By Kelly M. Pyrek
Members of industry are introducing new products and technologies that are designed to help fight healthcare-associated infections (HAIs), but not every hospital or health system can either adopt this innovation as quickly as desired or even reach a consensus about adoption, and barriers to implementation exist.
This issue was the topic of an in-depth report by British researchers Yiannis Kyratsis, Raheelah Ahmad and Alison Holmes, of the National Centre for Infection Prevention and Management at Imperial College London. The report was commissioned by the Department of Health and examines how 12 hospitals handled the adoption of new technologies to combat healthcare-associated infections (HAIs). These hospitals were recipients of the UK Department of Health Healthcare Associated Infection (HCAI) Technology Innovation Award for outstanding contributions to fighting infections in 2009, and split the award money to procure technologies that could help reduce HAIs. The award was given as part of the UK Department of Health's HCAI Technology Innovation Program which aims to speed up the development and adoption of new technologies that could help combat HAIs, particularly methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile.
Kyratsis, et al. (2010) note that while a number of technologies exist to address HAIs and programs are in place to facilitate innovation adoption, overall, the UK's NHS has been a slow adopter of innovative technology, and this award provided a significant opportunity to continue to learn about the adoption of technologies in the area of infection prevention and control. The researchers examined three phases of technology adoption:
- Decision-making: focusing on aspects such as how the decision to spend the award
- Procurement: focusing on issues such as the ease and process of procurement
- Adoption: focusing on implementation issues and measures of success
The researchers did not evaluate the technology's impact on HAIs.
Across the 12 hospitals, a total of 38 selections were made of 34 different technologies, and these spanned the range of infection prevention and control priority areas, with technologies to address environmental hygiene being most commonly selected. In the UK, products receiving a Rapid Review Panel Recommendation 1 (RRP 1) rating is defined as a product for which "basic research and development, validation and recent in use evaluations have shown benefits that should be available to NHS bodies to include as appropriate in their cleaning, hygiene or infection control." Of the 38 technology selections, 15 selections of products with an RRP 1 at the time of the award, were made. RRP 1 products as of February 2009 included Bard BARDEX® I.C silver alloy catheter; 3M Clean-Trace ATP Hygiene Monitoring system; Bioquell Hydrogen Peroxide Vapor (HPV) Decontamination System; Enturia Ltd. ChloraPrep; ConvaTec Flexi-Seal® Faecal Management System (FMS); and the Zassi Bowel Management System®.
Kyratsis, et al. (2010) conducted more than 100 interviews in the 12 hospitals, talking to clinical and non-clinical managers, members of hospitals' executive boards, nurses, doctors, clinical biochemists, clinical microbiologists and staff from domestic services and facilities departments, and determined several key considerations for technology selection in the healthcare setting related to infection prevention and control.
The researchers found that innovativeness of the product and their newness to the marketplace was accepted differently across the 12 hospitals in the study; Kyratsis, et al. (2010) report that few hospitals adopted cutting-edge technologies. They found that hospitals considered both the short-term and long-term costs associated with technology selection, and that high operational costs were the main financial consideration. Hospitals used three strategies to maximize their funding opportunity: selecting high-cost technologies that would have been impossible without the award; procuring technologies with low on-costs for sustainable solutions; and selecting a number of different technologies to allow local trial within the facility to better inform future procurement decisions.
An important consideration for hospitals in their decision-making process was evidence of effectiveness of technologies. The main sources of evidence used were peer-reviewed literature, technologies in use in other hospitals, professional networks, supplier information, the UK's Rapid Review Panel rating of technologies, and the UK's HAI Technology Innovation Program initiatives. Many of the hospitals in the study viewed this funding opportunity to specifically develop methodologies to evaluate the technology interventions, and most intended to write up findings for wider dissemination. One hospital even appointed a research nurse to manage the implementation and evaluation process.
Kyratsis, et al. (2010) also discovered that the size of the hospital and the size of the core infection prevention and control team had a more significant impact on the process adopted by the hospital in making the technology selection decision rather than the technology type. For example, none of the larger hospitals (with sizeable infection prevention and control teams) consulted with outside staff to generate ideas for consideration. Conversely, smaller hospitals with small infection prevention and control teams relied more on the cooperation of ward staff for generation of ideas and technology implementation.
Most importantly, the researchers found that a pro-innovation culture was essential in the decision-making process. As Kyratsis, et al. (2010) explain, "Across the (hospitals) there was a range of (hospital-wide) programs to encourage innovation across disciplines. The extent to which infection prevention and control teams were engaged with these wider activities varied. While this pro-innovation culture was largely a positive influence, there were instances of disjointed efforts. Cross-departmental collaboration is essential, especially if innovations are to be rolled out (hospital-wide). For example in Hospital 10, the ICU team already had invested in a fecal management system, however the infection prevention and control team selected another similar system with essentially the same functionality as were unaware of this previous procurement. This gives rise to duplication of training, inconsistencies and issues of compatibility for staff and patients. Pro-innovation was consistent with a non-blaming open and honest culture. For example, in Hospitals 5 and 11 support staff were confidently able to monitor all staff for "bare below the elbows,? while in other (hospitals) nurses did not feel able to raise this issue with doctors."
Additionally, the researchers saw evidence that the same technologies had been defined and interpreted differently by dissimilar categories of adopters. As Kyratsis, et al. (2010) note, "The perceived benefits and weaknesses of the technologies reviewed by the hospitals, as well as the evidence supporting them and the sources and type of evidence sought varied across adopter categories. For instance, clinical microbiologists and infection control nurses looked at the same technologies differently and made dissimilar judgments about the value of specific technologies, or valued dissimilar sources and types of evidence. Professional training, experience and role, as well as personal interests of adopters all shaped technology selection decisions across the (hospitals) studied."
Throughout all decision-making, communication was the bedrock of the process, the researchers emphasize: "For example, a 'champion' for an individual technology emerged in the majority of cases and facilitated the implementation phase. Communication approach varied from 'top down' cascade of information to 'peer mediated,' and 'grassroots spread' of new technology information among users through word of mouth and trial and error learning. The latter approaches heightened feelings of ownership by users and led to swift and efficient technology implementation, particularly evident in the adoption of hygiene monitoring and ultraviolet light technologies by housekeepers in Hospital 11."
Kyratsis, et al. (2010) add that internal communication within the hospital was viewed as "an opportunity to raise the profile of infection prevention and control. Communicating effectively the rationale for technology selection, (including results of any evaluations) and the implementation strategy to key people, who are involved in or can influence implementation, facilitated staff engagement. The use of existing (hospital) forums for such communication efforts streamlined information flow across the (hospital). Informing patients and the public about adopting innovative technologies was deemed a useful tool for raising the profile of (hospitals) and facilitating patient involvement, but was lacking in the majority of cases." They continue, "For example, Hospital 7 did not invest in patient communication activities and in retrospect realized that patientstook the new technologies for granted and did not appreciate the extra effort and resources invested by the (hospital). In contrast, Hospital 11 invested significantly in patient communication when introducing the individual patient MRSA-decolonization packs. This resulted in high patient involvement and better informed patients, and as reported by staff, less patients blaming the hospital for catching MRSA."
No discussion about technology adoption is complete without a realistic examination of the factors that enable decision-making as well as the barriers to implementation. As Kyratsis, et al. (2010) explain, "Consistently the biggest barrier encountered during implementation was lack of staff capacity within infection prevention and control and also trust-wide in intended implementation wards/units Adopting and implementing innovative technologies was an additional task on top of routine operations which stretched the (hospital) innovation coordinator; the impact was higher on (hospitals) with small infection prevention and control teams."
The second significant barrier (absent any structural or cultural barriers to implementation) was insufficient attention to the "how-to" knowledge required to implement the technology. Kyratsis, et al. (2010) found that in hospitals where detailed implementation plans had been formulated and discussed with suppliers, managers and technology users, actual implementation went smoothly. The researchers also found that none of the hospitals reported staff resistance, and they attribute this to the consistency of the decision-making processes with organizational culture. As Kyratsis, et al. (2010) emphasize, "Optimum implementation occurred when relevant involvement of actors and consideration of implementation at the point of decision-making was made, coupled with well structured and managed implementation plans. Early engagement of frontline clinical staff and technology users in decision making led to technology modification and adaptation to fit the local context at implementation stage. Early engagement and regular steering of the process by a core group of managers, responsible for the service areas, facilitated the implementation process. Cross-departmental team working, champions and endorsement from senior management were evident to varying degrees across the (hospitals), but all helped implementation."
It was important to hospitals that the technology under consideration fit into their overall HAI prevention strategy, and this, according to the researchers, "allowed for sustainable investment in the particular technology." Hospitals also expected that the benefits of the technology would expand over time as the technology evolves, and mesh with other, future technology investments. Additionally, it was important to facilities that "pre-existing or co-adopted technologies facilitate implementation of new technologies by resolving issues of structural compatibility," according to the researchers.
Ahmad R, Kyratsis Y and Holmes A. When the user is not the chooser: stakeholder involvement in innovation adoption and implementation for addressing HCAIs. BMC Proceedings 2011, 5(Suppl 6):O36.
Kyratsis Y, Ahmad R and Holmes A. Understanding the Process of Innovation Adoption in 12 NHS trusts technology selection, procurement and implementation to help reduce HCAIs. Sept. 2010.
A Q&A with Yiannis Kyratsis
ICT spoke with Yiannis Kyratsis, currently a research fellow at the Centre for Infection Prevention and Management at Imperial College London.
Q: You mention that the National Health Service (NHS) has been a slow adopter of innovative technology; do you think this might be representative of most healthcare organizations, no matter the country or the size or patient mix? Do you think that historically, the healthcare industry in general might be slow to partake in available technologies? Is it due to cost considerations, clinical evidence that might sway decision-making, or something else?
A: The factors are all relevant to certain degree. Our work at The National Centre for Infection Prevention and Management looks at issues particularly relevant to nationally funded health services. Here, there are particular challenges due to cost and processes of decision making. Organizations which are publicly funded operate in a highly politicized and regulated environment, and have a highly professionalized workforce encounter more barriers than private industry. The problem of slow adoption of innovative technology is not a new one (i.e., implementing large-scale health service IT projects in the United Kingdom and other countries has proved difficult and the failure to adopt the first ever national computer system in the English NHS which cost billions of pounds is a prime example. Christensen and colleagues (2000, Harvard Business Review) offer a striking example of how factors such as state regulation, powerful industry influences, and professional interests can bring to an absolute halt the spread of a novel medical technology, namely, a very promising portable, cost-effective low-intensity X-ray machine). But there are successes also. In the NHS in England, substantial government funding for modernization of the service has brought about innovative improvements in primary care, cancer, heart disease and emergency care; the highly specialized and sophisticated technology adopted and routinely used in diagnostic and surgical departments in modern hospitals is common experience for most developed or even developing countries. Adopting and mainstreaming innovations is foremost a process of social change. To adopt a novel idea or practice involves risk and uncertainty for the potential adopters and implies change in behavior for individuals and organizations; the problem with healthcare is that in many instances the process is informed by the dominant biomedical model rather than social science research which is better equipped to provide more comprehensive explanations on issues of human behavior.
Q: Do you believe that most clinicians can be open-minded when evaluating new products and technologies, or do you think they carry with them existing prejudices or misperceptions? How potentially would this impact the ability to implement new technologies of merit for addressing healthcare-associated infections?
A: Innovation history and professional background do play a role. And the medical communities tend to be primarily local in their orientation and do not easily trust others than their peers, especially personally unfamiliar sources of authority. Our recent literature review ("Innovation adoption in the prevention and control of healthcare-associated infections: a systematic literature review" under review) highlights that few studies actually look at the process using any theoretical lens to be able to answer this question with transferability. There have been some good research case studies and champions have been cited as agents for change. And this is in line with the recommendations and experience in the wider literature on innovation diffusion. But what about when champions leave or competing priorities emerge? We are interested in how sustainable innovation adoption occurs. Especially in the field of infection prevention and control due to its cross-cutting and multidisciplinary nature -- more than one champion may be required for effective spread.
Q: The barriers to implementation in healthcare are always intriguing are staff shortages really the biggest barrier or are other dynamics at work, such as knowledge gaps mimicking implementation gaps?
A: It is important to consider the wider context including politics, regulation, finance and incentives as they impact on what happens at the organizational level. And of course structural factors such as staff capacity and resource availability have an impact on innovation capacity. However there are also cultural factors such as leadership style which may facilitate or act as barrier. These issues have all been raised in a recent study we completed on the adoption and implementation of innovative technology related to HAIs covering all regions in the English NHS (https://www.wp.dh.gov.uk/hcai/files/2011/07/Technology-Adoption-Study_DH-Approved_FINAL-FULL-REPORT_Feb-2011_including-Acknlowledgments.pdf)
Q: Technologies that require greater levels of healthcare worker training for correct implementation are these less likely to be adopted because of these inherent challenges?
A: There is evidence that the larger the scale of a novel technology adoption project in healthcare, the greater its chances of failure; this is because such projects are complex, multi-faceted in nature and raise unique administrative, cultural, strategic, technical and even security challenges. Introducing novel technologies requires extensive changes at multiple levels, including individual roles, relationships, delivery structures, business processes. The more complex an innovation is the slower its adoption and there is strong evidence to support such claims both from within healthcare and from other industries. In our empirical comparative cross-case study in the NHS in the field of HCAIs, innovations that required greater levels of user training proved to be more challenging to implement (https://www.wp.dh.gov.uk/hcai/files/2011/07/Technology-Adoption-Study_DH-Approved_FINAL-FULL-REPORT_Feb-2011_including-Acknlowledgments.pdf)
Q: Some hospitals tend to be slow in adoption of technologies because they believe there is inadequate evidence in the literature is there a tipping point when enough evidence is perceived and acceptance is greater? Do we have time to sit and wait on the evidence when infections are such a problem?
A: To have a good chance of adoption every innovation project needs to make a good case for it so that potential adopters identify a clear benefit or value in it. To create this perception the innovative technology needs to be supported by sufficient evidence of effectiveness and affordability. Every project is different and the amount of evidence required will depend on the nature of each technology considered for adoption. However, codified and explicit forms of knowledge in the form of scientific evidence are not the only sources of influence on adopters behavior. Adopters also draw on empirical and experiential forms of knowledge with respect to innovative technologies. This is an important and under-researched resource we identified in our previous research in the NHS and an area we explore further in ongoing research project funded by the National Institute for Health Research (http://www.sdo.nihr.ac.uk/projdetails.php?ref=09-1002-38). It is also worth noting that evidence might mean different things to different individuals and different types and sources of evidence might be prioritized by dissimilar professional groups.
Q: A greater number of infection preventionists are involved in product evaluation and purchasing committees what is your advice to them for helping guide decision-making about technology and innovation?
A: Evidence from our empirical studies on technology adoption in the field of infection prevention and control suggests that engagement of technology users and members of the hospital core infection control team in the decision making led to more effective implementation of the selected technologies. User feedback and involvement during the stage of technology selection assisted in better aligning the technology with the delivery system and the expectations of those who use it. In particular, technology customization to the needs of the users improved effective implementation by increasing technology acceptability. And this is great opportunity for infection preventionists to actively influence the process and increase the chances of successful adoption; their cross-cutting perspective comprises an invaluable source of advice.