Authors: BRIANNE KALLAM1 , CHRISTIE PETTITT-SCHIEBER2 , MEDGE OWEN3 , REBECCA AGYARE ASANTE4 , ELIZABETH DARKO4 , and ROHIT RAMASWAMY2 , 1Kybele, Inc., Lewisville, NC 27023, USA, 2Public Health Leadership Program, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA, 3Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC 27157, USA, and 4Department of Child Health, Ridge Regional Hospital, Accra, Ghana.
Interventions that are known to work well to improve the quality of care often fail because of poor implementation, especially in low resource settings. At a tertiary hospital in Accra, Ghana, an outbreak of sepsis led to an increase in mortality in the Neonatal Intensive Care Unit (NICU). A local quality improvement (QI) team, led by the director of nursing and including NICU nurses, used the well-known Six Sigma QI method to identify lapses in hand hygiene as a major factor contributing to neonatal infection.
Methods for improving hand hygiene are well established, and the World Health Organization (WHO) has developed global guidelines for best practice. Based on these guidelines and local constraints, the QI team developed a hand hygiene intervention that involved: (a) a training presentation based on the WHO guidelines; (b) visual hand hygiene reminders posted in the NICU and (c) assured supply of clean towels for drying hands. The team recognized that this intervention would not bring about change unless it could be successfully implemented and integrated into everyday activities associated with the care of newborns in the NICU. The emerging field of implementation science has developed frameworks to facilitate the use of systematic and scientific implementation approaches to embed evidence-based interventions into routine clinical practice. A popular implementation science framework called the “Interactive Systems Framework” (ISF) was adopted to ensure that the hand hygiene solutions developed by the QI team recommendations could be successfully implemented.
The framework states that successful implementation of an evidence-based intervention requires attention to three components or “systems” that need to work together. First, to increase acceptability, the intervention must be adapted to fit local conditions and contexts (referred to as the “synthesis and translation system”). Second, to reduce the burden of implementation, the delivery of the intervention must be integrated into everyday workflow so as not to overburden the staff (the “delivery system”). Third, to build motivation and capability, the implementation must be supported by leaders and by implementation experts who can coach staff in the most effective and sustainable ways of implementing the intervention (the “support system”).
The QI team carefully designed each component of the framework to ensure successful implementation. To fit the local context, the hand hygiene presentation employed images from the NICU and was narrated by the nursing director. The posters used images of hospital staff and patients. To reduce staff burden, nurses could undergo the training when their schedules permitted and training reinforcements were integrated into already-scheduled staff meetings. Motivation to adhere to good hand hygiene practice was built through a support system that included engaging organizational leaders to emphasize the need for implementation and showing the nurses what bacterial contamination looked like by culturing swab samples from their hands.
Three months after implementation began, all staff passed the knowledge test for hand hygiene and adherence to hand hygiene practice improved significantly across all NICU activities. The systematic use of implementation science holds promise for improving the quality of care in low resource settings like Ghana.
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