Background

Creating and sustaining an institutional climate conducive to patient and health worker safety is a critical element of successful multimodal hand hygiene improvement strategies aimed at achieving best practices. Repeated WHO global surveys indicate that the institutional safety climate consistently ranks the lowest among various interventions.

Methods

To develop an international expert consensus on research agenda priorities related to the role of institutional safety climate within the context of a multimodal hand hygiene improvement strategy, we conducted a structured consensus process involving a purposive sample of international experts. A preliminary list of research priorities was formulated following evidence mapping, and subsequently refined through a modified Delphi consensus process involving two rounds. In round 1, survey respondents were asked to rate the importance of each research priority. In round 2, experts reviewed round 1 ratings to reach a consensus (defined as ≥70% agreement) on the final prioritised items to be included in the research agenda. The research priorities were then reviewed and finalised by members of the WHO Technical Advisory Group on Hand Hygiene Research in Healthcare.

Results

Of the 57 invited participants, 50 completed Delphi round 1 (88%), and 48 completed round 2 (96%). Thirty-six research priority statements were included in round 1 across five thematic categories: (1) safety climate; (2) personal accountability for hand hygiene; (3) leadership; (4) patient participation and empowerment and (5) religion and traditions. In round 1, 75% of the items achieved consensus, with 9 statements carried forward to round 2, leading to a final set of 31 prioritised research statements.

Conclusion

This research agenda can be used by researchers, clinicians, policy-makers and funding bodies to address gaps in hand hygiene improvement within the context of an institutional safety climate, thereby enhancing patient and health worker safety globally.

Background

The way that data are presented can influence quality and safety initiatives. Time-series charts highlight changes but do not clarify whether data lie outside expected variation. Statistical process control (SPC) charts make this distinction and have been demonstrated to be effective in supporting hospital initiatives. To improve the uptake of the SPC methodology by hospitals in England, a training intervention was created. The current study evaluates the effectiveness of that training against the background of a wider national initiative to encourage the adoption of SPC charts.

Methods

A parallel cluster randomised trial was conducted with 16 English NHS hospitals. Half were randomised to the training intervention and half to the control. The primary analysis compares the difference in use of SPC charts within hospital board papers in a postrandomisation period (adjusting for baseline use). Trainees completed feedback forms with Likert scale and open-ended items.

Results

Fifteen hospitals participated across the study arms. SPC chart use increased in both intervention and control hospitals between the baseline and postrandomisation period (29 and 30 percentage points, respectively). There was no statistically significant difference between the intervention and control hospitals in use of SPC charts in the postrandomisation period (average absolute difference 9% (95% CI –34% to 52%). In the feedback forms, 93.9% (n=31/33) of trainees affirmed learning and 97.0% (n=32/33) had formed an intention to change their behaviour.

Conclusions

Control chart use increased in both intervention and control hospitals. This is consistent with a rising tide and/or contamination effect, such that the culture of control chart use is spreading across hospitals in England. Further research is needed to support hospitals implementing SPC training initiatives and to link SPC implementation to quality and safety outcomes. Such research could support future quality and safety initiatives nationally and internationally.

Trial registration number

NCT04977414.

The stepped-wedge cluster randomised trial is a popular design in implementation and health services research. All clusters, such as clinics or hospitals, start in the control state, and gradually switch over to treatment in a random order until all clusters have received the intervention. The design allows for the incorporation of an experiment into the gradual roll-out of an intervention across clusters. However, the traditional stepped-wedge layout may not be the best choice in many scenarios. In this article, we discuss modifications to the stepped-wedge design that maintain a staggered roll-out, but which may improve some key characteristics. We consider improving the timing of implementation periods, reducing the volume of data collection and allowing for the recruitment of clusters over the course of the trial.

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