Health Care Practitioners
Compliance with the hand hygiene protocols will ultimately be determined by the health care practitioners, from the primary care physicians to the RNs, CNAs, and other hospital staff. It is, therefore, essential that the protocols being introduced or modified are acceptable to the workers. In other words, health care practitioners and staff are a major stakeholder whose compliance with the protocols is provided by removing the barriers (Jammali-Blasi et al., 2016; Compton & Davenport, 2018). For instance, if an alcohol-based hand rub is recommended for use but affects some of the practitioners, such as when they are allergic or if it affects their skin condition, they will have to be accommodated or be provided with more convenient alternatives.
Trainers and Observers
The second group of stakeholders is the trainers who are responsible for educating the health care practitioners and hospital staff about the importance of adhering to the hand hygiene protocols and educating them on the recommended practices. If no hand hygiene protocols existed at the facility, it is their responsibility to train the trainers first (Ott & French, 2015; Manresa et al., 2020). Observers, on the other hand, are responsible for the continuous re-evaluation of the protocols and monitoring compliance to ensure that the goals are being met.
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Hospital Administration and Management
None of the hand hygiene protocols can be implemented and sustained without approval from the hospital administration and management. Some of the initial infrastructural changes to be done, such as ensuring a constant supply of running water, sinks, and alcohol-based hand rubs, cost money that the administration has to set aside in their budgeting. The costs for producing the training materials, training the trainers, and compensating the observers will be borne by the hospitals. These stakeholders are also responsible for changing hospital protocols by backing them with their authority and power. Therefore, the approval of the hospital administration and management is essential to implementing any interventions. Note, however, that the administration and management are potential barriers to the implementation of the interventions.
Management Structure/Process Issues
The management structure might pose restrictions on the implementation process or effectiveness of the interventions because they control the budget and the number of resources that can be allocated to the interventions. Note, however, that the issue might also be the lack of infrastructural resources. For instance, some of the hospitals and facilities lack clean running water. Therefore, the preferred hand hygiene protocol would be to use alcohol-based hand rubs. However, the hand rubs might also be unavailable locally; thus, the hospital or facility might be forced to produce them locally or import them with additional costs. As a result, resource inadequacies might cause a challenge to the implementation of hand hygiene protocols at a hospital or health care facility. On the other hand, the issue might not be resource constraints but resistance to change by the management, hospital administration, and the health care practitioners and staff. Therefore, the implementation plan for the interventions needs to consider the sources of resistance and eliminate them. Otherwise, the hospital or facility will revert back to its original practices, resulting in the intervention failing to provide the desired outcomes.
How Lewin's Management Change Model will be Utilized when Interacting with the Stakeholders
Lewin's management change model will be utilized in all three phases of the implementation plan. In the unfreezing phase, the model will be used to create uncertainty, break the status quo, and prepare the hospital or facility to accept the interventions. Different stakeholders will be targeted with different reasons to support the plan. For instance, health care practitioners will be convinced to accept the changes if they understand the impact their non-compliance with the protocols has on their patient's morbidity and mortality (Han et al., 2017). On the other hand, hospital administration and management can be convinced to fund the intervention if they understand that complying with hand hygiene protocols will not only increase the quality of services delivered but might also decrease the costs in the long-term.
Furthermore, the hospitals and health care facilities stand to enjoy benefits under the Affordable Care Act (ACA) if they reduce their readmissions rates and increase the quality of services provided (Gaffney & McCormick, 2017; Pang et al., 2020). In the second phase, the model will ensure that the training materials and new practices are accepted. In the last step, the model will ensure that the outcomes are sustained in the long-term, especially when the interventions are continuously re-evaluated and updated as needed.
Resources Needed to Implement the Plan
Infrastructural Resources
Overall, financial resources will be required throughout the implementation plan, its evaluation, and subsequent re-evaluation to sustain outcomes. Specifically, however, some of the resources needed will be infrastructural. For instance, there will be a need to develop surveys and questionnaires to collect information about the subjective and objective opinions of the health care practitioners and staff. These data collection tools will require both computational resources to store the data and analyze it. Therefore, there will be a need for personnel conversant with data collection and analysis tools and the epidemiological background to interpret the data to information that can be used to change or modify practice as needed.
The second type of infrastructural resources will be required when educating and training the practitioners and staff on the hand hygiene protocols. Later on, professional observers will require survey and data analysis tools to monitor compliance with the hand hygiene protocols. The training resources, therefore, will be needed to train the trainers, observers, and health care workers. Furthermore, there will be a need to create hand hygiene technical reference manuals made available to the workers as well as brochures to be handed out during the training sessions. Posters and leaflets will also need to be designed, printed, and distributed at strategic locations in the hospitals of facilities.
Running Water and Alcohol-based Hand Rubs
Two of the key hand hygiene protocols are the installation of sinks with running water and soap for the health care workers to use. If running water is not readily available, alcohol-based hand rubs are a recommended alternative. Note that installing and maintaining these stations require an installation cost and continuous management cost that can be added to the cost of maintaining other equipment at the hospital or facility. Therefore, if the administration does not have an adequate budget, it is recommended to add these costs and set aside the required funds to implement the plan. Note, however, that these restraints are issues that will delay the implementation of the plan. After all, it would be unrealistic to expect all hospitals and health care facilities to have extra financial resources at hand.
Continuous Resource Consumption that Needs Budgeting
Depending on the baseline compliance with hand hygiene protocols and the target to be achieved by the implementation of the intervention, the hospital or health care facility will have to budget for and set aside funds to sustain the desired outcomes. For instance, there will be a continuous consumption of soap and water (from utilities or other sources) that will need to be sustained for the long-term. On the other hand, if running water is unavailable, the hospital or health care facility will have to budget for and establish a supply chain with a manufacturer of an alcohol-based hand rub. Note that different brands of hand rubs will be required to cater to the needs and preferences of the health care workers, such as those who have adverse reactions to the hand rubs or are allergic to some of the ingredients that make them.
If, however, both running water and purchasing the alcohol-based hand-rubs are not an option, the hospital or health care facility will be forced to design and build the infrastructure for producing it locally. As a result, the initial setup cost will include purchasing the equipment and building the production facilities. Note that the hospital or health care facility will have to adhere to the applicable regulations, especially the allowable products and safety precautions. This option is recommended if the other two are not available. However, if the hospital has excess cash or is financially healthy, they can invest in the local production facility and create an extra revenue source by selling the excess to local hospitals or health care facilities.
Evaluation Plan
The implementation plan needs to be carried out using the principles of evidence-based practice (EBP). Therefore, there needs to be an evaluation plan that continuously monitors the performance of the interventions and, when needed, suggest improvements and updates. The objective of the evaluation plan, therefore, will be to improve compliance with hand hygiene protocols among the health care workers. The implementation of an evaluation plan is especially crucial for hospitals and facilities that are implementing a hand hygiene protocol for the first time. Therefore, the first step of the plan will be to conduct a baseline evaluation of the hospital or facility at all levels. The objective will be to collect information about existing hand hygiene practices, their perception among the health care workers, knowledge levels, and existing infrastructure to support the implementation of the interventions. The primary purpose of the baseline will be to establish the target for the implementation plan within a specified time frame. For instance, if baseline compliance with hand hygiene practices is at 40%, the target after six months will be 60% and 80% after a year. The other purpose of the baseline is to establish a benchmark through which future monitoring will be based (Stewardson et al., 2016).
Different tools will be required to evaluate the implementation and performance of the intervention. First, an observation form will be used to collect information about the performance of the hygiene protocols among health care workers in their routine care. Secondly, a form to help the applicable stakeholders, such as the researchers, trainers, and hospital management, to easily calculate compliance rates and monitor the amount of progress towards achieving and exceeding the set objectives. Monitoring compliance with hand hygiene protocols during routine care is the most effective and objective measure to derive compliance rates and ensure that the baseline results are always exceeded.
Reassessment/Re-evaluation Strategy
While establishing a baseline (benchmark) and using it to achieve the desired compliance rates is part of the initial evaluation of the plan, the study will have to end after three months. Therefore, it is essential to continuously monitor and reassess the intervention. If compliance rates start to fall, changes can be introduced before they go below the baseline. Lewin's management change model has the last step (refreezing) that ensures all changes implemented are internalized and institutionalized into practice and organizational culture. As a result, the cost of maintaining the expected behavior reduces. For instance, if the implementation plan succeeds in changing the perspectives of the health care workers, who incorporate it into routine care, the cost for training and education will be reduced.
The re-evaluation plan, therefore, will involve two processes. First, trained observers will continuously monitor compliance rates by collecting data during routine care. Secondly, there are bound to be some challenges or issues discovered after the implementation of the intervention. Lewin's change model recommends that these challenges need to be constantly addressed if the desired behavioral changes are to be sustained. Therefore, surveys will have to be conducted to assess the perception of the health care workers, hospital administration, and senior managers. Furthermore, the knowledge of the health care workers will have to be reassessed to determine if further training will be needed.
The re-evaluation surveys will be conducted every month. Participants of the survey will be selected randomly so that they become representative of their populations. Once the surveys are handed out, the participants will have five working days to fill them out, provide their feedback, and return them for analysis and interpretation. The suggestions from the feedback forms in the surveys will provide information about the current state of the intervention and help determine if changes or updates need to be done. However, if compliance rates continuously fall, the re-evaluation strategy can be used when it does not coincide with its scheduled dates.
References
Compton, D., & Davenport, T. E. (2018). Compliance with hand-washing guidelines among visitors from the community to acute care settings: a scoping review. Journal of Acute Care Physical Therapy , 9 (1), 19-34.
Gaffney, A., & McCormick, D. (2017). The Affordable Care Act: implications for health-care equity. The Lancet , 389 (10077), 1442-1452.
Han, A., Conway, L. J., Moore, C., McCreight, L., Ragan, K., So, J., ... & McGeer, A. (2017). Unit-specific rates of hand hygiene opportunities in an acute-care hospital. infection control & hospital epidemiology , 38 (4), 411-416.
Jammali-Blasi, A., McInnes, E., & Middleton, S. (2016). A survey of acute care clinicians' views on factors influencing hand hygiene practice and actions to improve hand hygiene compliance. Infection, Disease & Health , 21 (1), 16-25.
Manresa, Y., Abbo, L., Sposato, K., de Pascale, D., & Jimenez, A. (2020). Improving patients' hand hygiene in the acute care setting: Is staff education enough?. American Journal of Infection Control .
Ott, M., & French, R. (2015). Hand hygiene compliance among health care staff and student nurses in a mental health setting. Issues in mental health nursing , 30 (11), 702-704.
Pang, Y., Ren, Z., & Wang, J. (2020). Impact of the affordable care act on utilization of benefits of eye care and primary care examinations. Plos one , 15 (11), e0241475.
Stewardson, A. J., Sax, H., Gayet-Ageron, A., Touveneau, S., Longtin, Y., Zingg, W., & Pittet, D. (2016). Enhanced performance feedback and patient participation to improve hand hygiene compliance of health-care workers in the setting of established multimodal promotion: a single-centre, cluster randomised controlled trial. The Lancet Infectious Diseases , 16 (12), 1345-1355.
