The structure of the current research allowed a number of research contributions to be identified. These stemmed from the individual studies and from their combined response to the principle research question. These contributions are summarised in Table 1-3 and discussed in more depth in Table 1-4.
Table 1-3: Research Contributions and Recommendations
No. Study Output Target Contribution (C)
Recommendation (R)
1 1 Recommendations for
Healthcare Setting
Methods to establish and reveal domain knowledge (C)
2 1 Recommendations for
Healthcare Setting
Implementation of full PDSA cycle (Quality Management approach) (R)
3 1 Recommendations for
Healthcare Setting
Implementation of WHO 5 Moments measurement(R)
Additional Actionable Feedback model to ensure meaningful data (C)
4 2 Recommendations for
Technology
Fit for Purpose Matrix for hand hygiene technology assessment(R)
5 2 Recommendations for
Technology
Inclusion of domain knowledge in hand hygiene technology development(R)
6 3 Recommendations for
Future Research
Type of clinical activity can affect likelihood of hand hygiene
(study design/findings)(C)
7 n/a Future System of Measurement in Hand Hygiene
System of measurement with QM focus: allowing manual and technological data collection, and generation of
meaningful data(C) 8 n/a Future System of
Measurement in Hand
Conceptual splitting of WHOMy 5 Moments for Hand Hygieneto aid ease
Table 1-4: Discussion of Research Contributions
No. Recommendations for Healthcare Setting (Study 1)
1. Current measurement processes may contain hidden weaknesses. These include data accuracy, efficacy, validity of produced data, and
perceptions of meaning amongst those involved with the process.
Use of domain knowledge, through identifying and involving individuals from all areas of a given process, can allow access to hidden
weaknesses, providing clarity. In the current research two novel diagrams allowed this process to occur: API Diagram and New Current State Map.
These may offer benefit as frameworks for adaptation in other settings where process evaluation is desired.
2. Lack of integration of routine auditing with additional Quality
Management (QM) systems was highlighted as a potential explanation regarding unclear feedback loops revealed via participants in Study 1. A recommendation from the research was the implementation of a QM approach of Plan, Do, Study, Act (PDSA) cycles. The aim was to rebalance the focus from chiefly being on systematic data collection (Do) to considering the implications of collected data (Study), and courses of action appropriate for desired improvement (Act,Plan). 3. Lack of meaning was found to be a major perceived weakness of the
existing system of measurement at the case study site.
This included a disconnect between the content of training and education priorities, felt to be centred around the WHOMy 5 Moments for Hand Hygiene, and the measurement criteria, which utilised the ICNA (2004) Hand Hygiene Audit Tool.
A recommendation of the research was that the case study site moves to a tool based on the WHO 5 Moments, providing a basis for meaningful feedback. Further, an existing model of actionable feedback was adapted to provide guidance when considering new forms of measurement, to ensure generated data is able to provide meaning, aiding performance improvement.
Recommendations for Technology Developers (Study 2)
4. Fit For Purpose (FFP) of existing hand hygiene technologies was assessed using a specifically designed matrix, evaluating their ability to monitor, measure and feedback data on hand hygiene at each of the WHO 5 Moments.
This tool is seen as a simple, effective scorecard approach to allowing technology developers, and potential customers, to establish whether innovations possess sufficient capabilities for the objective desired. This is particularly important in light of the previously established requirement for measured data to possess meaning for those involved within the process. Therefore the FFP matrix, incorporating globally recognised guidelines, would allow clear goals and functional requirements to be set.
5. The adaptation of a conceptual model from the human factors field
(Human-Tech Ladder, Vicente, 2006) was suggested as a potential vehicle for incorporating domain knowledge into the development of hand hygiene technologies, in addition to the use of the FFP matrix.
The application of domain knowledge to the assessment of technology examples allowed a much wider discussion of their potential at the case study site than would be possible by just applying the FFP matrix alone. Healthcare professionals offered contextual information concerning why certain technologies would or would not be appropriate. They also offered insight into how they felt technology may have a place for measuring hand hygiene at some, yet not all, the WHO 5 Moments. Such information allowed further research to be planned (Study 3) and also indicated that a perfect score on the FFP matrix may not be required. This would suggest technology developers could produce an innovation deemed useful in the eyes of healthcare professionals which did not need to perform perfectly on the FFP matrix.
Involvement of healthcare professionals in the assessment of hand hygiene technologies has previously been sparse. The literature review found only one technology discussing such an involvement, and no work similar to that
Recommendations for Future Research (Study 3)
6. The likelihood of hand hygiene occurring in response to specific clinical activities, categorised as Inherent or Elective, was examined through a pilot study for Study 3. Results indicated that Inherent clinical activities
triggered significantly higher levels of hand hygiene than Elective clinical activities (χ2 (df 1) 11.077, p=<0.001). The study provides the first data of its kind from within an NHS acute setting.
The study design developed allows for replication in similar contexts. This can test and refine the framework method, and obtain further data regarding the influence of human behaviour on likelihood of hand hygiene.
A Future System of Measurement in Hand Hygiene
7. The data from the three individual studies conducted, and associated discussions, combine to form a response to the primary research question. Both domain knowledge and human behaviour have an important role in the development of quality audit processes and associated technologies, in this example as applied to healthcare hand hygiene. A potential future system of measurement was developed to demonstrate how both concepts could be of benefit. This system allows both manual and technological measurement to be deployed. Data is generated, analysed and fed back within a Quality Management system for improvement.
8. Within the proposed future system of measurement, and wider discussion, specific focus is placed on the ability to incorporate the WHO 5 Moments. This is to ensure hand hygiene data discussed possesses meaning.
A conceptual splitting of the WHO 5 Moments is offered as a starting point for further work. This is based on findings from the human behaviour research (Study 3), which supported the perceptions of healthcare professionals (Study 2).
This is to allow for greatest impact when discussing and training/educating healthcare professionals with regard to required hand hygiene priorities and performance.