Advanced Infection

Prevention and
Control Training

Leadership and programme management in

infection prevention and control
2018

WHO Global Unit 2017

Module outline
Leadership and programme management in infection prevention and
control (IPC)

Session 1: The role of the IPC focal person in 120 mins

developing and implementing IPC programmes.

Session 2: Becoming an IPC leader – an

90 mins
exploration of what makes an effective leader.

Session 3: Implementation strategies and 90 mins

behaviour change.

Session 4: Effective communication in IPC. 45 mins

Summary of the module
Session 1 Session 2 Session 3 Session 4

Introduction to Drill-down on IPC Exploration of Focus on

leadership in the leadership: implementation and communication and
context of: what makes a good behaviour change: advocacy:
the core leader; împlementation communication skills
components; the relevance of success factors; in IPC;
the multimodal leadership to IPC; behaviour change choosing the right
strategy; leadership and implementation; communication
implementation characteristics; quality improvement channels;
resources; types of leaders; cycles and leadership and
project management; leadership implementation; conflict resolution.
IPC interlinkages; challenges and leadership
principles of adult opportunities. challenges and
learning. solutions.
3
The symbols explained
You are encouraged to participate in
Interactive discussion questions, where you can
question use your own experience and prior Some suggested answers to
Answers
knowledge. activities/group work.

Group You are encouraged to participate in

work group activities to drill into key topics.
In-depth case study applying
Case study
learning into practice.

Key Essential content (not to be missed!).

resource

Video material to supplement

Video
learning.

Reference/ Key reference for consolidating

reading
learning.
Required reading or reflection
Homework
outside of the classroom.
Session 1:

The role of the

IPC focal person
Competencies

• Lead the design, prioritization, implementation and evaluation of an

evidence-based IPC programme, informed by project management
principles.

• Advocate for synergy between IPC and related programmes

including patient safety, quality improvement and other vertical
programmes.

• Successfully influence relevant stakeholders to gain support and

necessary resources for an IPC programme.

• Support educational interventions and a learning environment to

address gaps in knowledge, skills and competence of IPC workers.
Learning objectives

• Demonstrate awareness of the role of the IPC focal person.

• Describe core functions and responsibilities of the IPC focal

person.

• Identify leadership development opportunities for IPC focal

persons.

• Consider appropriate programme and project management

strategies to support IPC programme development and
implementation.

• Develop teaching approaches that satisfy a variety of

learners.
Key points

• The WHO core components are a road map for how IPC can
prevent harm due to health care-associated infection (HAI) and
antimicrobial resistance (AMR).
• The IPC focal person1 should oversee the development,
implementation, coordination and evaluation of the IPC
programme and all its activities.
• The development of leadership and programme management
skills supports success.
• IPC focal persons must be aware of their important role in
advocating for a multimodal approach to improvement.

1IPC focal person is a term used to denote the lead IPC practitioner at every level of the health care system.
Impact of effective IPC

http://www.who.int/gpsc/HAI-Infographic.pdf?ua=1
The core components of
an IPC programme

• WHO guidelines (2016).

• A critical resource for IPC
leaders.
• Describe the evidence-based
core elements of an effective
IPC programme at the national
and acute health care facility
level.

http://www.who.int/infection-prevention/publications/core-components/en/
IPC leaders describe the Core
Components

https://www.youtube.com/watch?v=LZapz2L6J1Q&feature=youtu.be
Handouts 1 & 2
Refer to handouts 1 & 2 in the student handbook for the next part of the
session

Handout 1 Handout 2
Core component 1

CV Two high-quality studies shows that IPC programmes including

CX dedicated, trained professionals are effective in reducing HAIs
X in acute care facilities.
• Clearly defined objectives.
• Dedicated, trained professionals & multidisciplinary team.
• Support from the facility leadership.
• Good quality microbiological laboratory.
Core component 2

CV Six high-quality studies show that guidelines implemented in

CX combination with health care workers’ education and training
X are effective in reducing HAI.

• Expertise required. • Monitoring implementation.

• Local prioritization. • Health care workers’ (HCWs)
education on recommended
• Providing resources for
implementation. practices.
Essential guidelines
The following are considered essential according to the core
components

• Standard precautions • Transmission-based

precautions (including
• Decontamination
patient identification,
• Safe handling of linen and
placement and personal
laundry
protective equipment)
• Health care waste
• Aseptic technique for
management
invasive procedures
• Respiratory hygiene and (including surgery)
cough etiquette
• Device management for
• Environmental cleaning clinical procedures
• Prevention of sharps injuries • Sterilization and medical
• Hand hygiene devices decontamination
Core component 3

CV 15 high-quality studies show that a practical hands-on approach

CX incorporating individual experiences is associated with
X decreased HAI and increased hand hygiene compliance.

• Pre-graduate, postgraduate, in-service training.

• Evaluation of training impact.
• Collaboration with local academic institutions.
Core component 4

CV 13 facility level and one national study showed a decrease in

CX HAI with surveillance and also that timely feedback of results is
X influential in the implementation of effective IPC actions.

• Standardized definitions, appropriate methods, good quality laboratory

support, quality control.
• Training and expertise needed.
Core component 5

CV 44 national and 14 facility level high-quality studies show that

CX implementing IPC activities at facility level using multimodal
X strategies is effective to improve IPC practices and reduce HAI.

A multimodal strategy comprises several elements or components (three or

more; usually five) implemented in an integrated way with the aim of improving
an outcome and changing behaviour. It includes tools, such as bundles and
checklists, developed by multidisciplinary teams that take into account local
conditions.
Multimodal strategies
Handout 3
Refer to handout 3 in the student handbook

IPC focal persons

must be able to
clearly articulate
how the multimodal
strategy applies to
all IPC activities

Interim Practical Manual supporting national implementation of the WHO guidelines on core components of infection prevention and
control programmes. Geneva: World Health Organization; 2017.
The multimodal strategy
in real life
Consider the following scenario

• A hospital launches a training

Will the
programme on safe disposal of used strategy
needles.
work?
• All HCWs are educated (teach it),
posters are placed on the walls (sell it)
and regular audits are introduced
(check it).
• But procurement of sharps bins is
problematic, supplies regularly run out
(build it) and the hospital management
are not committed to regularly
reviewing audit results (live it) .
07/03/2018 20
Core component 6

CV Six high-quality facility level and one national study showed that
CX regular monitoring/auditing of IPC practices paired with regular
X feedback is effective.

• To achieve behaviour change or other process modification.

• To document progress and impact.
Core component 7 (facility)

CV 19 high-quality studies showed that bed occupancy exceeding

CX the facility standard capacity and inadequate HCW staffing
X levels is associated with an increased risk of HAI.

• Standards for bed occupancy: one patient per bed with adequate
spacing between beds.
• HCW staffing levels should be adequately assigned according to
patient workload.
• Overcrowding recognized as a public health issue that can lead to
disease transmission.
Core component 8 (facility)

CV 11 studies showed that the availability of equipment and

CX products at the point of care (particularly for hand hygiene)
X leads to increased compliance with good practices and
reduction of HAI.
• Appropriate clean and hygienic environment, water, sanitation and hygiene
(WASH) services and materials and equipment for IPC, in particular for
hand hygiene.
The core components
at-a-glance

Resources are
available to support
implementation
Implementation resources

Practical Assessment Academic Videos Advocacy

manual to tools to publications explaining the video on IPC,
support support to convince core HAI and AMR
implementing baseline and senior components
the core follow-up managers and
components assessment and leaders leadership in
IPC

http://www.who.int/infection-prevention/tools/core-components/en/
Key roles and tasks of the IPC
focal person (1)
Development, implementation, coordination and evaluation of
the IPC programme.

Development and support of implementation of IPC

activities at facility & district level.
Understand the
role of project
Liaison with relevant hospital/district departments to
management
ensure integration of IPC activities.

Development, updating, and management of IPC

strategies, guidelines and all tools and resources.

Auditing and monitoring of progress of facility IPC plan.

Key roles and tasks of the IPC
focal person (2)
Development of surveillance systems for HAIs, etc. in
collaboration with epidemiologists and a surveillance team.

Interpretation and communication of data on infrastructure

and process and practice indicators for decision-makers.
Understand the
role of project
Sustainability of the IPC workforce through training.
management

Awareness-raising of HAIs and AMR among the public and

health care professionals.

Advice about IPC supplies, technical specifications and

procurement systems.
Project management –
an important skill

Understand the
role of project
management in
IPC programmes
Project management and IPC
programmes

• A successful IPC programme can be

enhanced through understanding the
principles of project management.

• Projects have to be delivered on time, on

budget and with a determined level of quality
But...
• They also require the collaboration of what is a
multiple professionals
project?
• IPC focal persons must be familiar with
standard project management terminology and
approaches, and recognize critical stages
and risks in managing projects.
What is a project?
A unique process consisting of a set of:

• Coordinated and controlled activities

• With start and finish dates
• Clear roles and responsibilities and delegation of tasks
• Undertaken to achieve an objective
• Conforming to specific requirements, including
• Constraints related to time, cost, quality and resources
Project management and
implementation
Step 3: developing and executing the plan

Developing and executing an action

plan requires good project
management skills:
• Agree timelines.
• Consider budget and resource
needs.
• Establish monitoring mechanisms.
• Consider risks to success.
Assessments and situation
analysis as a key step of project
management (steps 2 and 4)
Infection prevention and control assessment
tool (IPCAT2)
• National-level assessment tool.
• Provides baseline and ongoing data for improvement.

Infection prevention and control assessment

framework (IPCAF)
• Facility-level assessment tool.
• Provides baseline and ongoing data for improvement.

Hand hygiene self-assessment framework

(HHSAF)
• Diagnostic tool for health care facilities.
• Provides baseline and ongoing data for improvement.

07/03/2018 http://who.int/infection-prevention/tools/core-components/en/ 32
Example: national level (step 3)
• Conduct assessment to understand where your
country stands on WHO IPC core components as
well as current strengths/gaps.
• Use data to develop a specific, measurable,
actionable, realistic and timely (SMART) action
plan to be refreshed (bi-)annually.
• Identify who needs to lead and be involved in the
assessment.
• Remember to draw on existing relevant
assessments, for example, HMIS/SARA, joint
external evaluation (JEE), national AMR
assessments, etc.
• Use results to provide actionable feedback to all
stakeholders.
• Share with IPC team/committee, national leaders
and decision-makers, other relevant programmes
(can re-assess joint areas of work).
• Present results in a format suitable to each
07/03/2018 | Title of the presentation audience. 33
 An example of a structured IPC
action plan

http://www.who.int/infection-prevention/campaigns/clean-hands/cc-implementation-guideline.pdf?ua=1
IPC relevant programme
interlinkages

Who should
IPC link
with?
Linkages with other
programmes
IPC focal person advocates for IPC across programmes

Waste Hepatitis B/C

management Tuberculosis/
HIV

Antimicrobial
Community
stewardship
engagement
IPC
focal
Patient
safety
person Occupational
health

Water & Media

sanitation Policies &
guidelines
Core components and the
principles of adult learning

Understand the
principles of adult
learning
Understanding the principles of
adult learning
A key part of effective training and education

• IPC is a discipline that requires specific

knowledge acquisition.
What
expertise do
• Educational interventions are crucial IPC
quality improvement elements.

we have in
• IPC focal persons must be able to support
educational interventions and therefore be

the room?
familiar with pedagogical approaches.

• Implementation, adaptation and innovation

in IPC practice require constant learning.
Application to the real world
1. What were the aims and outcomes –
were they clear?
Think of a 2. What methods were used to help you

recent
learn - how were you encouraged to
participate?

learning 3. How were you assessed?

experience 4. How did you evaluate your experience?

5. What feedback was provided to support

your learning?
Developing an educational
intervention in IPC
Key considerations

• Identify aims and what the learners will learn (outcomes).

• Consider learners’ preferences and adapt methods.

• Prepare assessment (evaluation) methods that reflect a variety of

outcomes and learners.

• Offer feedback to signpost achievement and progress.

Learning outcomes Marking

Aims Assessment methods
Learning methods Feedback
Supplementary information is
available for home reading
Refer to student handbook

• David Kolb’s theory of adult learning.

• Tailoring your teaching to different situations.
• Teaching approaches for IPC.

Kolb D. Experiential learning: experience as the source of learning and development. Englewood Cliffs, NJ: Prentice Hall, Inc.; 1984.
Leadership saves lives!
Effective leadership and influence in IPC saves lives

You play a critical role in supporting and stimulating the right action at the
right time to:
• Support the development of an effective IPC programme.
• Support the implementation of the core components of IPC
programmes in your facility.
• Contribute to a reduction in HAI and AMR.
• Run effective projects.
• Link with other relevant programmes.
• Train the health workforce effectively.
We need to influence doctors, nurses, managers and leaders and all
disciplines in health care!
 Further reading on IPC
programmes
WHO (2016). Guidelines on core components of infection prevention and control programmes at the
national and acute health care facility level.
http://apps.who.int/iris/bitstream/10665/251730/1/9789241549929-eng.pdf?ua=1

WHO (2009). A guide to the implementation of the WHO multimodal hand hygiene improvement strategy.
http://apps.who.int/iris/bitstream/10665/70030/1/WHO_IER_PSP_2009.02_eng.pdf

Zingg W, et al. Hospital organisation, management, and structure for prevention of health-care-associated
infection: a systematic review and expert consensus. Lancet Inf Dis. 2015;15(2):212–224.

WHO (2009). A guide to the implementation of the WHO multimodal hand hygiene improvement strategy.
http://apps.who.int/iris/bitstream/10665/70030/1/WHO_IER_PSP_2009.02_eng.pdf

Saint S, et al. The importance of leadership in preventing healthcare-associated infection: results of a

multisite qualitative study. Infect Control Hosp Epidemiol. 2010;31(9):901-907.

Storr J, et al. Redefining infection prevention and control in the new era of quality universal health
coverage. J Res Nursing. 2016;21(1) 39–52.
Further reading on project
management

WHO (2004). Planning and implementation of district health services.

http://www.who.int/management/district/planning_budgeting/PlanningImplementationDHSAFROMd4.pdf?u
a=1

WHO (2007) A guide for fostering change to scale up effective health services.
http://www.who.int/management/AGuideFosteringChangeScalingUpHealthServices.pdf
ISO 10006:2017. Quality management -- guidelines for quality management in projects.
https://www.iso.org/standard/70376.html
UNICEF/UNDP/World Bank/WHO (2005). Effective project planning and evaluation in biomedical research.
http://apps.who.int/iris/bitstream/10665/69237/2/TDR_RCS_PPE_05.2_eng.pdf?ua=1
Further reading on adult
learning

Anderson P, et al. Teaching infection prevention using concept mapping learning

strategies. Am J Infect Control. 2016; 41(6):S58.

Koo E, et al. Making infection prevention education interactive can enhance

knowledge and improve outcomes: results from the Targeted Infection Prevention
(TIP) study. Am J Infect Control. 2016;44(11):1241–1246

NHS Education for Scotland. Qualitative analysis of learning needs in infection

prevention and control (IPC) staff.
http://www.nes.scot.nhs.uk/media/3957464/ipc_tna_report_final.pdf

Kolb D. Experiential learning: experience as the source of learning and

development. Englewood Cliffs, NJ: Prentice Hall, Inc.; 1984.
 Session 2:

Becoming an
IPC leader

An exploration of what makes

an effective leader.
Competencies

• Communicate a vision of IPC that aligns organizational and workforce

priorities.

• Foster and support collaborative and effective individual, team and

organizational IPC performance.

• Use relevant quality improvement approaches to increase individual,

team and organizational IPC performance.

• Develop a comprehensive, evidence-based strategy for effective IPC

services.
Learning objectives

• Define leadership.

• Describe the influence of leadership on selected IPC outcomes.

• Identify different domains of leadership in the literature.

• Discuss a variety of leadership styles.

• Reflect upon such styles and apply them to their own leadership style
and personality.
Key points

• Robust leadership in IPC is essential for effective decision-making,

efficient use of resources and the provision of high-quality, safe,
effective, person-centred care.
• Strong leadership supports activities to prevent and control infection
within the organization, in particular by catalyzing participation and
motivation among local teams, and is essential to achieve reduction of
patient harm due to HAIs and AMR.
• Leadership must be aligned – from the hospital management team
to the executive and specialist infection control team, to clinical and
non-clinical staff.
Leadership - a critical success
factor

Understand the
value of leadership
in effective IPC
What would a great IPC leader
look like?

Write down what you think are

the top three things that a
great IPC leader does to Example:
“A great IPC
demonstrate their leadership. leader is a
No right or wrong answers! good
communicator”
IPC leadership worldwide
Leadership - what are we
talking about?

Leadership describes the ability to:


- influence
- motivate and
- enable
members of an organization to contribute to
the effectiveness and success of the
organization.

House RJ, et al. Understanding cultures and implicit leadership theories across the globe: an introduction to project GLOBE. J World Business,. 2002;37(1): 3-10.
Leadership - what are we
talking about?
The ability to influence, motivate, enable…

The implementation of
guidelines into practice

Behaviour change through

multimodal strategies
What is the relation between
leadership and effective IPC?

• Leaders in close and regular contact with clinical teams in wards and
units positively influence quality of care.
• Leaders support others to develop, implement and evaluate their own
solutions to problems.
• Leadership associated with improved practices for hand hygiene,
gowning and gloving.
• Staff engagement and hospital leadership are significantly associated
with knowledge related to IPC. (Sinkowitz-Cochran et al, 2011)1
• Positive leadership behaviours are associated with a reduced
incidence of pneumonia and urinary tract infections. (Houser, 2003)2
1Sinkowitz-Cochran RL, et al. The associations between organizational culture and knowledge, attitudes, and practices in a multicenter Veterans Affairs quality
improvement initiative to prevent methicillin-resistant Staphylococcus aureus. Am J Infect Control. 2012;40(2):138–143.
2Houser J. A model for evaluating the context of nursing care delivery. J Nurs Adm. 2003;33(1):39e47.
Characteristics of a leader
In your opinion, who is a leader?

Leader?

Leader? Leader?

 What are the traits/features of a leader that you know

(in real life or a celebrity, politician, sports person)?
– which of these do you have as well?
 How does thinking about that particular person make
you feel?
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Characteristics of an IPC leader
• Leaders foster a
culture of excellence.
• Leaders develop an
Personality Behaviour organizational vision.
• Leaders focus on
previewing and
resolving challenges
Culture Actions that could be
IPC opportunities to
Leader improve.
• Leaders inspire,
encourage, and
motivate others to lead.

(Saint et al, 2010)

Situational leadership
Adaptable leaders

• Situational leaders adapt their leadership style to situations.

• Leadership ‘based on a relationship between the leader’s supportive
and directive behaviour, and between the follower’s level of
development’. (Grimm, 2010)
• Leader’s support requires personal involvement, sustained
communication and emotional support.
• Leader’s direction refers to the steering provided by the leader as well
as the allocation of follower roles.

www.pixabay.com (CC0 Public Domain, Free for personal and commercial use, No attribution required)
www.pexels.com (CC0 License, Free for personal and commercial use, No attribution required)
mm JW. Effective leadership: making the difference. J Emerg Nurs. 2010;36(1):74-77.
Transformational leadership
Visionary leaders

• They have and share a vision for

what an organization should be.
(Sims, 2009)

• They develop others to exceed their

own self-interests for a higher
purpose. (Vinkenburg et al, 2011)

• Leader-follower relationships are

based on interactions or exchanges.
(Rolfe, 2011)

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Transactional leadership
Performance-oriented leaders

• Empowered to evaluate, correct, and

train subordinates.

• Performance shaped by punishment

or rewards.

• Highly visible leader, top of ‘chain of

command’.

• Motivation to be effective and

efficient.

www.pixabay.com (CC0 Public Domain, Free for personal and commercial use, No attribution required)
(Bass, 2008)
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IPC leadership in action
Group work 1:
• Read the summary document in your group.
• Discuss the problem described by the authors.
Summarize in writing what you think was the
main problem that needed to be addressed.
• Identify key challenges – discuss and write
down the main challenges to HAI prevention. As
you discuss these challenges, think about the
core components and the multimodal strategy.
• Discuss whether you have faced similar
challenges.
• Choose three of the challenges that
you/members of your group have also faced
and write down what action was taken to
address these challenges in your own place of
work.
Dramowski A, Cotton MF, Whitelaw A. A framework for preventing healthcare-associated infection in neonates and children in South Africa. S Afr Med J. 2017;107(3):192-195.
 Group work 1 – how the authors
addressed the challenges
Challenge Action
Policies and • IPC norms and standards for outpatient and inpatient settings developed.
guidelines • IPC guidelines for paediatric/neonatal wards and clinics developed.
Education, • A national core curriculum on IPC for undergraduates developed.
training and • In-service training for all HCWs initiated.
advocacy for • IPC champions to lead education, advocacy and research established.
patient safety • Advocacy and buy-in from managers and departmental heads to prioritize
safe care of children agreed upon.
• Integration of IPC with existing structures, for example, quality
improvement committees.

Provisions and • Building norms for new and renovated neonatal and paediatric services
infrastructure established.
• Basic provisions for HAI prevention, for example, soap, water, alcohol-
based handrub, personal protective equipment, agreed upon.

Surveillance and • Recommendations for HAI surveillance methods, frequency and targets
research implemented.
• Outbreak reporting established.
• Addition of HAI to existing morbidity and mortality registers.
• identification of key research questions to improve HAI implementation.
Making improvement with
limited resources
Refer to student handbook

• Damani highlights three approaches to

improve IPC in settings with limited
resources:
• focus on improving no-cost practices
• focus on improving low-cost practices
• stop wasteful and unnecessary
practices.

• These three approaches have the potential

to save money, time and improve the
quality and safety of health care.

Damani N. Simple measures save lives: an approach to infection control in countries with limited resources. J Hosp Infect. 2007;65(Suppl. 2):151-154.

63
Further reading & references

A guide to the implementation of the WHO multimodal hand hygiene improvement strategy. Geneva: World Health
Organization; 2009.
(http://www.who.int/gpsc/5may/Guide_to_Implementation.pdf)
House RJ, et al. Understanding cultures and implicit leadership theories across the globe: an introduction to project GLOBE.
J World Business. 2002;37(1): 3-10.
Sinkowitz-Cochran RL, et al. The associations between organizational culture and knowledge, attitudes, and practices in a
multicenter Veterans Affairs quality improvement initiative to prevent methicillin-resistant Staphylococcus aureus. Am J Infect
Control. 2012;40(2):138–143.
Houser J. A model for evaluating the context of nursing care delivery. J Nurs Adm. 2003;33(1):39e47.
Yuki GA. Leadership in organizations global edition. Harlow (UK): Pearson Education Limited; 2013.
Adair J. Action-centred leadership. New York, NY: McGraw-Hill; 1973.
Saint S, et al. The importance of leadership in preventing healthcare-associated infection: results of a multisite qualitative
study. Infect Control Hosp Epidemiol. 2010; 31(9): 901-907.
Grimm JW. Effective leadership: making the difference. J Emerg Nurs. 2010;36(1):74-77.
Crevani L, Lindgren M, Packendorff J. Leadership, not leaders: on the study of leadership as practices and interactions.
Scand J Management. 2010;26(1):77-86.ims.
Sims HP, Faraj S, Yun S. When should a leader be directive or empowering? How to develop your own situational theory of
leadership. Business Horizons. 2009;52(2):149-158.
Further reading & references

Vinkenburg CJ, et al. An exploration of stereotypical beliefs about leadership styles: is transformational leadership a route to
women’s promotion? The Leadership Quarterly. 2011;22(1):10-21..
Rolfe P. Transformational leadership theory: what every leader needs to know. Nurse Leader. 2011;9(2):54-57.
Bass BM. The Bass handbook of leadership: theory, research, and managerial applications. Fourth edition. New York, NY:
Free Press; 2008.
Palmer R, Rayner H, Wall D. Multisource feedback: 360-degree assessment of professional skills of clinical directors. Health
Serv Manage Res. 2007;20(3);183-188.
Goleman D. Leadership that gets results. Harvard Business Rev. 2000; March–April.
Kets de Vries MF et al. Development and application of the leadership archetype questionnaire. Int J Human Res Manage..
2010;21(15):2848-2863.
Briggs I, Myers P. Gifts differing: understanding personality type. Mountain View, CA: Davies-Black Publishing; 1995.
Carroll B, Ford J, Taylor S. Leadership. Contemporary critical perspectives. London: Sage Publications Ltd.; 2015.
Damani N. Simple measures save lives: an approach to infection control in countries with limited resources. J Hosp Infect.
2007; 65(S1):151-154.
Session 3:

Implementation
strategies and
behavioural
change
Competencies

• Describe key IPC implementation strategies including considerations of

behavioural change, system change, multimodal strategies and
campaigning.

• Lead the development and implementation of behavioural components

related to IPC programmes.

• Evaluate the effectiveness of behavioural interventions and components

related to an IPC programme.
Learning objectives

• Define implementation as well as implementation science.

• Describe factors supporting successful implementation of
interventions.
• Recognize implementation components in available WHO
materials.
• Critique experiences reporting on implementation of IPC
interventions.
• Be familiar with individual, team, organization and societal
factors influencing implementation.
Key points

The WHO core components are a road map to indicate how IPC
can effectively prevent harm due to HAI and AMR.
Implementation, including effective leadership, is key to
translate guidelines into practices.
• Not always easy and takes time.
• Multimodal/multidisciplinary strategies support implementation
(monitoring approaches; patient-centred; integrated within
clinical procedures; innovative and locally adapted; tailored to
specific cultures and resource level).
• Understanding quality improvement methodology is important.
Implementation and
behavioural change strategies
Why these are important for successful IPC

Quality improvement interventions in IPC require individual,

team and organizational behaviour change.
Understanding cultural, behavioural, organizational and
clinical factors influencing behaviour change is essential for the
successful implementation of guidelines and interventions.
Several psychological frameworks have been used to
understand how the different factors interplay.

The implementation of guidelines into

practice

Behaviour change through

multimodal strategies
What do we mean by
‘implementation’?

Implementation is the
translation of research
evidence into clinical,
organizational,
professional practice.
(Ferlie, 2000)

Ferlie E, Fitzgerald L, Wood M. Getting evidence into clinical practice: an organisational behaviour perspective. J Health Serv Res Policy. 2000;5(2):96–102.
What is required for
successful implementation?
Context
• Inner context
• Local and organizational
• leadership support
• culture
• organizational priorities
• Outer context
• policy drivers and
priorities
• incentives and
mandates
• networks How does an understanding of context
help implement a sharps safety
improvement?
What is required for
successful implementation?

Inner context

• Do organizational leaders believe there

is a problem?

• Do leaders prioritize sharps safety?

Outer context

• Are there national guidelines or

mandates on sharps safety?

• Is there a national campaign to reduce

sharps?
What is required for
successful implementation?

Context Innovation
• Inner context • Added benefit of
• Local and organizational the intervention
• leadership support • Ease of use
• culture • Evidence
• organizational priorities • research
• Outer context • clinical
• policy drivers and • experiential
priorities
• incentives and
mandates
• networks
What is required for
successful implementation?

Context Innovation Recipients

• Inner context • Added benefit of • Motivation
• Local and organizational the intervention • Values/beliefs
• leadership support • Ease of use • Goals
• culture • Evidence • Skills
• organizational priorities • research • Knowledge
• Outer context • clinical • Time
• policy drivers and • experiential • Resources
priorities • Support
• incentives and • Opinion leaders
mandates • Power
• networks • Authority
What is required for successful
implementation?
Context Innovation Recipients
• Added benefit • Motivation
• Inner context
• Ease of use • Values/beliefs
• Local and organizational
• Evidence • Goals
• leadership support
• research • Skills
• culture
• clinical • Knowledge
• organizational priorities
• experiential • Time
• Outer context
• Resources
• policy drivers and
• Support
priorities
• Opinion leaders
• incentives and
• Power
mandates
• Authority
• networks

Social, cultural and organizational Process of implementation

factors (for example, plan, evaluate and
reflect)
Practical examples: core
component 1 (IPC programmes)
Extracts from the Interim Practical Manual supporting national implementation of the WHO Guidelines on
core components of infection prevention and control programmes

Outer context

Inner context,
innovation and
recipients

http://www.who.int/infection-prevention/tools/core-components/cc-implementation-guideline.pdf?ua=1

07/03/2018 | Title of the presentation 77

WHO implementation aids

http://www.who.int/infection-prevention/tools/en/
Hand hygiene multimodal
improvement strategy
Supporting implementation

Handout 3
Example of successful
implementation using a
multimodal strategy Context
• December 2006-08, 55 departments in 43
hospitals in Costa Rica, Italy, Mali,
Pakistan, and Saudi Arabia.
Innovation
• WHO hand hygiene multimodal strategy.

Recipients
• Intervention launch endorsed by the
Minister of Health.

• Increased dispensers at point of care.

Allegranzi B, et al. Global implementation of WHO's multimodal strategy for improvement of hand hygiene: a quasi-experimental study. Lancet Infect Dis. 2013;13(10):843-851.
Revisiting wasteful and
unnecessary practices
(Refer to the student handbook for the full list)

Routine environmental
swabbing
Routine use of disinfectants
for environmental cleaning
Unnecessary use of These are ALL
injections behaviours
Overuse of antibiotics

Overuse of urinary catheters

07/03/2018 | Title of the presentation 81

Understanding behaviour to
support implementation
The three key steps

1. IDENTIFY 2. DESIGN 3. IMPLEMENT

BEHAVIOUR INTERVENTION INTERVENTION

• Successful implementation needs changes in the behaviour of

individuals, teams and organizations.

• Different theories have tried to explain the most important components

of behaviour change.

• Lasting behaviour change needs an assessment of the factors

influencing individuals and organizations.
What would you like to do?
1. Identify behaviour that needs addressing

Can be used for any IPC-related behaviour to identify

1. IDENTIFY
what action is needed to address capability,
BEHAVIOUR opportunity and motivation of health workers

CAPABILITY Psychological/physical ability

MOTIVATION Plan, believe, want

Physical, environmental,
OPPORTUNITY social

Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;;6:42.
Michie et al (2011) Implementation Science
Hand hygiene example
How can we influence HCW capability, motivation and opportunity to do the right
thing?

1. IDENTIFY
BEHAVIOUR
MOTIVATION
• Do HCWs believe the
evidence that hand hygiene
works?
CAPABILITY • Is there a campaign and
• Do HCWs know the fi reminders to promote hand
moments for hand hygiene?
hygiene?
• Do they know the correct
technique?

• Is handrub available at the

OPPORTUNITY• point of care?
Is here a system for
replenishing empty bottles?
Michie et al (2011) Implementation Science • Do the sinks work?
What would you like to do?
2. Design your intervention

1. IDENTIFY 2. DESIGN
BEHAVIOUR INTERVENTION

Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42.
What would you like to do?
Focus on the ‘red’ part of the behaviour change wheel

2. DESIGN
INTERVENTION
Education = knowledge
Persuasion = communication
Incentives = reward
Coercion = punishment
Training = skills
Restriction = limits
Environmental restructuring
Modelling = role model
Enablement = barriers

Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;;6:42.
What would you like to do?
Identifying measures in optimal injection safety

2. DESIGN Measure to be used Yes/No

INTERVENTION Education = knowledge
Persuasion = communication
Incentives = reward
Coercion = punishment
Training = skills
Restriction = limits
Environmental restructuring
Modelling = role model
Enablement = barriers
Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011; 3;6:42.
What would you like to do?
Focus on the ‘grey’ part of the behaviour change wheel

2. DESIGN
INTERVENTION

Communication/marketing
Legislation
Service provision
Regulation
Fiscal measures
Guidelines
Environmental/social planning

Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;;6:42.
Implement intervention
The WHO five-step cycle

3. IMPLEMENT
INTERVENTION

Based on the validated approach to implementation developed in relation to the WHO guidelines on hand hygiene in health care (2009)
The five implementation steps
Step Actions
1. Preparing for Ensure that all of the prerequisites that need to be in place for success are
action addressed, that is, planning and coordination of activities, identification of
roles and responsibilities and the necessary resources (both human and
financial) and infrastructures, and identifying key leaders and ‘champions’,
including an overall coordinator and deputy.

2. Baseline Conduct an exploratory baseline evaluation of the current situation,

assessment including identification of existing strengths and weaknesses.

3. Developing and Use the results of the baseline assessment to develop and execute an
executing an action plan based around a multimodal improvement strategy.
action plan

4. Evaluating Conduct a follow-up evaluation to assess the effectiveness of the plan with a
impact focus on its impact, acceptability and cost-effectiveness.

5. Sustaining the Develop an ongoing action plan and review cycle to support the long-term
programme over impact and benefits of the programme and the extent to which it is
embedded across the health system and country, thus contributing to its
the long term overall impact and sustainability.
90
How this fits together

• Context
1. IDENTIFY
BEHAVIOUR • Innovation
• Recipients

• National &
facility IPC
assessment
tools

• National and facility

IPC assessment tools

• Project management
The use of quality improvement
methods

(For example, Plan-Do-Study-Act [PDSA] cycle)

• PDSA cycles are ideal for small,

frequent tests of ideas before making
larger, system-wide changes.

• They can be used in adjunct with other

quality improvement approaches.

• The United States Institute for

Healthcare Improvement incorporates
PDSA cycles as part of its model to
accelerate improvement.

*PDSA Cycle graphic used courtesy of The W. Edwards Deming

Institute®
W. Edwards Deming, The New Economics for Industry, Government, Education, ©1994 The W. Edwards Deming Institute, published by The MIT Press, figure 13, p. 132.
Taking action: steps 4 & 5 in twinning partnerships for Improvement. Geneva: World Health Organization; 2018

92
IPC implementation in
practice
Group work 2

What behaviour required

changing?
What was the intervention
implemented?
• Could you identify context,
innovation and recipients?

How was impact measured?

What leadership skills were
used to resolve the challenges?
Nyiratuza A et al, (2016) "A quality improvement project to improve the accuracy in reporting hospital acquired infections in post cesarean section patients in a district hospital in Rwanda", On the Horizon, Vol. 24
Issue: 4, pp.319-326,
 Summary answers
Question Sample answer
Behaviour Under-reporting of HAI. At the individual level, there was only
one nurse. At the team level, a team approach was absent. At
the organizational level, the organization did not value data.
Intervention • Interventions: new ways of reporting; new and standardized
definitions; new tools; validation teams; training; guidelines.
• Context: leadership support; buy-in of senior managers;
open culture; readiness to change; organizational priority.
• Innovation: used existing validated tools – tool acceptance;
tools easy to use; tools based on research.
• Recipients: team approach; those with power/authority
mandated the change (chief nursing officer, head of
maternity); staff motivated; staff familiar with resources/tools
Impact Used quantitative indicators, that is, the difference between HAI
measurement rates detected through routine unit reports and the validation
team.
Leadership Elements of transformational and transactional leadership styles
skills used - engagement, involvement, communication to secure buy-in;
07/03/2018 | Title of the presentation 94
continuous follow-up.
Key literature

WHO. A Guide to the implementation of the WHO multimodal hand hygiene improvement dtrategy. 2009.
http://www.who.int/gpsc/5may/Guide_to_Implementation.pdf
WHO. Guidelines on core components of infection prevention and control programmes at the national and
acute health care facility level. 2016.
http://apps.who.int/iris/bitstream/10665/251730/1/9789241549929-eng.pdf?ua=1

TDR. UNICEF/UNDP/World Bank/WHO. Implementation research toolkit. 2014.

http://www.who.int/tdr/publications/year/2014/ir-toolkit-manual/en/
References

Saint S, Howell JD, Krein SL. Implementation science: how to jumpstart infection
prevention. Infect Control Hosp Epidemiol. 2010;31(Suppl. 1):S14-S17.

Ferlie E, Fitzgerald L, Wood M. Getting evidence into clinical practice: an organisational

behaviour perspective. J Health Serv Res Policy. 2000;5(2):96–102.

Eccles MP, Mittman MB. Welcome to implementation science. Implement Sci. 2006;1:1.

Andreasen A. Marketing social change--changing behavior to promote health, social

development, and the environment. San Francisco, CA: Jossey-Bass; 1995.
Evidence review: social marketing for the prevention and control of communicable
disease. Stockholm: European Centre for Disease Prevention and Control; 2012.
http://ecdc.europa.eu/en/publications/Publications/Social-marketing-prevention-control-
of-communicable-disease.pdf
Session 4:

Effective
communication
and advocacy
Competencies

• Advocate for the use of effective communication approaches to

facilitate multidisciplinary interactions.
• Source or support development of suitable IPC communication
resources for citizens, users and HCWs.
• Encourage active listening and use right language to encourage
constructive multidisciplinary discussions.
• Demonstrate communication values that foster building or
strengthening multidisciplinary relations.
• Communicate effectively with key external stakeholders about IPC
recommendations.
Learning objectives

• Define communication.

• Explain importance of communication towards optimal IPC.

• List components of the communication process.

• Describe communication channels frequently used in IPC.

• Select and apply suitable communication approaches to different real-

life scenarios.

• Define conflict.

• Describe skills and behaviours that contribute to optimal conflict

resolution.
Key points

• Effective communication is a critical part of IPC

leadership. Many IPC situations require effective
interpersonal communication, for example:
• implementing a new innovation
• dealing with infection outbreaks, epidemics,
emergencies…
• Providing information and modifying behaviours of
professionals and patients demands effective
communication.
What is communication?
The deliberate or accidental transfer of information

Essentially, communication is Likely to include thoughts or

feelings. (Pearson J et al, 2000)
Good communication would allow the parties involved to
speak and be listened to without interruption, ask questions,
and express thoughts in an understandable manner for all
individuals or groups involved.

Pearson J, Nelson P. Introduction to human communication: understanding and sharing. Boston, MA: McGraw-Hill; 2000.
Using communication skills in
IPC

• Can you think of any IPC situation where you had to

use communication skills?
• What worked well and what was challenging?
Using communication skills in
IPC

Can you think of any IPC situation where you had to use
communication skills?
• Developing leaflets for patients and family members or staff.
• Leading multidisciplinary teams during outbreak investigations.
• Reporting to hospital management on performance indicators.
• Responding to journalists about hospital performance.
• Presenting a successful hand hygiene programme at a conference.
• Advocating for more resources (including an IPC budget).
Essential components of
communication
Seven key elements

Seven key elements are essential in the process of

communicating information.
1. People involved
2. Message(s) sent and/or perceived
3. Channel(s) used
4. Amount of ‘noise’ present
5. Context where communication happens
6. Feedback sent in response
7. Effect on the people involved
Communication channels
(Not exhaustive)

• Direct communication • E-learning systems

• Practice regulations • Intranet/Internet
• Education • E-mail
• SMS • Bleep
• Mass media • Social networks
• Telephone communication • Radio
• Meetings • Internet
• Policy, guidelines • Banners/posters
• Care pathways
• Information packs
• Handbooks
• Formal education
• Informal training

(Edwards 2012)
Communication channels

Which channel works best in the following situations?

• A new type of urinary catheter is going to be used from now on in
your facility.
• A surgeon had a sharps injury whilst operating on a patient with a
bloodborne virus and she is worried about her career.
• A peer IPC focal person would like to meet and discuss creating a
network of IPC focal persons in the country.
• WHO has launched a new campaign on IPC and AMR and you
want to launch in the facility/district/nationally.
Communication channels
Sample answers

Situation Channel
A new type of urinary catheter is going Meetings, guidelines and standard
to be used from now on in your facility. operating procedures, training (formal
and informal), Grand Rounds, posters.
A surgeon had a sharps injury whilst Direct face-to-face communication,
operating on a patient with a telephone.
bloodborne virus and she is worried
about her career.
A peer IPC focal person would like to Direct face-to-face communication.
meet and discuss creating a network of
IPC focal persons in the country.
WHO has launched a new campaign on Meeting with managers to secure
IPC and AMR and you want to launch in agreement, handbooks and advocacy
the facility/district/nationally. materials, videos, mass media, radio,
social media, intranet, posters/banners.
Managing conflicts in IPC
Introducing change may sometimes result in conflict

• Conflict and tensions are natural,

routine situations in the lives of HCWs
and organizations.

• Conflict is “a dynamic process between

individuals and/or groups as they
experience negative emotional
reactions to perceived disagreements
and interference with the attainment of
goals”. (Barki & Hartwick, 2004)

• The anticipation of conflict and its effect

on people, teams, organizations are
much more negative than conflict itself.
www.pixabay.com (CC0 Public Domain, Free for personal and commercial use, No attribution required)
www.pexels.com (CC0 License, Free for personal and commercial use, No attribution required)
Barki H, Hartwick J. Conceptualizing the interpersonal conflict. Int J Conflict Managmt. 2004;15(3):216-244.
Leader’s skills for dealing
with conflicts

• As a leader, you should

Excellent Situational
communication awareness demonstrate these skills and
qualities when dealing with
Fostering conflict.
Role modelling
positive culture
• They may also serve to prevent
Organizational such conflict.
Zero tolerance
support
• Communication is an important
Visibility and Being
aspect of conflict resolution.
presence responsive
Resolving conflicts
constructively
Plan and prepare the environment and the people involved

1. Choose the right moment.

- Avoid distractions, be prepared and able to spend time discussing.

2. Focus your attention on ‘active listening’.

- Take turns to speak, summarize and paraphrase each intervention

3. Set a goal of finding a solution.

- Work together and think of ‘win-win’ outcomes.

4. Identify what is needed for all the parties involved.

- Aim to resolve each issue affecting each party, empathise.

5. Disentangle cognitive and emotional aspects of the conflict.

- Disagree about ideas or approaches, but do not personalise.
Reference and further reading
Brewster L, Tarrant C, Dixon-Woods M. Qualitative study of views and experiences of performance management for
healthcare-associated infections. J Hosp Infect. 2016;94(1):41-47.
Hale R, et al. Working practices and success of infection prevention and control teams: a scoping study. J Hosp Infect.
2015;89(2):77-81.
Elliott P. Infection control: a psychosocial approach to changing practice. Oxford: Radcliffe Publishing; 2009.
Almost J, et al. Managing and mitigating conflict in healthcare teams: an integrative review. J Adv Nurs. 2016;72(7),1490–
1505.
Barki H, Hartwick J. Conceptualizing the interpersonal conflict. Int J Conflict Managmt. 2004;15(3):216-244.
Jehn K. A multimethod examination of the benefits and detriments of intragroup conflict. Adm. Sci. Q. 1995;40:256-282.
Friedman R, Currall S, Tsai JC. What goes around comes around: the impact of personal conflict styles on work conflict and
stress. Int J Conflict Managmt. 2000;11(1):32-55.
Jehn K, Bendersky C. Intragroup conflict in organizations: a contingency perspective on the conflict-outcome relationship. In:
Staw B, Cummings LL, editors. Research in organizational behavior, Greenwich, CT;JAI Press; 2003:189-244.
Pearson J, Nelson P. Introduction to human communication: understanding and sharing. Boston, MA: McGraw-Hill; 2000.
Barnlund DC (2008). A transactional model of communication. In; Mortensen CD, editor. Communication theory (2nd ed.).
New Brunswick, NJ: Transaction; 2008:47-57.
Edwards R, et al. Communication strategies in acute health care: evaluation within the context of infection prevention and
control, J Hosp Inf. 2012;82: 25-29.
References and further reading

Abad C, Fearday A, Safdar N. Adverse effects of isolation in hospitalised patients: a systematic review. J Hosp Infect.
2010;76(2):97-102.
Best practices for communicating with the public during an outbreak. Report of WHO Expert Consultation on Outbreak
Communications. Singapore, 21–23 September 2004. Geneva: World Health Organization; 2005.
http://www.who.int/csr/resources/publications/WHO_CDS_2005_32web.pdf?ua=1

WHO. Outbreak communication guidelines. 2005.

http://apps.who.int/iris/bitstream/10665/69369/1/WHO_CDS_2005_28_eng.pdf?ua=1&ua=1

WHO. Effective media communication during public health emergencies. 2005.

http://www.who.int/csr/resources/publications/WHO%20MEDIA%20FIELD%20GUIDE.pdf

Technical Report. Rapid evidence review of interventions for improving health literacy Insights into health communication,
Stockholm: European Centre for Disease Prevention and Control; 2012.
http://ecdc.europa.eu/en/publications/Publications/1205-TER-Improving-Health-Literacy.pdf

WHO. Effective communications: participant handbook: communications training programme for WHO staff. 2015.
http://www.who.int/communicating-for-health/resources/participant-handbook-english.pdf?ua=1
Reference/
Vayalumkal J, et al. Effective communication of infection control data: how do we give them what they want?. Am J Inf
Control. 2014;42(6):S72.
Abraham T. Risk and outbreak communication: lessons from alternative paradigms. Bull World Health Org. 2009;87(8):604-
607.
Recap on key points
Session 1 Session 2 Session 3 Session 4

Introduction to Drill-down on IPC Exploration of Focus on

leadership in the leadership: implementation and communication and
context of: what makes a good behaviour change: advocacy:
the core leader? implementation communication skills
components; relevance of success factors; in IPC;
multimodal strategy; leadership to IPC; behaviour change choosing the right
implementation leadership and implementation; communication
resources; characteristics; quality improvement channels;
project management; types of leaders; cycles and leadership and
IPC interlinkages; leadership implementation; conflict resolution.
principles of adult challenges and leadership
learning. opportunities. challenges and
solutions.
113
Thank you

Global IPC Unit

WHO
20 Avenue Appia
1211 Geneva 27
Switzerland
WHO Infection Prevention and Control Unit 2017