El desarrollo de la propaganda y la época de los congresos.

5.5.

management

This section of the questionnaire aims to identify what good practice guidance documents are used from the plethora of guidance documents in the delivery of facilities management

172

cleaning services in the control of exogenous healthcare-associated infections in NHS hospitals. What is presented in this section are findings on the effectiveness of the guidance documents and compliance monitoring tools which are used, and the highest level at which identified HCAI risks are reported. One aim of this is to obtain answers to research question 1 and to fulfil research objective 1 (see section 1.7.1).

Section 3 of the questionnaire begins with questions on the following topic:

Adopted good practice guidance document/tools used in monitoring compliance to

5.5.1.

good practice in FM cleaning service delivery practice in the control of exogenous HCAI in each hospital

Opinions were sought from healthcare facilities managers within NHS acute and non-acute hospitals in England on the usefulness of good practice guidance documents in terms of their adaptability, understandability usability. Findings will be set in the context of individual factors that might enhance or inhibit effective knowledge management processes within the hospital knowledge infrastructure capabilities. Figure 5.3 presents the findings from the questionnaire in response to this question.

Figure 5.3: Good practice guidance documents for the control of HCAIs in FM services

Figure 5.3 presents the results of the 85 questionnaires completed, and seeks to ascertain if there are other guidance documents apart from those sampled that are being used in monitoring compliance with good practice in hospital cleaning services for the control of exogenous HCAIs in NHS hospitals in England. The findings show the frequency of use of

173

these documents, and no other document was mentioned in the open-ended question section of the questionnaire.

Twenty-nine (29) of the respondents, or 34% of the total, reported using ICT bespoke guidance documents in monitoring compliance with good practice in the control of exogenous HCAIs. Thirty-one (31) respondents, representing (37%) indicated that they used a combination of ICT bespoke guidance documents and PLACE, while Eleven respondents (13%) used the National Specification for Cleanliness. Nine of the respondents (11%) use their hospital's bespoke audit tools developed by the ICT, and seven of the respondents (8%) said that they used only PLACE. Five of the respondents (6%) used FM bespoke audit tools (checklist and tick box). Only one of the 85 respondents acknowledged using the NHS Premises Assurance Model (NHS PAM).

Findings from this question showed that all the current guidance documents used in the delivery of hospital facilities cleaning services for the control of exogenous HCAIs have been covered in this research. This provides further evidence of the rigour and validity of this research.

To further explore this issue, respondents were asked to rate the effectiveness of the adopted guidance documents used. Responses will enable the researcher to fully capture the context within which decisions are made in order to achieve the targeted objective. The next question sought opinions on this.

Indication of the level of effectiveness of the adopted guidance document/tools

5.5.2.

used in the monitoring of compliance with good practice in FM cleaning service delivery in the control of exogenous HCAI in each hospital

After respondents had identified the guidance documents/tools used in the delivery of FM cleaning services, they were asked to rate the efficacy of the documents to achieve target standards. A Type “A” Likert scale of 1 - 5, with 5 being the highest rating, was used for this question. Relative Importance Index (RII) scores (see Figure 4.18) were then calculated for all the guidance documents in Figure 5.3 and arranged in ascending order of effectiveness. The guidance document with the highest RII score (i.e. closest to 1)indicates the most effective, while the lowest scores (those closest to 0) indicate the least effective guidance documents for the control of exogenous HCAIs.

174

The parameters used in the ranking had to do with the documents' adaptability understandability and usability, i.e., how far they might enhance or inhibit effective knowledge management processes within the hospital knowledge infrastructure capabilities.

Table 5.2: RIIs and rankings of guidance documents used in the control of HCAIs

Guidance Documents Respondent Scores 1 Don’t know 2 Not effective 3 Less effective 4 Effective 5 Very effective RII Rank

ICT bespoke guidance doc. + PLACE

4 0 21 36 24 0.779 1

NHS National specification for cleanliness

6 0 28 36 15 0.727 2

Patient Led Assessment of the Care Environment (PLACE)

2 2 34 34 13 0.727 2

ICT Bespoke guidance documents

9 2 24 39 11 0.696 3

Others 13 2 52 11 7 0.593 4

FM bespoke audit tools (checklist and tick box)

7 34 35 9 0 0.508 5

NHS Premises Assurance Model (NHS PAM)

52 3 21 8 1 0.372 6

The findings presented in Table 5.2 show that Infection Control Team (ICT) bespoke guidance documents in combination with PLACE are considered the most effective of the seven documents, with an RII of 0.779 and a ranking of 1. There was a tie between the National Specification and PLACE when used independently, with a joint RII of 0.727 and a joint ranking of 2. Infection Control Team bespoke guidance documents when used independently ranked third with an RII of 0.696. In fourth place in terms of effectiveness was “Others", with an RII of 0.593. It could be argued that what respondents are saying here is that these documents are all good, but they have to be “mixed and matched” in order to achieve the desired outcome. The facilities management ‘checklist & tick box’ audit tool was ranked fifth, with an RII of 0.508. This tool could be viewed as a ‘spot-check’ measure used for a ‘snapshot’ overview during routine inspections. It was noted that the NHS Premises Assurance Model (NHS PAM), which was ranked sixth with an RII of 0.372, is not a popular guidance document. It should be recalled that PAM was launched with the aim of raising

175

awareness of the impact that NHS facilities can have on the care environment (Department of Health, 2014c). It is an environmental improvement guidance document which was used to create awareness of environment-centered issues within NHS facilities and services and could also be described as a guidance tool specific to healthcare environments that was used to sensitise healthcare facilities management personnel to the importance of the safe management of hospital services including the internal environment, water, energy and transport.

April 2013 saw the introduction of PLACE, which is the new document currently used for assessing the quality of the patient environment, replacing the old Patient Environmental Action Team (NHS England, 2013a). The major emphasis of PLACE compared to other guidance documents is on the care environment, and it provides robust indicators to be met by hospitals in this regard. It emphasises the requirement in the NHS constitution that “(the) patient should be cared for in a clean and safe environment with compassion, and dignity.” The use of PLACE in combination with ICT bespoke audit tools could indicate that local factors are taken into account to maximize efficiency in the control of exogenous HCAIs.

Further research should focus on the impacts of cleaning and infection control related policy and guidance issued by the Department of Health... This should inform future

cleaning related initiatives (May 2013).

These findings show that the guidance documents sampled were those being used across NHS hospitals to monitor compliance with good practice in the delivery of facilities management cleaning services in the control of exogenous HCAIs. It is important to mention that the findings reflect the perspective of hospital facilities managers across NHS hospitals in England (see Figure 5.1 and Figure 5.2).

The level of effectiveness of adopted methods employed to ensure compliance with

5.5.3.

good practice guidance document/tools in FM cleaning service delivery in the control of exogenous HCAI in each hospital.

In the eighty-five (85) responses analyzed, ‘individual ward/unit inspection’ came top as the most effective method with an RII of 0.878 (see Table 5.3). This could be argued to be a direct response by the infection control team to points 1 and 3 of the 10-point commitment to improvement in the NHS set out in ‘The Matron’s Charter’ (Department of Health, 2004a). The first commitment in the charter states that “keeping NHS clean is everybody’s

176

responsibility,” with the third giving the ward/unit Matron responsibility for ensuring everyone is committed to this action. It states that “The Matron will establish a cleanliness culture across their unit.” The overwhelming consensus on this as the most efficient method shows that the monitoring of compliance with the infection control strategy is seen as not only the responsibility of the infection control team. This conclusion is further supported by the fact that the ‘routine ICT inspection’ approach was ranked fifth with an RII of 0.638 (Table 5.3). The measure ranked the second most effective was the use of electronic tools, relative to the use of internet medium to achieve targeted outcome with an RII of 0.748. Checklists and surveys were ranked third and fourth respectively.

Table 5.3: RII and ranking of approaches for managing good practice compliance

Tool/approach Respondent Scores 1 Don’t know 2 Not effective 3 Less effective 4 Effective 5 Very effective RII Rank Individual ward/unit inspection 4 0 8 20 53 0.878 1 Electronic tools 7 2 20 33 23 0.748 2 Checklist 7 2 34 24 18 0.704 3 Survey 6 2 40 27 10 0.678 4

Routine ICT Inspection 28 1 7 25 24 0.638 5

These findings reflect the perception among NHS hospital facilities managers in England that hospitals have processes in place to ensure that compliance with good practice protocols are managed as scheduled to achieve the desired outcome.

Cleanliness is everyone’s responsibility, not just the

cleaners (Department of Health, 2004a)

Having identified the guidance documents/tools which are used and their perceived levels of effectiveness, the methods or approaches used to ensure compliance were explored. It is thus imperative to ascertain the frequency of checking to make sure the methods are fulfilling their purpose.

177

Frequency of monitoring performance against the chosen compliance

5.5.4.

management method for the control of HCAIs

Respondents were also asked to indicate the frequency of monitoring against the compliance monitoring method/approach used to achieve the desired outcome. 47 of the 85 respondents, representing 55% of the total, reported that they did this on a monthly basis, while 21 respondents (25% of the total) did it on a weekly basis. Thirteen (13) respondents, representing 15%) carry out such monitoring on a daily basis, while the remaining four respondents (5%) indicated ‘other’, but without providing further details (see Figure 4.5).

Figure 5.4: Frequency of compliance monitoring

This question sought to ascertain the level of monitoring compliance to set standards in order to meet the national standard for the cleanliness of healthcare environments. The findings show that there are variations in the frequency of monitoring across NHS hospitals in England. It should be recalled that the national standard for cleanliness in the NHS was published in 2001 in the wake of the publication of the NHS plan, following consultation with experts and professionals in the field of infection control. The aim of the national standard then was to raise standards of cleanliness to an acceptable level throughout the NHS (Department of Health, 2003a). Further to the acknowledgement that, all too often, cleaning contracts were driven by price, with insufficient focus on quality, the Department of Health published the revised National Specification for Cleanliness in 2007, which set out minimum frequencies for cleaning in hospitals in order to achieve the standard stipulated in the national

Series1, Daily, 13, 15% Series1, Weekly, 21, 25% Series1, Monthly, 47, 55% Series1, Others, 4, 5%

178

specifications (National Patient Safety Agency, 2007). It provided a comparative framework within which hospitals in England can established details of the way cleaning services will be provided and assess ‘technical’ aspects of cleanliness to ensure compliance with the national standard.

Findings from this question reflect the perceptions of healthcare facilities managers within NHS hospitals in England. They show that NHS hospitals in England have a variety of schedules for monitoring compliance to good practice in the control of exogenous HCAIs in FM cleaning services.

There are several influencing factors or considerations that motivate individual hospitals to ensure that they comply with the standards, and the extent to which they take these into consideration the prevailing knowledge management process in FM cleaning services for the control of exogenous HCAIs. The next question seeks to identify these influencing factors in order to achieve the overall research aim.

Key drivers for monitoring compliance in FM cleaning service delivery in the

5.5.5.

control of exogenous HCAIs in each hospital.

Over the years, several initiatives for quality improvement targeted at clinicians and non- clinicians have been introduced in the NHS to improve standards of practice and enhance quality healthcare delivery outcomes. Some of these initiatives were introduced around the time of the publication of the NHS Plan, and include the Commission for Health Improvement (CHI), launched in November 1999. This was later replaced with the Commission for Healthcare Audit and Inspection (CHAI) in 2004 (Day & Klein, 2004; Department of Health, 2005a). The current set of guidelines is PLACE, which was introduced in 2013 to replace PEAT (NHS England, 2013a). All these initiatives have a common focus, and their mandate is to identify and highlight inherent challenges and dilemmas associated with inspections and the monitoring of compliance with good practice standards in the NHS. According to Day & Klein (2004), methods of judging performance and compliance to standards within these initiatives include:

 Carrying out reviews and investigations of the provision of healthcare and the arrangements to promote and protect public health. These include studies that are aimed at improving economy, efficiency and effectiveness in the NHS,

179

 Inspecting all NHS healthcare providers, and recommending special measures where failing standards are identified, and

 Reviewing the quality of data relating to health and healthcare delivery including published surveys of the views of patient and staff.

To achieve the objectives of such initatives, certain influencing considerations were defined, with each carrying a weighting used to benchmark their relative contribution to quality healthcare outcomes. Drivers for monitoring compliance with standards in facilities management cleaning service delivery in the control of HCAIs in NHS hospitals were identified from the literature and were sampled to ascertain which of them had the greatest influence. These drivers include those detailed in “The NHS improves: A study of the Commission for Health Improvement” (Day & Klein, 2004).

Table 5.4: RII and ranking of key drivers for monitoring the compliance of FM cleaning services

Drivers Respondent Scores 1: Don’t Know 2: Not Influential 3: Less Influential 4: Moderately Influential 5: Most

Influential _{RII Rank}

Patient health & safety 1 0 8 12 64 0.925 1

Better service delivery 2 2 12 9 60 0.889 2

Meeting targets set by NHS

0 0 11 26 48 0.887 3

Avoiding extra cost to the hospital

2 6 30 19 28 0.753 4

Concerns about being labelled 'a failed hospital' 3 7 38 16 21 0.706 5 To check the effectiveness of existing approaches 4 19 42 16 4 0.593 6

Table 5.4 shows respondents' ranking of drivers for monitoring compliance with good practice standards in facilities management cleaning services in the control of exogenous HCAIs in hospitals. The findings from the ranking of the eighty-five (85) responses show that concern for patient health and safety was the top consideration in monitoring compliance with good practice in facilities management cleaning service delivery for the control of exogenous HCAIs. This variable has a RII of 0.925. The second most important consideration was the

180

desire for “better service delivery” by the hospital, with a RII of 0.889, while meeting NHS targets was third, with a RII of 0.887. Avoiding extra costs to the hospital, arising from claims of negligence and NHS penalties for failing standards, was ranked fourth with a RII of 0.753. Concerns about being labelled a 'failed hospital' was ranked fifth with a RII of 0.702. Monitoring compliance with good practice as way of checking the effectiveness of tools or approaches used was the least influential driver, with a RII of 0.593.

In the face of the prevailing trend in healthcare-associated infections in NHS hospitals in England, it is worth noting that the findings from this question showed that a focus on better service delivery outcomes is still on the agenda of most NHS hospital facilities managers. This was reflected in the top three considerations. All of these are fundamental objectives of the main documents relating to quality improvement in the NHS, including The NHS Plan, the NHS Constitution, the Matron Charter, PEAT and PLACE (Department of Health, 2013d, 2004, 2000; National Health Service England, 2012). It is important to mention that the findings of this research reflect the perceptions of hospital facilities managers in NHS hospitals in England.

Section two Interpretations:

5.5.6.

This section of the questionnaire survey evaluates the current guidance documents used in facilities management cleaning service delivery in the control of exogenous HCAIs in hospitals. The effectiveness of these guidance documents was assessed, and this included examining the methods and approaches used to monitor compliance with the standards they set out, as well as the frequency of monitoring. The factors, which motivate the monitoring of compliance with good practice as detailed in the documents were also explored.

The finding from this section of the questionnaire is that there is a variety of approaches to the control of exogenous HCAIs as there is plethora of good practice guidance documents in NHS hospitals. This finding is consistent with the concerns raised in this regard leading to the publication of several guidance documents focused on cleaning service delivery in hospitals (see Table 2.4). In the light of these findings, it is imperative to explore further, to ascertain if there are other guidance documents used for the delivery of FM cleaning services which are not covered above. There is also a need to investigate the reasons for the use of a particular document in preference to another. This issue was addressed in the qualitative (face-to-face)

181

phase of the research sequential explanatory mixed method strategy to achieve the overall research aim and objectives.

According to Creswell (2014), qualitative data in sequential explanatory mixed method research helps to provide more depth and more insight into the quantitative results. The interviewees were asked the following closed-ended questions to help provide more depth and insight into the findings in this regard:

 Which of the available guidance documents is the hospital using to monitor compliance with good practice in facilities management cleaning service delivery for the control of exogenous HCAI?

 What are the reasons for the choice of this particular guidance document?

The next chapter presents findings from the qualitative phase of the methodological research strategy.

The next section presents the findings from the questionnaire survey on the prevailing procurement strategies/methods for the delivery of hospital facilities management cleaning services in relation to the control of exogenous healthcare-associated infections.