa decisions. Queen s Printer and Controer of HMSO 2014. 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. 133

SYNTHESIS AND INFERENCES This conceptuaisation buids and expands on the key eements of EBMgt presented by Briner et a. 97 by aso expicity refecting on the infuence of poicy and practitioner embodied knowedge and skis as sources of credibe evidence. 98 Sensemaking in organisations This study has provided insights into the sensemaking processes of diverse professiona groups in the context of acute NHS trusts. Athough sensemaking is ongoing and iterative by its very nature, this process becomes more pronounced and easier to capture in the context of uncertainty and change. Our study examined decision-making in innovation adoption and impementation processes, which are inherenty associated with newness and change. The context of IPC is aso cosey reated to issues of operationa uncertainty and cinica risk. Everyday sensemaking in heath care In organisationa sensemaking theory, there is ess emphasis on empirica studies that dea with the day-to-day processes of sensemaking than on those that dea with crises and critica events. There are fewer inquiries into sensemaking that occurs among many diverse organisationa stakehoders as they address a range of issues. 46,62 By appying this theoretica ens to the investigation of manageria decisions on the adoption and impementation of innovative technoogies, we empiricay contribute to the fied. Coective sensemaking: strategic and operationa decision-making The construction of shared meanings, or coective sensemaking, 46 is key for understanding how new types of evidence may be successfuy embedded in certain contexts, or even be rejected under conditions of innovation uncertainty and ambiguity. However, ess attention has been paid to the socia processes that underpin sensemaking at the organisationa eve. 62 In this study we empiricay examined issues in which a arge and diverse group of stakehoders was invoved, giving rise to differentia needs for evidence (i.e. for strategic or operationa decision-making) and dissimiar perspectives on its interpretation. Connecting micro cognitive processes with macro shared tempates Our findings highight the importance of sensemaking in context. Drawing on our empirica work, we suggest that sensemaking theorisations that overook the roe of arger socia contexts (i.e. in this study the use of evidence being shaped by diverse professiona frames of rationaity) in expaining cognition are necessariy incompete. This is in ine with recent arguments in conceptua papers, which highight the ack of an expicit account of embeddedness of sensemaking theory in socia space and time. 56 We found that professionas within heath-care organisations drew, through sensemaking practices, on existing shared rationaised frames of reference to make sense of issues in decision-making (this is detaied beow.) We approached sensemaking as an ongoing communication process by which actions, events, situations and circumstances are taked into existence. 46 The emergence of evidence tempates Athough the focus of this study was around perceptions and use of evidence in organisationa decisions, this was one dimension of the process. We aso note that, athough the perceptions and reported use of evidence in phase 1 interviews may have refected more espoused beiefs rather than what managers actuay did (see the works from McGynn et a. 99 and Runciman et a. 100 for a review of what constitutes evidence by cinicians), this discrepancy is in itsef important. What managers think that they ought to be doing, or what they woud ike to be doing, is important. In phase 2 we were abe to party reay which contextua factors impacted on these espoused beiefs. In addition, phase 2 aowed us to capture part of what happens when the decision-making dynamics change by virtue of those invoved, and aso to capture infuences of oca organisationa priorities and macro-eve poicy agendas. We refect here on how decision-making processes compared across professiona groups. It is usefu to refect on two contextua issues which contributed to the way different organisationa members made decisions. First, the issue of who is the decision for? : this coud be the individua/patient, unit or ward, organisationa or popuation eve. Second, the issue of who makes the decision?. Is it essentiay an 134 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 individua or a coective decision? By exporing these issues, we understand more about the usua roe of evidence in decision-making for these diverse professionas. At one end of the continuum we coud position doctors, who argey make cinica decisions about an individua patient on a case-by-case basis, sometimes with immediate feedback of the impact on the patient. At the other end of the continuum we coud pace non-cinica managers, who make decisions argey for an organisation, usuay with onger-term and often uncear direct impacts. How different organisationa members make sense of evidence is then interinked to how they make decisions and how we they transate this usua sensemaking when considering organisationa decisions, which are carried out coectivey. We saw from phase 2 that, with the exception of DIPCs, doctors were not present in coective decision-making. Given these different professionay dominated ways of doing things, what happens when these members come together to make essentiay organisationa-eve decisions? Making sense of evidence in the context of the organisationa decisions described in this study can be conceptuaised through the use of evidence tempates and the purposefu action of adopting an evidence tempate by different organisationa members to make sense either for sef or for others. Specificay, we consider three apparent tempates: the biomedica-scientific tempate, the practice-based tempate and the rationa-poicy tempate (described in detai beow). These constituted a source of interpretive and egitimating resources in the cognitive processes of individua professionas making sense of evidence. We discuss beow how the different tempates dominated in different contexts and at different times aong the innovation process. We found that adoption of an evidence tempate was shaped by professiona background, current organisationa roe, current decision and the presence of other stakehoders in the decision-making process either expicity or impicity. Tested/proven according to the biomedica-scientific tempate The biomedica-scientific approach minimises risk to patients in that a thorough eve of testing has been competed. This tempate formed the basis from which medica and other cinica professionas embarked. Ony once this evidence was avaiabe woud they proceed to ook at other eves of evidence. This tempate payed a centra roe in the earier stages of the organisationa innovation process. The degree to which other eves of evidence were considered was shaped by experience and who ese was at the tabe making the case for any particuar decision. Cose teamwork among the professiona groups and advances in the way nurses sourced evidence required attention to the biomedica-scientific tempate, but this took more of a baanced, compementary roe aongside other evidence tempates. The roe of nurses, in particuar in convincing a wide range of stakehoders, may have shaped their convergence towards the biomedica paradigm, given the reported preference of doctors for this tempate and their centra position in decision-making. Tested/proven according to the practice-based tempate A stakehoder groups gave importance to this approach, but to different degrees and at different times. Accounts about earning from other trusts and peers featured in making sense of the evidence under this tempate. This tempate foowed a ogic of practica action and dominated the focus of attention of the decision-makers in the ater stages of the innovation process. Potentia adopters wished for extensive information about the technoogy, its workings and its anticipated impact; it was not easy to access this. Considerabe (persona) effort and improvisation was needed and informa networking proved invauabe. However, this type of information retrieva produced information of variabe quaity and appicabiity. The extent of industry invovement in the decision-making was surprising but expained by the dearth of both skis and accessibe information. Technica training for users, on the whoe, was the responsibiity of the industria suppier of the technoogy and was we organised. Rationa-poicy tempate: tested/proven according to the discourse of bureaucratic rationaity This was determined by the goas of the organisation, which are shaped by the macro environment, particuary reevant reguation and poicy. The organisationa roe of non-cinica managers appeared to be most aigned with this approach, when compared with other organisationa members. Their performance Queen s Printer and Controer of HMSO 2014. 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. 135

SYNTHESIS AND INFERENCES requirements and remit of responsibiity matched this paradigm. Poicy endorsement and mandate shaped cognition and attention of decision-makers to certain forms of evidence. Such issues permeated the whoe organisationa innovation process. Our findings suggest there are shortcomings of inear evidence-based conceptuaisations of innovation adoption, and a need for context-sensitive, practice and poicy contingent approaches. 19 We noted the importance of decision-makers and significant others understandings of the nature of the perceived probem and the associated risk and safety issues, as we as the perceived need for various forms of evidence. For exampe, oca trias, and the need for pragmatic evidence, were deemed important by decision-makers in the eary stages of innovation adoption. For innovations (and especiay for those that require significant changes in practices or processes to be impemented), creating an evidence base wi require agreement about what is regarded as a egitimate epistemoogica basis for verifying and vaidating evidence and reevant knowedge. For exampe, shoud the evidence base for impementing an innovation in a specific context rey excusivey on scientific reproducibiity and expicit, codified forms of knowedge? Or, aternativey, shoud the basis of evidence aso account for a wider conceptuaisation of vaid and reevant knowedge (incuding practice-based and experientia tacit forms of knowedge)? How might puraist evidence and knowedge bases be reconcied? Evidence sources and types appeared to be variaby prioritised and used by decision-makers depending on their professiona background. Doctors and nurses prioritised evidence on the cinica efficacy and effectiveness of innovations. High importance was accorded to systematic forms of knowedge by doctors, whereas non-cinica managers and nurses reied more on their own or peers experientia knowedge. Non-cinica managers and nurses aso considered evidence on ease of use, incuding oca trias of innovative products and technoogies, as highy important. Different evidence hierarchies emerged in practice and were reinforced through routine enactment. The antecedents and ongoing sensemaking that shaped interpretive frameworks of different stakehoders were articuated in tempates that structured shared cognition. The confuence of diverse tempates Within a heath-care setting, the evauation of an innovation can take a number of forms and incude technica, economic and socia assessments. Adoption decisions invove a number of stakehoders, and therefore it is important that the evidence used to support adoption is not just sufficient but aso reevant and perceived as appropriate to address the concerns of a parties. As described above, different professiona members had different roes in decision-making in our empirica study. Another differentiating feature is the entry point of heath-care practitioners when compared with non-cinica managers. Heath-care professionas have a we-defined entry point that estabishes within these professionas a common frame of reference or tempate through forma training and then through sociaisation within practice. Non-cinica managers in heath care come from a variety of professiona backgrounds and may have received no forma management training. 2 The fact that management does not have a commony shared frame of reference to define quaity criteria of evidence has ed to the prominence of experientia evidence. 101 The various professiona groups drew variaby on co-existing evidence tempates to hep them make sense of the evidence base. In our empirica cases, nurses drew on a diverse tempates in circuation and aimed for evidence pausibiity to sef and others and were the ony professiona group who expicity tried to make the case to other stakehoders. Non-cinica managers aso drew on a diverse tempates in circuation but aimed primariy for evidence pausibiity to sef and then sought to justify to others, based on this evidence tempate. In contrast, doctors drew primariy on the biomedica-scientific tempate and were excusivey concerned with evidence pausibiity to sef. The use of evidence tempates by heath-care managers aigns with the conceptuaisation by Gabbay and Le May 102,103 of cinica mindines, namey, internaised, coectivey reinforced, tacit guideines for knowedge use by cinica practitioners. We share with these authors the empirica experience and conceptuaisation of evidence representing knowedge in 136 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 practice in context rather than accepting inear rationa approaches to expain how knowedge is mobiised and used as evidence in practice. Unike mindines, evidence tempates are sociay embedded frames of cognition coectivey shared by groups of organisationa decision-makers, rather than being idiosyncratic cognitive guideines informing cinica decisions. However, we refer to evidence tempates as abstractions that hep organisationa decision-makers reconcie and make sense of compex knowedge that often crosses epistemoogica paradigms of what constitutes vaid knowedge. Cinica decisions taken within the we-estabished epistemoogica biomedica paradigm trigger quaitativey different sensemaking processes. Strengths and weaknesses/imitations of the study Athough our study draws on rich empirica data from a arge-scae mutisite project, which heped untange important dynamics on the use of evidence in organisationa decisions, more work is needed to expand our understanding. Our quaitative study is imited to the fied of IPC; we draw on data from specific organisations and technoogies, aso reporting on a specia type of decision, namey innovation adoption. Generaisations, therefore, from this data set must be treated with caution. We deiberate here some imitations of our methodoogy and then refect on some of the strengths of the study, which have been discussed in detai in the methodoogy section. First, we need to acknowedge that most of the primary data in this research are drawn from interviews and structured questionnaires that expored views, perceptions and sef-reported accounts on activity and practices. The quaitative study is based on our purposefu sampe of respondents rather than the trust popuation. The interviews were conducted in retrospect for most of the microcase exampes, and as a resut we cannot competey mitigate reca bias. The interviews were semistructured, aowing respondents to eaborate on faciitators, barriers and prevaiing conditions at the time of decision-making; however, the accounts were essentiay a reconstruction of events. Potentia bias owing to seective memory for events that occurred in the past and retrospective and attribution bias might have shaped the responses given by the study participants, and need to be considered when making inferences from the study. One strategy we used to avoid probems of retrospective bias and aso to avoid dominance of one particuar viewpoint was to interview organisationa members at severa different eves of seniority, from different parts of the organisations, and from different professiona groups. We aso used direct questions in each of the phase 2 interviews, such as who made the fina decision ; this tactic heped to highight discrepancies in the accounts and any perceptions of forgone concusions versus debated and transparent decision-making. We further checked, whenever possibe, against documentary and other secondary sources (e.g. websites) regarding timescaes and any wider invovement in the decision-making process. We reported as findings ony those events and reationships that were corroborated by mutipe informants and that were consistent with documentary data, whenever such data were avaiabe. We aso purposefuy imited the timespan of technoogies incuded in the study to the period after 2007 to minimise the potentia bias of reca and issues of incompete accounts as a resut of staff turnover. Second, our study context and questions reate to a wide range of possibe factors that potentiay impact on evidence use in the organisationa innovation processes. We empoyed an integrated approach to anaysis as opposed to pure grounded theory, which may have given rise to aternative expanations. The scope and reevance of the study required a baanced approach between externa vaidity through cross-comparative anaysis and an in-depth smaer-scae study empoying a more open framework of anaysis. For exampe, a foow-up in-depth study based on ethnographic work may revea the interpay among evidence, knowedge and power. Aternativey, empoying a more deductive framework, and using an expanatory theory such as interprofessiona power, woud have undoubtedy reveaed some findings to support the theory but, at the same time, stifed any new or aternative expanations being discovered. A third important methodoogica imitation is due to practica constraints of time and accessibiity. We were not abe to conduct rea-time observations of discussions in meetings and observe instances of Queen s Printer and Controer of HMSO 2014. 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. 137

SYNTHESIS AND INFERENCES decision-making and evidence use in action across a participating trusts. We were abe to attend ony one meeting in T4. Obtaining observationa data proved chaenging in the high-pressure environment of busy NHS trusts, in part because of the reativey short window of opportunity for data coection; access issues were further exacerbated during the winter months owing to fu emergencies and in summer months owing to staff hoidays. Extending the data coection period woud have caused important deays to our project. We were fortunate to compete coection of a other data in eight of the nine panned trusts. One trust (T8) decided to drop out because of issues of high operationa demands during the course of the study. In some cases, we were not abe to observe the fina outcome of a decision-making process within the ifespan of this project and these decisions have been reported as ongoing. A carefu baance needed to be maintained to avoid cosing the door for future researchers. Despite the imitations described above, the study has important strengths that distinguish it from earier research exporing simiar issues. First, the study draws on a arge sampe of informants and investigates quaitativey mutipe and comparabe cases, focusing on heath innovation technoogy as the tracer issue. We foowed a phased approach that expored individua and coective processes of evidence mobiisation in decisions. In the first phase we investigated accounts of how individuas, from various professiona backgrounds and organisationa roes situated in diverse organisations, reported accessing and using evidence to accompish individua tasks in reation to innovation decisions. In the second phase we contrasted such accounts with experiences in coective decision-making processes. Second, whereas most previous empirica investigations using sensemaking as a theoretica ens focused amost excusivey on either individua or organisationa processes, this study empoyed a mutieve perspective to aso account for wider contextua infuences, such as the coective frames of rationaity or evidence tempates, we identified in this research. This aigns we with the nature of compex heath-care organisations, such as the NHS, which are distinctivey mutiayered entities. It aso responds to repeated cas for mutieve organisationa research. 95,96 Third, the study aowed for tracing the possibe reationships between the quaity of decisions and fina outcomes. We ooked at fu processes, namey the innovation process from initiation to adoption decision and impementation, and inked this process to adoption and impementation outcomes for specific technoogy products in specific trusts. We purposefuy samped for innovation rejections and discontinuances, which are rarey empiricay studied. 138 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Chapter 11 Impications and suggestions for future research In this chapter we concude with a discussion of the potentia impications of our findings for poicy and practice and suggestions for future research. Impications for poicy and practice In our empirica findings we presented systematicay and in detai a arge number of innovation decisions which unfoded across diverse heath-care organisations. We described in detai 27 microcases of the what, who, how and why aong the decision-making and impementation process. This incuded the eve of invovement of diverse stakehoders at different stages of the process, the issues they encountered, the sources and types of evidence mobiised at each stage and the fina outcomes of these decisions. The varied roe payed by different professionas in how evidence is coectivey used has impications for who to invove and for what purpose. An EBMgt approach that infexiby appies the principes of EBM negects how evidence is actioned in practice. The nuanced and processua consideration of evidence gives rise to an iterative exchange between codified, systematised knowedge generated from research and other forms of evidence that are aso vaued by decision-makers. This research demonstrates that experience, persona knowedge and expertise, perspectives and preferences of stakehoders, poicy mandates and endorsement, and evidence from the oca context a may contribute as credibe and reevant evidence sources. Cinicians and managers were infuenced by centra or nationa-eve institutions (e.g. The Cochrane Library, NICE, Nationa Service Frameworks, the NPSA), some of which have been active in producing research and disseminating knowedge about the organisation and deivery of heath care. There was, however, disconnect between what was perceived as credibe (as these sources were) and what was deemed reevant to the decision-making process. How do managers use the research produced by these institutions or infuence its production? Our findings showed that the impact of these centra institutions differed greaty owing to varied awareness and perceptions of these sources. This eads to the question: is there a need for a centra evidence database/depository for manageria practice? Athough some informants were aware of NHS Evidence, they rarey used it to source evidence in decisions. The NIHR HS&DR and the NHS Institute for Innovation and Improvement were rarey mentioned and never used (phase 2). There appears currenty to be a gap in credibe evidence sources reevant to manageria practices in the studied context. The open-access HS&DR journa, which is part of the new onine NIHR Journas Library, has the potentia to pay the roe of the management decisions evidence porta, provided that the awareness, credibiity and reevance of the journa can be estabished among practitioners. The issue of who in organisations searches for, synthesises and presents evidence to others is important. As doctors invariaby hod the unique position of being perceived as highy credibe at the decision-making tabe, they need to be engaged. The case of IPC puts nurses at the frontine; in our cases, nurses were the most invoved group in innovation processes and charged by defaut with making the case within organisations. The ack of invovement of key stakehoders (e.g. doctors, procurement, the research and deveopment department) was perpetuated in some of our cases to avoid counterproductive interactions among professiona groups. Nonetheess, the deayed invovement of key stakehoders gave rise to the possibiity of decisions being chaenged at a ater stage. This differentia engagement positioned the evidence tempates (biomedica-scientific, rationa-poicy, practice-based) in competition, uness the organisationa cuture mediated a consensus approach. This ack of invovement of doctors (phase 2) not ony contributed to sowing the adoption of innovations, but aso curtaied opportunities to draw upon diverse evidence tempates. Queen s Printer and Controer of HMSO 2014. 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. 139

IMPLICATIONS AND SUGGESTIONS FOR FUTURE RESEARCH The NHS and other heath systems have expicit poicy goas to promote the uptake of innovations and systematise new practices across heath-care organisations. 10 Our findings suggest that oca processes, and professiona and microsystem considerations, pay a significant roe in adoption and impementation. On the basis of this, and significant other research, 16,104 106 this poicy goa of systematisation appears to be infeasibe, because of the idiosyncrasies of situated circumstances and cutures. This has substantia impications for the effectiveness of arge-scae projects and systems-wide poicy. Reported missing research Respondents in phase 1 reported that areas of missing research comprised behavioura studies, impementation research and organisationa studies or management research. They were particuary interested in how to tacke non-conformance behaviour and better understand impementation chaenges. In particuar, pharmacists reported a ack of research in this area, foowed by nurses and non-cinica managers. Doctors were ess attuned to this aspect of organisationa change. Frequenty reported medica resistance towards IPC practices confirm this finding doctors representing the professiona group east aware of behavioura change. T1, T3, T6 and T9 appeared to be more behavioura-change conscious than other trusts. This coud be inked to their proactive organisationa cuture or reevant research strategies set up through coaboration with oca universities, as documented in Chapter 6. Suggestions for future research This study has provided origina insights into the use of evidence by heath-care managers in organisationa technoogy adoption. Whereas we investigated in detai the individua and coective sensemaking processes as managers sourced and appied evidence during the innovation journey, future research can further deveop such insights and assess their transferabiity and reevance to other contexts. We suggest the foowing ideas that can inform future research (these are not isted in order of priority or importance): Whie we eicited compex dynamics of the innovation process, from initiation to impementation, our study draws primariy on data derived from sef-reported accounts. An understanding of the discourse between professiona groups and non-verba cues woud provide further insight into the actua decision-making processes. Direct observation using in-depth ethnographic studies woud be the most appropriate approach. Further exporation of the evidence tempates and how they ink to broader shared cognitive frames of rationaity in the form of institutiona ogics in the fied of heath care 107,108 is needed to address the foowing questions: what are the constitutive eements of these tempates?; what roe do the tempates pay in knowedge production as we as utiisation and what are the consequences for practice?; and how does the interpay of diverse tempates occur in practice in different contexts? A ongitudina research design with mutipe case studies at the eve of the organisationa fied focusing on evidence use by heath-care managers from diverse professiona backgrounds can be a fruitfu option for this stream of inquiry. An in-depth study ooking at the theme highighted in this research regarding making sense for others and a more focused research question about interprofessiona power dynamics. In this study we incuded technoogy products bounded within NHS acute trusts. We suggest simiar dynamics are expored for innovations across different boundaries (sectora, eve of care) and with ess ceary defined boundaries (process, organisationa innovations). This is particuary reevant given the restructuring of the Engish NHS, with pubic heath-functions based in oca government. We aso point out that the dissemination of such research needs to transcend mainstream management and organisationa iterature. Respondents cited a ack of reevant empirica studies in peer-reviewed management journas argey because there is a discord between where such iterature is pubished and the sources used by these decision-makers. 140 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 A arge-scae popuation-based survey of the structured questionnaire. Such a survey woud hep determine the extent to which the reported differentia preferences on access and use of evidence sources and types by professiona groups in our purposefu sampe can be generaised. Athough this study aowed for investigating the fu innovation process from initiation to adoption decision and impementation, as a resut of time constraints we were not abe to study the ater stages of assimiation and routinisation for a technoogies. Moreover, because of the study s focus on sensemaking processes, emphasis was given to decision-making rather than practice adaptation and assimiation. Future research coud investigate in more detai how front-ine users impement and assimiate technoogies into their estabished day-to-day routines, which are issues that have received imited attention in current empirica studies. Queen s Printer and Controer of HMSO 2014. 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. 141

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Acknowedgements We acknowedge the input of Professor Sue Dopson as expert academic advisor on the research. We acknowedge the vauabe advice received from members of the Project Steering Group, namey Professors Chris Chapman, Sue Dopson and Martin McKee, the patient advisers Mr Tim Sims and Mr Roy Oiver, the NHS cinica manager Mr Darren Neson and Mr Chris Gush for his former invovement in the Department of Heath s HCAI Innovation Technoogy Programme. We woud ike to thank Anthony Sewe for his support in the primary data coection for two trusts, support in secondary data coection for one trust and trianguation, and Siddharth Mookerjee for his support in secondary data coection. We thank the academic and administrative staff at NIHR HS&DR for their support, especiay Sue Pargeter. We woud aso ike to deepy thank the cinicians and managers who generousy gave their time to be interviewed. We are particuary gratefu to the nine NHS organisations that hosted the case studies in phase 1 and the eight of them that aso hosted the case studies in phase 2. Finay, we are gratefu to four anonymous reviewers of the first draft, whose insight improved this report. Contributions of authors Yiannis Kyratsis (Lecturer in Heath Management and Leadership) was the co-principa investigator responsibe for oversight of the fied work, study design, cross-case anaysis and writing of the report, and contributed to data coection. Raheeah Ahmad (Senior Lecturer in Pubic Heath) ed on the empirica chapters on sensemaking, co-ed (with Yiannis Kyratsis) on study design, cross-case anaysis and writing of the report, and contributed to data coection. Kyriakos Hatzaras (Senior Research Soutions Anayst, Heathcare Innovation and Technoogy) ed on the typoogy of technoogies and empirica chapters on microcases, contributed to cross-case anaysis, project management of fiedwork research and data coection. Michiyo Iwami (Research Associate, Heathcare Organisation) ed on secondary data coection and anaysis, contributed to the cross-case anaysis, ed on empirica chapters on contextua infuences and commented on drafts of the fina report. Aison Homes (Professor, Infectious Diseases) was chief investigator iaising with NIHR HS&DR, ed on IPC themes, supported access to empirica sites and commented on drafts of the fina report. Queen s Printer and Controer of HMSO 2014. 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. 143

ACKNOWLEDGEMENTS Pubications 1. Kyratsis Y, Ahmad R, Homes A. Making sense of evidence in management decisions: the roe of research-based knowedge on innovation adoption and impementation in heath care. Study protoco. Impement Sci 2012;7:22. 2. Kyratsis Y, Hatzaras K, Iwami M, Ahmad R, Homes A. Making Sense of Evidence Behind Innovations: a Mutisite Comparative Study in Infection Prevention and Contro in the NHS. Poster presented at the eighth Internationa Heathcare Infection Society (HIS) conference and Federation of Infection Societies (FIS) annua conference, Liverpoo, November 2012. 144 NIHR Journas Library www.journasibrary.nihr.ac.uk

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DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Appendix 1 Samping options appraisa (9 May 2011) Dimension and options Identified strengths Identified risks Seection Tempora To be guided by trusts Option 1: bound innovations/technoogies to be considered by time 2007 12 Captures period of major poicy initiatives regarding IPC (The Heath Act 2006; EPIC guideines 2; 71 mandatory reporting of MRSA and C. difficie; Saving Lives programme 2007; Cean Safe Care 2008) Reca bias High staff turnover resuting in gaps in data Change in poicy and socia context of a 5-year period Possibe if trust staff and records avaiabe Particuary usefu for successfu impementation of innovations/technoogies Time period sufficient to observe change in practice Aows study of impementation and sustainabiity Aows study of rejections Aows study of organisationa earning Option 2: bound innovations/technoogies to be considered by time X 2012 (where X > 2007) Higher data quaity owing to shorter reca time and staff consistency Shorter time period to study the process of impementation and rejections Possibe to be guided by trust (2010 2012). Going back earier if trust staff and records avaiabe HCAI Dimension not to be used as incusion/ excusion criterion Option 1: bound innovations/technoogies to be considered by one type of infection, such as MRSA or C. difficie Focused Logisticay manageabe within project timeine Depth rather than breadth MRSA and C. difficie are subject to mandatory reporting Good comparative data Broad scope of technoogies More opportunities for comparison across trusts May be difficut to differentiate technoogies aimed at one microorganism (e.g. hand hygiene appies to a) Narrow scope of technoogies May not be a priority and therefore ow investment in some trusts Large time impications for participating trusts Innovations/technoogies are not mutuay excusive to infections for exampe, hand hygiene and environmenta hygiene prevent MRSA and norovirus Option 2: consider innovations/technoogies for a mandatory reported HCAI microorganisms in that time frame (MRSA and C. difficie) Broader scope of technoogies Large time impications for participating trusts Unmanageabe within project timeine Option 3: consider innovations/technoogies for wider seection of HCAI microorganisms (MRSA and C. difficie and norovirus, and VRE, and Acinetobacter, etc.) Queen s Printer and Controer of HMSO 2014. 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. 153

APPENDIX 1 Dimension and options Identified strengths Identified risks Seection High impact interventions (HII) Option 1: bound technoogies to be considered by one HII aimed at prevention of SSI or CAUTIs, etc. Look at key high-risk cinica procedures or care processes Good comparative data Mandatory ony for orthopaedic SSIs but reported as good practice for other SSIs Narrow scope of technoogies Dimension not to be used as incusion/ excusion criterion These technoogies may not be found across the trusts making comparisons difficut and increasing the degrees of freedom Narrow scope of technoogies excuding wider stakehoder groups May feature in second step of samping for highy innovative technoogy Option 2: consider technoogies for a HIIs aimed at prevention of SSI and CAUTIs and VAP, etc. Broader scope of technoogies Time intensive for participating trusts Feasibiity within project timeine IPC priority area Option 1 seected Option 1: bound innovations/technoogies to be considered by one particuar IPC area incuding hand hygiene, diagnostics, environmenta hygiene/ceaning/ disinfection, antibiotic prescribing, catheter-reated care, training and education, medica devices/ equipment hygiene, information technoogy surveiance systems, patient hygiene Option 2: Consider a reevant IPC priority areas Focused Logisticay manageabe within project timeine Good comparative data Mutifaceted approaches resuting in a broad sampe of technoogies Compare different approaches to an IPC probem with the option of engaging many stakehoders Broader scope of technoogies May not be a consistent focus across trusts Technoogy may address more than one area Feasibiity within project timeine Rationae for choice of IPC area Feasibiity within project timeine IPC priority area: environmenta hygiene Strengths and rationae: Environmenta hygiene is a cross-cutting intervention for various HCAIs There has been particuar attention to this area in reguation deep cean programme, CQC There is a proiferation of products in this area Diverse stakehoders in trusts are targeted with marketing materia from companies Diverse stakehoders and teams are invoved in environmenta hygiene Interventions range from basic ceaning products to new to NHS /cutting-edge products Interventions range from inexpensive to prohibitivey expensive (i.e. from posters to hydrogen peroxide robots) From our recent study of innovation adoption, environmenta hygiene technoogies represented 50% of seection decisions 154 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Dimension and options Identified strengths Identified risks Seection Evidence base very broad from suppier marketing materia to academic pubished artices (e.g. ATP) Two out of the seven RRP1 products focus on this area; with six more currenty RRP2 products Showcase reports are avaiabe for the RRP1 products (ATP and hydrogen peroxide) Many trusts have invested significanty in environmenta hygiene. Figure from one trust in our previous study reported 300,000/ year to deep cean, i.e. 28/m 2 Has different reevance for PFI and for non-pfi buidings (negotiation, cost impications) Hence, wi enabe indepth exporation of mutipe dynamics on making sense of evidence within teams, the organisations and at the institutiona eve Mitigating risks: Environmenta hygiene represents an IPC priority area consistent across trusts We can incorporate an additiona stage 2 samping: focus on perceived radicay innovative or cuttingedge products within each of the trusts or a sampe of trusts once we have this as the baseine or comparator for the nine trusts. This wi highight differences in approaches to decision making and use of evidence. Potentia to aso incude stakehoder groups that were excuded in environmenta hygiene Aso expore rejections Option not seected Number of innovations/ technoogies For further consideration Queen s Printer and Controer of HMSO 2014. 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. 155

APPENDIX 1 Dimension and options Identified strengths Identified risks Seection Number of innovations/technoogies Option 1: one innovation/ technoogy per trust Option 2: a reevant innovations/technoogies generated by appying the seected dimensions and options Option 3: one common innovation/technoogy across the trusts Focused Manageabe Broader scope of technoogies Focused Enabes comparison Structured Opportunities for comparison imited Feasibiity within project timeine Breadth instead of depth Seected innovation/ technoogy may not be of simiar priority across trusts For further consideration Fina decision to be made once we have the innovations/technoogies according to dimension D Potentia to custer by common innovation/ technoogy may be greater with dimension D First, expore a environmenta hygiene innovations/technoogies considered by each trust within a defined time period Second, seect from these the foowing cases: (a) An innovation/ technoogy that has been seected but not impemented yet (b) An innovation/ technoogy that has been seected and successfuy impemented An innovation/technoogy that has been rejected Option 4: a common innovations/technoogies across the trusts Focused Enabes comparison Feasibiity within project timeine if number of common innovations/ technoogies is high CAUTIs, catheter-associated urinary tract infections; SSI, surgica site infection; VAP, ventiator-associated pneumonia; VRE, vancomycin-resistant enterococci. 156 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Appendix 2 Participant information sheet and consent form Queen s Printer and Controer of HMSO 2014. 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. 157

APPENDIX 2 158 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Queen s Printer and Controer of HMSO 2014. 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. 159

APPENDIX 2 160 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Queen s Printer and Controer of HMSO 2014. 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. 161

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Appendix 3 Study protoco SDO Protoco project ref: 09/1002/38 Version: 2 Date: 19 September 2011 Making sense of evidence in management decisions the roe of research-based knowedge on innovation adoption and impementation in heathcare Chief investigator Professor Aison Homes Sponsor Imperia Coege London Funder NIHR/SDO NIHR Portfoio number SDO 09/1002/38 ISRCTN registration (if appicabe) n/a Making sense of evidence in management decisions the roe of research-based knowedge on innovation adoption and impementation in heathcare 1. Aims/Objectives: The study aims to investigate how heathcare managers draw upon and make sense of different types and sources of evidence when they make decisions about innovations. We incude genera managers and hybrid managers (cinicians in a manageria roe). Specia attention is paced on the roe of scientificay produced knowedge and its use by these managers during the decision making process under conditions of innovation uncertainty. The study design incorporates mutipe eves of anaysis as foows: (a) expores the infuences of wider macro eve contextua dynamics on managers decision making, (b) expores decision making processes at the meso organisationa eve, (c) anayses at a micro eve the processes by which heathcare managers construct meaning of avaiabe evidence and how they might use such evidence when deciding on the adoption or rejection of innovations. Our key research questions are: How do managers make sense of evidence? What roe does evidence pay in management decision-making when adopting and impementing innovations in heathcare? How do wider contextua conditions and intra-organisationa capacity infuence research use and appication by heathcare managers? Queen s Printer and Controer of HMSO 2014. 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. 163

APPENDIX 3 2. Background: Heath service deivery and organisation as we as cinica practice can be improved by appying research findings reating to good practice. Whie there are many evidence-based heathcare innovations avaiabe, new knowedge disseminates sowy, if at a. As a resut, heath research findings are not aways transated appropriatey into heathcare practice. This reaity aso raises the pressing question of how to spread best practices and impement promising innovations within heathcare and specificay in the NHS. Our empirica study is theoreticay based and grounded in the practica experience of heathcare managers deaing with innovation processes. The study focuses primariy on the meso organisationa eve and argey draws on the diffusion of innovations iterature. One of the centra questions in this body of iterature that aigns with the scope of the proposed project is as foows: Why do innovations not readiy spread, even if backed by strong evidence? There is a growing body of evidence, drawing on exampes from heathcare settings, which argues that the adoption of heath technoogies and practices supported by sound research evidence is a far more dynamic and compex process than previousy suggested. The cassic innovation diffusion mode of change has infuenced much heathcare poicy and suggests that the adoption of innovative ideas, practices, or artefacts is conditioned by the interaction among the attributes of the innovation, the characteristics of the adopter and the environment (Rogers, 1995). This eary innovation diffusion work has been criticised however for adopting a simpistic rationa view of change, ignoring the compexities of the change process and aso focusing on individuas rather than organisations. Later work by Rogers (2003) party addressed the criticism by having expicity considered the adoption process within organisations. Recent studies have departed from the inear mode of innovation diffusion (Rogers, 1995) to offer conceptua notions that are more dynamic and interactive (Wiiams & Gibson, 1990; Van de Ven, et a, 1999). Buiding on the atter mode it is suggested that innovation adoption is a process which is highy dependent on the interactions between the innovation, oca actors and contextua factors (Ferie et a., 2000; Timmons, 2001; Dopson et a., 2002; Fitzgerad et a., 2002; Denis et a., 2002, Atun, Kyratsis et a. 2007). In addition, the nature or definition of evidence reated to particuar innovative technoogies or practices is often ambiguous and contested (Greenhagh et a, 2004; Fitzgerad & Dopson, 2005). Managers make decisions reying on experience, persona expertise, judgement, inference, advice, and do not passivey receive new knowedge even if presented as evidence which is scientificay produced and vaidated. Research-based knowedge has to be constanty interpreted and reframed aong with the oca context and cinica or manageria priorities, a process that often invoves power strugges among various professiona groups (Ferie et a. 2001). Different professiona and manageria groups may interpret evidence differenty, or they may prioritise dissimiar types of evidence party as a resut of their disparate professiona roe, training and professionaisation processes. We empoy a sensemaking perspective to gain insight to this inter and intra professiona eve and how this pays out in the context of decision making and impementation (Weick, 1995). This ens pays particuar attention to the socia construction and co-production of evidence through the interaction of a range of diverse professiona and manageria groups. We wi contribute to this body of iterature which has been usefu in expaining organisationa response to critica events in the heath care setting (Weick et a., 2005; Weick & Sutciffe, 2003). Our work addresses a significant gap in evidence-based heathcare impementation iterature. We respond to the ca for more sustained interpretive work, which expores the roe and motives of actors and the infuence of the organisationa context and the socia construction of evidence (Ferie & Dopson, 2005). Overa, we aim to address issues that permeate many stages of the research innovation pathway and more specificay wi investigate processes that reate to the stages of evauation, adoption and diffusion. By contributing to the debate on the aforementioned areas our study wi add to the current NHS poicy and practice body of knowedge as articuated in the NIHR/SDO Research Brief which this proposa responds to. Our work aso compements recent and ongoing research commissioned by NIHR research programmes; in particuar, it fits we the NIHR/SDO 2008 ca for proposas that aso focused on issues of knowedge utiisation in heathcare management. We compement and add to this work by ooking at different types of decisions, in different heathcare settings. 164 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 3. Need: This research is important from practice, poicy and theoretica perspectives. Beow we outine how this research: (a) addresses a significant heath need, (b) responds to ca for research supported by sustained intent, (c) has potentia to generate new knowedge. (a) Heath need Infection contro is one of the biggest chaenges facing the NHS today. In Engand 8.19% of a patients within the NHS acquire an infection (Smyth et a, 2008). The reporting of MRSA bood stream infection and C. difficie are mandatory and there are nationa and oca targets for reduction. New technoogies and interventions have the potentia to make a rea difference in heping reduce eves of Heath Care Associated Infections (HCAIs) by competing good cinica practice. However, their adoption and impementation too often proves chaenging and sow. Budgets, competing priorities, and monitoring procedures a pay a part in the decision making process when organisations seect nove interventions. In addition, professionas and managers may have differing views of what is the optimum intervention given access to evidence, as we as perceptions of this evidence by sef and others. To provide sustainabe reductions in HCAIs we need to know what has worked, under what conditions, and why. In addition, we need to earn from those settings where an intervention has not worked. (b) Expressed need for the research supported by sustained interest and intent Reevant NHS poicy reports (DH, 2003; DH, 2008) and egisation (Heath & Socia Care Act, 2008) have highighted that countermeasures of known effectiveness have not been universay impemented. In addition, the NHS has commissioned arge projects to identify new technoogies and products which work best in the fight against HCAIs. One such exampe is the Department of Heath Showcase Hospitas Programme. We buid on this work by understanding how and why technoogies are adopted and disseminated across the NHS. This is where our proposed work woud make a significant contribution to the NHS and to patient benefit. Our proposed research is supported by sustained intend aso due to the strong poitica drivers surrounding the contro of HCAIs both nationay and internationay. Pubic and Patient interest in this issue wi continue demand for transparency of investments and resutant benefit to patients and the NHS. (c) Capacity to generate new knowedge The theoretica basis of the research draws on three main streams from the management and organisationa behaviour iterature, namey, diffusion of innovations, sensemaking in organisations and neo-institutiona theory in organisations. The potentia for earning and creating new knowedge from this in depth, muti-method study is substantia due to its theoretica grounding, incorporating micro and macro eve perspectives. We wi be abe to provide a hoistic understanding of the phenomenon under consideration 4. Methods: Setting & Design The study aims to buid theory inductivey from mutipe in-depth case studies (Eisenhardt, 1989; Yin, 2003). Nine acute NHS Trusts have been seected across three broad geographic regions in Engand. Our seected NHS Trusts are equay distributed in three regiona custers: (a) London, (b) Northern and Centra Engand, (c) Southern Engand. The nine research case studies wi be conducted concurrenty. The seection of cases invoved theoretica, rather than random samping (Yin, 1995). In our sampe of cases we incude exampes of research-engaged heathcare organisations such as Academic Heath Science Centres (AHSC), University/Teaching Hospitas and ordinary heathcare service providers such as District Genera Hospitas. To better deineate the impact of contextua factors in research use and appication by heathcare managers on the adoption and impementation of the same innovation we incude more than one showcase hospitas (as seected by the Department of Heath to evauate the in-use vaue of Heath care associated infection reated technoogies) for comparative reasons. Queen s Printer and Controer of HMSO 2014. 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. 165

APPENDIX 3 As we as individua case studies across the nine acute NHS Trusts, we wi conduct cross-case anaysis to identify patterns of convergence and divergence, which wi enabe us to generate new theoretica propositions as we as repicate and extend emerging ones (Figure 1). Data coection Contextua data coection Detaied tempates have been deveoped and appied to capture and summarise important contextua infuences for each of the trusts participating in the study. Primary data coection: participants recruitment and samping Primary data comprise semistructured research interviews and research fied notes. The study wi ast two years and data coection wi be ongitudina. Hence the research participants wi be invoved in the study for two years. Incusion criteria for respondents: Informants wi incude senior, midde and operationa managers, representatives from different professiona groups incuding medica doctors, infection contro speciaists, cinica microbioogists, nurses and aied heath professionas, patient representative groups, and administrative personne. Incusion criteria for events: Trust board meetings, infection contro team meetings, procurement action group meetings, trust based presentation events for new technoogies, interventions adopted in the ream of HCAIs currenty or since 2007 Excusion criteria for respondents: Individuas who are not directy or indirecty invoved in the decision making processes of the interventions under study. Excusion criteria for events: interventions adopted in the ream of HCAIs prior to 2007. Tota number of interviews wi vary according to the size of the Trust and type and span of the innovation (seected to be studied in phase 2). A sampe of 6 10 respondents per trust is panned, with foow up interviews and further snowbaing to address gaps in the emerging story. Hence, it is estimated that approximatey 90 100 respondents wi be interviewed overa. Year 1 Year 2 Theory + Initia Emperica study propositions Purposefu Case Studies Seection (Trusts) Data Coection Protoco Conduct 1 st Case study Conduct 2 nd Case study Conduct (...3 rd 4 th 5 th 6 th 7 th 8 th Case studies) Conduct 9 th Case study Individua case report Individua case report Individua case report (9 in tota) Cross-Case Anaysis Patterns of Divergence/ Convergence Study s Propositions Theory Modification Poicy impications Fina Cross-case Report FIGURE 1 Study design diagram. 166 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Semistructured interview schedues, incuding short questionnaires with a more structured format, have been deveoped and appied for the two phases of primary data coection. A data coection toos are quaitative in nature. The interview accounts are being audio recorded once consent is given by participants. The direct invovement of participants to the study primariy invoves their participation in an initia and foow up interview with one of the researchers, each asting approximatey between 45 to 60 minutes. Once identified, potentia participants are approached ocay via the Director of Infection Prevention & Contro (DIPC) in the trust or another identified key oca coaborator. Either the Chief Investigator Prof Homes or Co-PI Dr Kyratsis write to potentia participants via e-mai inviting them to take part in the study and this e-mai is accompanied by a participant information sheet. The scheduing of interviews aows the coection of primary data with opportunity for further snowbaing (and subsequent incusion into the study sampe of additiona potentia participants) and foow-up interviews with the same respondents where appropriate. This process of participant recruitment is iustrated in detai in Figure 2. Data anaysis Soon after the competion of interviews the content of audio recordings is verbatim transcribed. Upon competion of transcription, four researchers thoroughy read through the fu transcribed text severa times to enabe understanding of the meaning of data in its entirety (Pope et a, 2000). The Quaitative Data Anaysis computer software package NVivo 9 (QSR Internationa) is used to systematicay code the coected data and assist anaysis. In ine with recommendations by quaitative methodoogists we wi use mutipe coders to enhance interrater reiabiity of the quaitative study. (Soafer, 1999 Pope et a, 2000). Our quaitative anaysis foows an integrated approach (Bradey et a, 2007). We wi empoy an inductive approach to open up new ines of enquiry and then agree a framework for data anaysis based on these findings together with our theoretica framework (deineating factors which infuence the adoption process of compex heath innovations) and our previous work in 12 NHS Trusts ooking at adoption processes for new technoogies. Hence, we wi empoy both an inductive and ground up deveopment of codes as we as a deductive organising framework as a start up ist (Bradey et a, 2007: 1762). DIPC Key coaborator in trust Key contacts in each directorate E-mai invitation to prospective participants Foow up e-mai Check for representation of key stakehoders E-mai Interviews schedued Interviews conducted Suggestions through snowbaing Foow-up interviews schedued E-mai invitation FIGURE 2 Participant recruitment process. Queen s Printer and Controer of HMSO 2014. 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. 167

APPENDIX 3 Based on the typoogy suggested by Bradey et a (2007: 1763), the code types empoyed in the study are the foowing: (a) Conceptua codes and sub-codes: to identify key concept domains and essentia dimensions of these domains; (b) Reationship codes: to identify inks between other concepts coded with conceptua codes; (c) Participant perspective codes: to identify whether the participant was positive, negative, or indifferent in attitude about a particuar experience or part of an experience; (d) Participant characteristic codes: based on professiona/occupationa group, hierarchica position, functiona roe; (e) Setting codes: incuding rura urban setting, hospita site, particuar geographic region, type of trust, Strategic Heath Authority The deveopment of the code structure wi be finaised when the point of theoretica saturation wi be reached in each of the empirica cases (Gaser and Strauss 1967; Patton 2002). Anaysis within cases wi be foowed by the cross case anaysis across emergent themes but aso against the more forma organisationa type used in our purposefu samping of sites. Individua case study reports with common formats wi be produced as an intermediate research output for each of the nine trusts studied. Summary tabes wi be used to simutaneousy compare severa categories and dimensions of the content and context of change impied by the adoption and impementation of the innovations across the 9 trusts. 5. Pan of Investigation: Individua case studies are being conducted in parae across a nine participating NHS Trusts. Data coection started in February 2011 and is panned to be competed by end of March 2012. Deveopment of contextua tempate for each participating trust Phase 1: deveopment and appication of an interview topic guide targeting senior and midde managers in the wider trust and within the infection prevention & contro team Phase 2: identification of specific exampes of innovations in the fied of environmenta hygiene. Deveopment and appication of an interview topic guide (different from phase 1) targeting members of the infection prevention & contro team to investigate the decision making and impementation processes of the seected innovation exampes. Within & cross-case anaysis (started in March 2011 and panned to be competed by end August 2012) Report writing Ongoing dissemination of interim & fina research findings 6. Project Management: Our study is being overseen by a project Steering Group which brings together broad expertise from theoretica and practica perspectives. (a) Darren Neson cinica, manageria and operationa issues on infection prevention and contro and expertise in change management and service re-design; aso bringing in the perspective of managing heathcare service deivery in the NHS. In addition his professiona nursing background provides speciaist insight to the infection prevention context; (b) Professor Martin McKee transating evidence to poicy; aso bringing in extensive experience on European and UK pubic heath interventions; (c) Roy Oiver and Tim Sims patient advisors to critique and invite comment from existing patient groups on a processes of the research (from study inception to dissemination of findings); (d) Professor Christopher Chapman organisationa performance indicators; his expertise ies in the nature and roe of performance evauation and contro systems. He expores the construction of organisationa 168 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 and inter-organisationa performance indicators from both a quaitative and quantitative perspective; these are reevant methods of inquiry for our research context. For NHS trusts, reporting of cinica and non-cinica performance indicators are important due to mandatory infection prevention and contro, quaity of services, as we as financia viabiity and capacity at organisationa eve. (e) Professor Sue Dopson knowedge mobiisation in the pubic sector, specificay in heathcare. Professor Dopson provides additiona input through dedicated expert advice to the co-pi Dr Yiannis Kyratsis and futime senior researcher Dr Raheeah Ahmad. Ad hoc speciaist guidance is compimented by a forma arrangement of quartery meetings between Professor Dopson and the project researchers. (f) Chris Gush formery from the Heath Care Associated Infections Technoogy Innovation programme of DH. He provides insight of centra DH innovation and evidence dissemination structures. 7. Service users/pubic invovement: Active pubic invovement of two patient advisors through Steering Group membership informs the research team to identify and ask the right questions in the right way, making sure that research is reevant to patients and peope using services and the pubic at arge. Activities of patient advisors incude informing the study design, study management, contribution to dissemination methods as we as providing diverse perspectives from two different ocaities and trust types (one an academic heath sciences centre, the other a district genera hospita). We aso have one service provider on the steering group (Darren Neson) bringing in the perspective of managing heath care service deivery within the context of a busy NHS trust. Sponsoring Institution Research Oversight Imperia Coege London Project Management Prof A. Homes Dr Y. Kyratsis Trust 2 Trust 1 Dr Y. Kyratsis Dr R. Ahmad A. Sewe K. Hatzaras Trust 9 Trust 8 Expert Advisory Pane Prof S. Dopson Trust 3 Project Fied Researchers Trust 7 CIPM Administrative Support Trust 4 Trust 5 Trust 6 Project Steering Group Prof S. Dopson Prof C. Chapman Prof M. McKee R. Oiver T. Sims D. Neson C. Gush FIGURE 3 Project Governance Structure. Queen s Printer and Controer of HMSO 2014. 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. 169

APPENDIX 3 8. References: Atun RA, Kyratsis I, Jeic G, Rados-Maicbegovic D, Guro-Urganci I. Diffusion of compex heath innovations impementation of primary heath care reforms in Bosnia and Herzegovina. Heath Poicy Pan 2007;22:28 39. Department of Heath. Winning Ways Working together to reduce Heathcare Associated Infection in Engand. Report from the Chief Medica Officer, December 2003. Department of Heath. Cean, safe care Reducing infections and saving ives. 2008. Dopson S, Locock L, Gabbay J, Ferie E, Fitzgerad L. Evidence based heath care and the impementation gap. In Dopson S, Fitzgerad L, editors. Knowedge to action? Evidence-based heath care in context. Oxford University Press. Ferie E, Gabbay J, Fitzgerad L, Locock L, Dopson S. Evidence-based medicine and organisationa change: an overview of some recent quaitative research. In Ashburner L, editor. Organisationa Behaviour and Organisationa Studies in Heath Care: Refections on the future. Basingstoke: Pagrove, 2001. Ferie E, Fitzgerad L, Wood M, Hawkins C. The Nonspread of Innovations: The mediating roe of professionas, Acad Manag J 2005;48(1):117 34. Fitzgerad L, Ferie E, Wood M, Hawkins C. Interocking interactions, the diffusion of innovations in heath care. Hum Reations 2002;55(12):1429 49 Fitzgerad L, Dopson S. Knowedge, Credibe Evidence, and Utiization. In Dopson S, Fitzgerad L, editors. Knowedge to action? Evidence-based heath care in context. Oxford University Press, 2005. Greenhagh T, Robert G, Macfarane F, Bate P, Kyriakidou O. Diffusion of Innovations in service organizations: Systematic review and recommendations. Mibank Q 2004;82:4(581 629). Isabea LA. Evoving interpretations as change unfods: How managers construe key organizationa events. Acad Manag J 1990;33(1). Rogers EM. Diffusion of innovations, 4th edn. New York: The Free Press, 1995. Rogers EM. Diffusion of innovations, 5th edn. New York: The Free Press, 2003. Smyth ETM, McIvenny G, Enstone JE, Emmerson AM, Humphreys H, Fitzpatrick F, et a. Four Country Heathcare Associated Infection Prevaence Survey 2006: overview of the resuts. J Hosp Infect 2008;69:230 48. Timmons S. How does professiona cuture infuence the success or faiure of IT impementation in heath services? In Ashburner L, editor. Organisationa Behaviour and Organisationa Studies in Heath Care: Refections on the future. Basingstoke: Pagrave, 2001. Van de Ven A, Poey ED, Garud R, Venkataraman S. The Innovation Journey. Oxford University Press, 1999. Weick KE. Sensemaking in Organizations. Thousand Oaks: Sage, 1995. Weick KE, Sutciffe KM, Obstfed D. Organizing and the Process of Sensemaking. Organ Sci 2005; 16(4):409 21. Weick KE, Sutciffe KM. Hospitas as Cutures of Entrapment: A Re-anaysis of the Bristo Infirmary. Caif Manag Rev 2003;45(2):73 84. Wiiams F, Gibson D. Technoogy Transfer: A Communication Perspective. Bevery His, CA: Sage, 1990. Yin RK. Case study research: Design and methods, 3rd Edition. Sage, 2003. This protoco refers to independent research commissioned by the Nationa Institute for Heath Research (NIHR). Any views and opinions expressed therein are those of the authors and do not necessariy refect those of the NHS, the NIHR, the SDO programme or the Department of Heath. 170 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Appendix 4 Interview schedue phase 1 Queen s Printer and Controer of HMSO 2014. 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. 171

APPENDIX 4 172 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Queen s Printer and Controer of HMSO 2014. 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. 173

APPENDIX 4 174 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Queen s Printer and Controer of HMSO 2014. 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. 175

APPENDIX 4 176 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Queen s Printer and Controer of HMSO 2014. 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. 177

APPENDIX 4 178 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Queen s Printer and Controer of HMSO 2014. 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. 179

APPENDIX 4 180 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Appendix 5 Interview schedue phase 2 Queen s Printer and Controer of HMSO 2014. 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. 181

APPENDIX 5 182 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Queen s Printer and Controer of HMSO 2014. 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. 183

APPENDIX 5 184 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Queen s Printer and Controer of HMSO 2014. 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. 185

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Appendix 6 Brief technoogy product descriptions Design Bugs Out commode The DBO commode has been co-deveoped by the Department of Heath, Design Counci, Angia Ruskin University, industria partners and participating trusts. The aim was to redesign the portabe patient toiet seat traditionay used in the NHS and deiver a speciay designed and constructed product that prevents growth of pathogens on its surfaces and saves space in wards. It became avaiabe to participating trusts for tria in mid-2009. Commode use is a ong-estabished practice in the NHS. Cine universa sanitising wipes (non-sporicida) The cine green, boxed wipe is designed for universa ceaning. It contains 2% chorhexidine and 70% ethano-based acoho. It is currenty icensed for use on medica equipment surfaces. Its use is based on a protoco presented on a diagrammatic card, detaiing the wipe s use and appication on surfaces. Bioque VHP RBDS and Steris BioGenie VHP decontamination system The Bioque VHP RBDS invoves use of a portabe vapour generator, an instrumentation modue used to programme the generator and an aeration unit. The generator and aeration unit are paced in a fuy seaed (incuding doors, windows, air conditioning outets, etc.) bay or ward. Vapour of 5% concentration of hydrogen peroxide, a highy oxidising compound that eiminates air-borne and surface pathogens, is then reeased within the seaed area. Items need to be positioned in the area in such a way to ensure good vapour exposure. The service can be used as and when required or form part of a hospita site ceaning regime. A simiar device (but not a simiar service) is aso marketed by Steris BioGenie. Disposabe sterie surgica site gowns Sterie gowns are a key part of surgica cothing used to prevent contamination or cross-infection between patients and care staff in operating theatres. They are made with specia materias that ensure microorganisms and any organic residues do not penetrate them. They must be used according to the manufacturer s instructions to ensure cross-infection does not occur. 3M Cean-Trace NG and Hygiena SystemSURE II ATP hygiene monitoring system The Cean-Trace NG uminometer manufactured and suppied by 3M invoves the use of a hand-hed test monitor and a disposabe samping rod. The disposabe rod is used to swab a surface and is then inserted into the hand-hed monitor for testing. Resuts are shown on the screen and are transmitted to a dedicated company server for access by users and ater examination. The uminometer measures adenosine phosphatase, a compound found in bacteria, yeast and moud, to assess the surface eve of environmenta ceaniness. In addition to microorganisms, the device detects the presence of any organic residues eft after ineffective ceaning or decontamination. Queen s Printer and Controer of HMSO 2014. 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. 187

APPENDIX 6 Another system whose operation is based on exacty the same principes, incuding the use of data anaysis software offering remote monitoring of resuts, is the Hygiena SystemSURE II ATP hygiene monitoring system. ASP GLOSAIR 400 aerosoised hydrogen peroxide system This is an area decontamination system based on hydrogen peroxide, formery known as Sterinis SR2 and presenty suppied by ASP, a Johnson & Johnson company. Its dimensions are 1080 mm (height) 512 mm (width) 620 mm (depth) and it has a net weight of 48.8 kg. It creates and reeases a gaseous biocide mix, described as dry mist hydrogen peroxide or ahp, of 5 6% hydrogen peroxide concentration and siver ions, from a water-based soution. According to Fu et a., 109 this soution bears the name STERUSIL (Goster Santé Europe, Tououse, France) and contains a mix of hydrogen peroxide ( 5%), siver ions (< 50 ppm) and orthophosphoric acid (< 50 ppm). The product is recommended for use in patient wards, emergency areas and infectious disease units ranging from 10 m 3 to 200 m 3. It is thought by some to be capabe of accessing area sections (i.e. ceiing, sma openings, etc.) not easiy reached by norma ceaning. UV ight inspection torch The UV 35-W torch mode marketed by UV Light Technoogy Ltd is a very high-intensity hand-hed torch designed for area irradiation. It weighs 0.75 kg and is powered by means of a rechargeabe battery. It produces fu UV ight output in 15 seconds after power-on, its battery can withstand approximatey 300 charging cyces and its bub has an operating time span of approximatey 2000 hours. It emits UVA ight radiation with the waveength range of 315 405 nm. It is, thus, suitabe for fuorescent inspection appications, but not for disinfection, as it is not capabe of emitting UVC radiation. Cine sporicida (red) wipes The cine sporicida wipe product is said to be highy efficacious, eiminating C. difficie spores within 1 minute, at a 6-og reduction scae or greater. It has been proven to eradicate a microorganisms, incuding spores. Its active ingredient is peracetic acid, which is understood to be a safe aternative to chorine, and is activated just by adding water. It is promoted as a simpe and easy-to-use wipe product, which requires no diution, increases compiance and reduces errors, and a wipe that is environmentay friendy and eaves no persistent toxic or carcinogenic residuas, such as any fumes posing risks to staff or patients. It has been tested to a number of European standards and is recommended for use with body fuid spis. Medixair UV air steriisation unit The Medixair UV air steriiser and Medixair Meos compact UV air steriiser units have been marketed by their suppier, Pathogen Soutions Ltd, as devices that steriise air in the environment. Air steriisation is conducted by means of air intake at the ower end of the unit, appication of UVC radiation at a waveength of 253.4 nm on that air stream in the unit s vertica cavity and reease of air from the top of the unit. The devices operate at a standard 110 W power rating, provide coverage of 75 m 3 and 60 m 3 and are of 90 cm and 45 cm in height (Medixair and Medixair Meos, respectivey). The suppier featured as a winner in the 2009 Smart Soutions for HCAI awards. The products were issued with a HPA RRP recommendation 2 in December 2008. 188 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 DIFFICIL-S disinfectant soution DIFFICIL-S is a disinfectant soution product advertised as a supremey powerfu broad-spectrum disinfectant ceaner deveoped to target and ki pathogens within 5 minutes, achieving a 5-og reduction of 99.999% (Cinimax Ltd, http://www.cinimax.net/diffici-s-cinica.php, accessed 28 January 2014). It is produced by fiing a mixing container with water to a specified ine marked on the container. Sachet A is then emptied into the container, foowed by sachet B. A pastic rod (suppied) is used to stir the contents for 10 seconds. The mix is then ready to be dispensed to bottes by means of a pump and hose. It can be used with a coth to cean bedside and other surfaces, or diuted at a ratio of two pumpings per itre to cean foor space. It retains its efficacy for 14 days; abes are suppied for staff to note the mixing date and attach to containers. Any iquid eft after 14 days can be disposed of at the sink. The container and bottes need to be repaced after 6 months. Virusove+ Virusove+ is advertised by its suppiers, Amity Internationa (http://www.amityinternationa.com/product/ virusove/), as an environmenta disinfectant ceaning product whose chemica composition incudes advanced dodecyamine-based structures, sovents and a fuy non-toxic, biodegradabe detergent. It does not contain any hazardous adehydes or chorine-generating components. It eiminates viruses, bacteria, fungi, yeasts and mouds, incuding MRSA bacteraemia, C. difficie, hepatitis B, human immunodeficiency virus agents, E. coi extended-spectrum beta-actamase and NDM1 (New Dehi metao-beta-actamase 1) and non-enveoped-type viruses, such as poio, adenovirus and norovirus, by disrupting the microorganism ribonuceic acid and preventing resistance. It is odouress, coouress and safe to use on any surface. Chor-Cean Chor-Cean is a ceaning product combining surface ceaning and disinfection in one operation. Most detergents, when used in tandem with chorine, deactivate some of the chorine s disinfecting properties. Therefore, a three-step process is required for ceaning and disinfection. Surfaces woud first be ceaned with a detergent. They woud then be washed with water to remove any detergent residues, before a chorine-based soution is appied. Chor-Cean tabets utiise sodium dichoroisocyanurate to produce a diution of 1000 ppm chorine, as per the recommendations of the Department of Heath and the HPA of using a hypochorite ceaning agent of appropriate ppm concentration (2008). 110 JLA OTEX aundry system The JLA OTEX aundry system is a machine washing system suitabe for ceaning and disinfecting hote-type (sheets, towes, etc.) and domestic equipment (mops, coths). Its active ingredient is ozone. The system first takes in and converts air to 90% pure oxygen gas. An eectrica charge is then appied to the gas, spitting oxygen moecues into atoms. These then recombine to form ozone moecues. A patented interfusor chamber pump system coects the ozone and deivers it without interruption into the wash. Ozone disinfects and destroys bacteria, moud, viruses and yeast by disentanging and fuy opening up inen fibres. Enhanced ceaning, quicker drying and fresh fuy disinfected aundry is thus deivered. The system comprises a speciay buit washing machine and an ozone safety and vaidation monitor that stops operation in cases in which the ozone concentration in the air is measured to be higher than the safety imit (ower than the Heath and Safety Executive imit of 0.2 ppm). JLA suggests those parts needing reguar maintenance are the oxygen concentrator intake fiters and the ozone generator. These need to be checked on a daiy basis and ceaned when necessary. Queen s Printer and Controer of HMSO 2014. 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. 189

APPENDIX 6 UV ight inspection cabinet The UV ight inspection cabinet marketed by DaRo UV Systems Ltd has aso been triaed at T7. This is a meta cabinet of approximatey 15 cm 12 cm 8 cm. An encosed ight source shines UVA ight on objects positioned inside the cabinet. Use of a specia hand rub ge iuminates hands and heps demonstrate the efficacy of correct, or otherwise, hand washing, scrubbing and disinfecting techniques. Cine and PDI Sani-Coth CHG 2% acohoic chorhexidine guconate wipes The cine and PDI Sani-Coth CHG 2% acohoic chorhexidine guconate wipes are designed for universa ceaning. They are presenty icensed for use on medica devices ony. Each wipe contains 2% chorhexidine and 70% ethano-based acoho. 190 NIHR Journas Library www.journasibrary.nihr.ac.uk

DOI: 10.3310/hsdr02060 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 6 Appendix 7 Technoogy products unit cost price ist The tabe beow ists the technoogy products according to their ist unit cost price in descending order, from the most to the east expensive. Prices are extracted from the NHS suppy chain porta. Certain prices incude costs of add-ons and accessories required for use. A prices incude vaue added tax at 20%. These represent the initia capita outay or upfront costs that trusts woud incur when adopting these technoogy products. They do not incude any maintenance or ongoing costs. Product Cost ( ) ASP GLOSAIR 400 ahp system 17,955.00 Steris BioGenie VHP decontamination system a 12,500.00 JLA OTEX aundry system a (JLA 40 high-spin machine with OTEX system fitted) b 8756.40 3M Cean-Trace NG uminometer a (with board and swab rods) 3027.45 Bioque VHP RBDS a (one hospita room) 2100.00 Medixair UV air steriisation unit a 1800.00 UV ight inspection torch a 1380.00 Hygiena SystemSURE II ATP hygiene monitoring system (with swab rods) 1078.80 Medixair Meos UV air steriisation unit a 600.00 DBO commode 352.58 UV ight inspection cabinet a (with ge and accessories) 254.40 DIFFICIL-S disinfectant soution (with mixing vesse and four bottes) 114.25 Virusove+ 102.62 Disposabe sterie surgica site gowns (box of 30) 33.20 Cine universa sanitising wipes (non-sporicida, six 200-wipe packs) 22.19 Cine sporicida (red) wipes (pack of 25) 7.65 Chor-Cean 7.50 PDI Sani-Coth CHG 2% acohoic chorhexidine guconate wipes (pack of 200) 2.07 a Prices have been obtained directy from the manufacturer. b JLA aso offers a Tota Care Package at 570/month for a singe washer fitted with the OTEX system. The minimum contract term of this package for a NHS site is 60 months. Queen s Printer and Controer of HMSO 2014. 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. 191

EME HS&DR HTA PGfAR PHR Part of the NIHR Journas Library www.journasibrary.nihr.ac.uk This report presents independent research funded by the Nationa Institute for Heath Research (NIHR). The views expressed are those of the author(s) and not necessariy those of the NHS, the NIHR or the Department of Heath Pubished by the NIHR Journas Library