Getting to zero: An evaluation of the Department of Health (England) Improvement Programme to reduce MRSA bacteraemias

Background:  England has reduced the number of MRSA bacteraemias by 74% since the Department of Health (England) Clean Safe Care improvement programme began in 2004. The programme interventions used to facilitate adoption, spread and sustainable change in organisational, team and individual behaviour included a national target for a 50% reduction in MRSA bacteraemia cases between 2005-2008, performance management, provision of tools and techniques for evidence based care, targeted improvement support and knowledge transfer.

Objective: Evaluate the experience and impact of the programme in promoting and embedding the prevention of healthcare associated infections (HAI) as ‘everybody’s responsibility’ and identifying the contexts and mechanisms that were critical to improvement.

Methods: A multiple methods design using nine case studies and existing programme data. Case studies were purposively selected to provide perspectives from national health service (NHS) acute care trusts (ACT) of varying sizes and complexity and facing different levels of challenge in reducing their MRSA bacteraemias. Data was collected using qualitative interviews with key individuals and practitioner groups and documentary and observational data. Analysis was undertaken using a realist framework (Pawson and Tilley 1997) to identify what worked for whom in what circumstances?

Results: Setting a national target was crucial to raising the profile of preventing HAI generally and MRSA bacteraemias in particular. NHS ACT emerged as being Improvement Resistant or Improvement Responsive. The programme and targeted support team were catalysts in moving trusts with high numbers of MRSA bacteraemias from ‘resistance to responsiveness' and creating the conditions for:

• A cultural shift.
• Supporting and cultivating leaders and champions.
• Challenging denial and complacency.
• Driving a shared understanding of where the ACT problems lay through better date, information systems and feedback.
• Changing the mindset of practitioners through the use of root cause analysis.
• Increasing the reliability of evidence based care practices.

Conclusions: Analysis of the experience and perceptions of the programme stakeholders provides insight into the mechanisms and contexts in which this national infection prevention improvement programmes are effective in achieving transformational change in the prevention of HAI.