Critical Appraisal Skills Programme (CASP) tool has been used for critical appraisal

1. JOURNAL PRESENTATION
Presenter : Dr. Sonali Kumari Shah
JR(2018)
SPH AND CM
BPKIHS,DHARAN
11th March, 2021

2. The Importance of Leadership in Preventing
Healthcare-Associated Infection: Results of a
Multisite Qualitative Study
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3. Contents
• Introduction
• Objective
• Methodology
• Result
• Discussion
• Conclusion
• Limitation
• Reference
• Critical appraisal
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4. Introduction
• Peter Drucker famously stated that “management is doing
things right; leadership is doing the right things.”
• “Manager manages things ,leaders lead people.”
• It is necessary to be good leader first to be a good manager.
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5. Definition of leadership
• The leadership is defined as “influence, that is, the art or
process of influencing people so that they will strive willingly
and enthusiastically toward the achievement of group goals”-
D.C.Joshi
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6. CHARACTERISTICS OF LEADERSHIP
• Leader must have followers
• It is working relationship between leader and followers
• Purpose is to achieve some common goal or goals
• A leader influences his followers willingly not by force
• Leadership is exercised in a given situation
• Leadership is a power relationship
• It is a continuous process
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7. Leadership Styles
• There are various styles the leaders adopt; these styles may be practiced
by different leaders and also by the same leader in different situations:
1. Situational Leadership
• Situational leaders adapt their leadership style to individual situations.
• This type of leadership is based on a relationship between the leader’s
supportive and directive behaviour and the follower’s levels of
development.
• In situational leadership the context shapes how the leader behaves.
Example:
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Mahatma Gandhi

8. 2.Transformational Leadership
• Transformational leaders are less relational and emotional in their
interactions with followers.
• They thrive on developing and communicating a vision and
empowering followers to embrace that vision.
• They have and share a vision for what an organisation should and
could be. This type of leader develops others to exceed their own
self-interests for a higher purpose.
• Examples:
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Nelson Mandela Mother Teresa

9. 3.Transactional Leadership
• Transactional leaders are more focused on the analytical
aspects of their role.
• This includes evaluation, measurement, and standardization
aligned with performance.
• These leaders function within a clear chain of command,
motivating their followers through reward and punishment.
• Example:
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Bill Gates

10. Hospital-Acquired Infections (HAI)
• HAI continue to be a source of great medical and economical
strain for clinics and facilities across the world.
• A hospital-acquired infection— also called “nosocomial
infection (NI) ” can be defined as: -
• An infection acquired in hospital by a patient who was
admitted for a reason other than that infection. - An infection
occurring in a patient in a hospital or other health care facility
in whom the infection was not present or incubating at the
time of admission.
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11. Characteristic of HAI
• For a HAI, the infection must occur:
 Up to 48 hours after hospital admission
Up to 3 days after discharge
Up to 30 days after an operation
• In a healthcare facility when someone was admitted for
reasons other than the infection
• Ideally, it should be less than 1-2%
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12. Hospital Acquired Infection Rate
• HAI Rate = (i / d)×100 Where,
• i = Total Number of Hospital Acquired Infections in a given
period
• d = Total Number of Discharges (Including Deaths) in a given
period
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13. Types of HAI
• Hospital-acquired infections are caused by viral, bacterial, and
fungal pathogens.
• The most common types are bloodstream infection (BSI),
pneumonia (eg, ventilator-associated pneumonia [VAP]),
urinary tract infection (UTI), and surgical site infection (SSI).
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14. Implications of HAIs
• HAIs not only threaten the patients' health and life but also
bring additional economic burden to the patients
and healthcare system including direct economic loss and
prolonged hospitalization.
• Total hospital length of stay (LOS) is known to be prolonged by
the occurrence of HAI.
•
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15. Leadership in HAI
• An IPC leader should seek to continuously improve
implementation of IPC programmes and all core components.
As a leader these soft skills can be used to influence
multimodal strategies to:
• Build a system (including infrastructures) that supports IPC
practices.
• Teach others about IPC.
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16. • Check that the organization is doing the right thing at the right
time.
• Sell it to others and keep them interested in adopting and
maintaining excellent IPC practices.
• Live it by embedding excellent IPC practices across
organization’s culture.
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17. Qualitative Research Methods
• Qualitative research involves collecting and analyzing non-
numerical data (e.g., text, video, or audio) to understand
concepts, opinions, or experiences. It can be used to gather in-
depth insights into a problem or generate new ideas for
research.
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18. Types of Qualitative method
1.Phenomenological Method
• Describing how any one participant experiences a specific event is
the goal of the phenomenological method of research. This method
utilizes interviews, observation and surveys to gather information
from subjects.
2.Ethnographic Model
• It immerses subjects in a culture that is unfamiliar to them. The
goal is to learn and describe the culture's characteristics much the
same way anthropologists observe the cultural challenges and
motivations that drive a group.
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19. 3.Grounded Theory Method
• This method tries to explain why a course of action evolved the way
it did. Theoretical models are developed based on existing data in
existing modes of genetic, biological or psychological science.
4.Case Study Model
• Unlike grounded theory, the case study model provides an in-depth
look at one test subject. The subject can be a person or family,
business or organization, or a town or city. Data is collected from
various sources and compiled using the details to create a bigger
conclusion.
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20. Qualitative data analysis
Most types of qualitative data analysis share the same five steps:
1. Prepare and organize data. This may mean transcribing interviews or typing up
fieldnotes.
2. Review and explore data. Examine the data for patterns or repeated ideas that
emerge.
3. Develop a data coding system. Based on initial ideas, establish a set of codes
that can be applied to categorize data.
4. Assign codes to the data. For example, in qualitative survey analysis, this may
mean going through each participant’s responses and tagging them with codes
in a spreadsheet. As you go through your data, you can create new codes to
add to your system if necessary.
5. Identify recurring themes. Link codes together into cohesive, overarching
themes.
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22. Advantages of qualitative method
• Flexibility
The data collection and analysis process can be adapted as new ideas or
patterns emerge. They are not rigidly decided beforehand.
• Natural settings
Data collection occurs in real-world contexts or in naturalistic ways.
• Meaningful insights
Detailed descriptions of people’s experiences, feelings and perceptions can
be used in designing, testing or improving systems or products.
• Generation of new ideas
Open-ended responses mean that researchers can uncover novel problems or
opportunities that they wouldn’t have thought of otherwise.
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23. Disadvantages of Qualitative methods
• Unreliability
The real-world setting often makes qualitative research unreliable
because of uncontrolled factors that affect the data.
• Subjectivity
Due to the researcher’s primary role in analyzing and interpreting
data, qualitative research cannot be replicated. The researcher
decides what is important and what is irrelevant in data analysis, so
interpretations of the same data can vary greatly.
• Limited generalizability
Small samples are often used to gather detailed data about specific
contexts. Despite rigorous analysis procedures, it is difficult to draw
generalised conclusions because the data may be biased and
unrepresentative of the wider population.
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24. Characteristics of qualitative research methods
1. Qualitative research methods usually collect data at the sight, where the
participants are experiencing issues or problems. These are real-time data
and rarely bring the participants out of the geographic locations to collect
information.
2. Qualitative researchers typically gather multiple forms of data, such as
interviews, observations, and documents, rather than rely on a single
data source.
3. This type of research method works towards solving complex issues by
breaking down into meaningful inferences, that is easily readable and
understood by all.
4. Since it’s a more communicative method, people can build their trust on
the researcher and the information thus obtained is raw and
unadulterated.
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26. About The Article
Journal : Infection control and hospital epidemiology
Received on: January 7, 2010
Accepted on : March 8, 2010
Electronically published : July 26, 2010
Authors :
Sanjay Saint, MD, MPH; Christine P. Kowalski, MPH; Jane Banaszak-Holl,
PhD; Jane Forman, ScD, MHS; Laura Damschroder, MS, MPH; Sarah L. Krein,
PhD, RN
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27. Reasons For Choosing This Article
• Topic of interest
• This articles is related to my field of study.
• As my thesis is based on the mixed method and the article is
based on similar method .
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28. INTRODUCTION
• Every year, approximately 100,000 people die of healthcare
associated infection (HAI) in American hospitals.
• The substantial economic costs of HAI will likely be increasingly
borne by hospitals, because the Centers for Medicare and
Medicaid Services no longer reimburses hospitals for the extra
cost of caring for patients who develop certain infections during
hospitalization.
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29. Introduction
.
• Although evidence-based recommendations are available to
prevent HAI, hospitals have implemented these recommended
practices to a highly variable extent.
• To determine which practices US hospitals are using to prevent
infection, they conducted a national, multicenter study that
entailed both quantitative and qualitative assessment.
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30. OBJECTIVE
• Healthcare-associated infections (HAIs) are costly and causes substantial
morbidity.
• The authors wanted to understand why some hospitals were engaged in HAI
prevention activities while others were not.
• Because preliminary data indicated that hospital leadership played an
important role, they sought better to understand which behaviors are
exhibited by leaders who are successful at implementing HAI prevention
practices in US hospitals.
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31. Materials and methods
• This article reports the second and third phases of a 3-phase sequential
mixed-methods project.
• During the first phase of the project, they conducted a quantitative survey to
discover what hospitals are doing to prevent HAI.
• They mailed this survey in March 2005 to the lead infection preventionist at
719 hospitals in the United States, including all Veterans Affairs (VA) medical
centers and a stratified random sample of non-VA general medical and
surgical hospitals.
• 516 of the hospitals sent responses i.e. 72% hospitals.
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32. Phase 2
• Study area: They used purposeful sampling to select 14
hospitals on the basis of their responses to the survey.
• Study period : Interviews were conducted during the period
from July 2005 through May 2006.
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33. Phase 3
• Study area: They identified 6 hospitals that would make up a
useful sample to elaborate themes that were emerging.
• Study period : From October 2006 through September 2007
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34. • Ethical approval : Institutional review boards of VA Ann Arbor
Healthcare System and of each hospital visited.
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35. Sample selection criteria
• They chose 14 hospitals in Phase 2 , on the basis of their responses
to the survey, used or did not use various practices to prevent HAI
and that varied across a number of other characteristics (eg,
number of beds or VA or academic status).
• For the third phase of the project, they identified 6 hospitals that
would make up a useful sample to elaborate themes that were
emerging. One such theme was the role of hospital leadership in
HAI prevention activities.
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36. Data Collection
• During phase 2, they conducted 2–4 semi-structured phone
interviews with participants at each of 14 hospitals, for a total of 38
interviews with a mean duration of 60 minutes.
• They were audio recorded and transcribed by a medical
transcriptionist.
• At least 2 team members conducted each interview. The first
interviewee at each hospital was an infection preventionist, who
was then asked to recommend other informants. Snowball sampling
was used for recruitment of interviwees.
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37. • They also interviewed staff whom the infection preventionist
did not mention but who they thought would provide valuable
information.
• Their interview guide included questions about practices that
the hospital used to prevent HAI, organizational characteristics,
and the involvement of leadership.
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38. • In phase 3, they conducted another 48 interviews during site
visits to 6 hospitals.
• The goal of the site visits was to fill in gaps and to test their
interpretations of issues identified in the phone interviews or
further explore these issues.
• They observed the hospitals’ environments and obtained
perspectives from additional staff, including senior executives,
mid-level managers, and front-line clinicians.
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39. Data Analysis
• Analyses were conducted with use of rigorous qualitative
procedures and included all of the phone and site visit interviews.
• Summaries were prepared after each interview, and the team met
at least monthly to identify and discuss emerging themes.
• Extensive summary reports, including one focused on leadership
were generated for each site by using all transcripts from phases 2
and 3.
• These summaries were prepared independently by 4 members of
the study team, and emerging themes were identified.
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40. RESULTS
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41. 41
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42. 42
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43. 43
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44. Discussion
• Empirical data was collected from multiple sites that revealed
several key behaviors exhibited by hospital leaders who successfully
implemented HAI prevention practices.
• Notably, many of the most important leaders were not the senior
executives traditionally envisioned when the term “leader” is
mentioned.
•Instead, hospital epidemiologists, nurses, quality managers, and
infection preventionists played crucial leadership roles in their
hospital’s patient safety activities.
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45. Discussion
• Leadership styles can be broadly categorized as either transactional
or transformational.
• In general, transactional leaders guide their followers by ensuring
that roles and tasks are clearly specified and by using reward and
punishment as motivation.
• Transformational leaders may influence their followers by being
inspirational, providing a vision, and behaving in a manner that
serves as an example.
• In this study, transformational leadership was displayed by those
leaders who drove their staff to focus on a culture of clinical
excellence and by the hospital epidemiologist who was described
by his colleagues as inspiring. 45
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46. Discussion
• Several themes emerged from their qualitative analyses, including
general agreement that “vision,” “knowledge,” and “people skills”
were all characteristic of effective leaders.
• Similar to this findings about the importance of cultivating a culture of
clinical excellence, established leaders in their study also believed that
“organizational orientation”, dedication to the institution’s overall
success was a characteristic of effective leaders.
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47. Conclusion
They found that leadership broadly defined plays a key role in infection
prevention.
The qualitative assessment provides hospitals with suggestions of how
leaders can work to prevent HAI.
The difficult process of translating the findings of infection prevention
research into practice can be eased by leaders who heed the advice and
experiences of their colleagues who participated in this study.
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48. Limitations
• First, they did not seek a priority to discover the behaviors or styles
of successful leaders.
• Instead, midway through the study it became clear that leadership
played an important role; they then began further exploring the
behaviors that successful leaders exhibited.
• Second, the goal was not to generalize findings from a study sample
to a population but to provide information that could not be
gathered by means of a quantitative study.
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49. References
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1. Estimates of healthcare-associated infections. Centers for Disease Control and Prevention Web site.
http://www.cdc.gov/ncidod/dhqp/hai.html. Published 2009.
2. Accessed December 23, 2009. 2. Graves N. Economics and preventing hospital-acquired infection. Emerg Infect Dis 2004;10:561–
566. 3. Pronovost PJ, Goeschel CA, Wachter RM.
3. The wisdom and justice of not paying for “preventable complications.” JAMA 2008;299:2197–2199. 4. Saint S, Meddings JA, Calfee
DP, Kowalski CP, Krein SL. Catheter-associated urinary tract infection and the Medicare rules changes.
4. Ann Intern Med 2009;150:877–885. 5. Wald HL, Kramer AM. Nonpayment for harms resulting from medical care: catheter-associated
urinary tract infections. JAMA 2007;298:2782– 2784. 6. Yokoe DS, Mermel LA, Anderson DJ, et al.
5. Executive summary: a compendium of strategies to prevent healthcare-associated infections in acute care hospitals.
6. Infect Control Hosp Epidemiol 2008;29(suppl 1):S12–S21.
7. Lo E, Nicolle L, Classen D, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect
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8. Wong ES. Guideline for prevention of catheter-associated urinary tract infections. Am J Infect Control 1983;11:28–36.
9. Saint S. Prevention of intravascular catheter-associated infections. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds.
Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Agency for Healthcare Research and Quality publication no.
01-E058. Rockville, MD: Agency for Healthcare Research and Quality; 2001:163–184.
10. O’Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter–related infections. Infect
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11. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care–associated pneumonia, 2003:
recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004;53:1–36.
12. Dodek P, Keenan S, Cook D, et al. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia.
Ann Intern
13. Collard HR, Saint S, Matthay MA. Prevention of ventilator-associated pneumonia: an evidence-based systematic review. Ann Intern
Med 2003; 138:494–501.
14. Saint S. Prevention of nosocomial urinary tract infections. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Making
Health Care Safer: A Critical Analysis of Patient Safety Practices. Agency for Healthcare Research and Quality publication no. 01-E058.
Rockville, MD: Agency for Healthcare Research and Quality; 2001:149–162.
15. Saint S, Kowalski CP, Kaufman SR, et al. Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin
Infect Dis 2008;46:243–250.
16. Krein SL, Hofer TP, Kowalski CP, et al. Use of central venous catheterrelated bloodstream infection prevention practices by US
hospitals. Mayo Clin Proc 2007;82:672–678.
17. Krein SL, Kowalski CP, Damschroder L, Forman J, Kaufman SR, Saint S. Preventing ventilator-associated pneumonia in the United
States: a multicenter mixed-methods study. Infect Control Hosp Epidemiol 2008;29: 933–940.
18. Krein SL, Olmsted RN, Hofer TP, et al. Translating infection prevention evidence into practice using quantitative and qualitative
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22. Welch J. Winning. New York, NY: Harper Business, 2005.
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Pearson Education, 2005.
24. Collins J. Good to Great and the Social Sectors: A Monograph to Accompany Good to
Great. 1st ed. New York, NY: HarperCollins, 2005.
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Acad Manag Ann 2008;3:387–438.
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27. Patton M. Qualitative Research and Evaluation Methods. 3rd ed. Thousand Oaks, CA:
Sage Publications, 2002.
28. Sandelowski M. Whatever happened to qualitative description? Res Nurs Health
2000;23:334–340.
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52. 29. Mason J. Qualitative Researching. Thousand Oaks, CA: Sage Publications, 2002.
30. Creswell J. Educational Research: Planning, Conducting, and Evaluating
Quantitative and Qualitative Approaches to Research. Upper Saddle River, NJ:
Merrill/Pearson Education, 2002.
31. Northouse P. Leadership: Theory and Practice. 5th ed. Thousand Oaks, CA: Sage
Publications, 2010.
32. Xirasagar S, Samuels ME, Stoskopf CH. Physician leadership styles and
effectiveness: an empirical study. Med Care Res Rev 2005;62:720–740.
33. Taylor CA, Taylor JC, Stoller JK. Exploring leadership competencies in established
and aspiring physician leaders: an interview-based study. J Gen Intern Med
2008;23:748–754. 34. Lobas JG. Leadership in academic medicine: capabilities
and conditions for organizational success. Am J Med 2006;119:617–621.
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53. CRITICAL APPRAISAL
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54. CASP tool
• The value of qualitative evidence synthesis for informing
healthcare policy and practice within evidence-based medicine
is increasingly recognised.
• The Critical Appraisal Skills Programme (CASP) tool is the most
commonly used tool for quality appraisal in health-related
qualitative evidence syntheses, with endorsement from the
Cochrane Qualitative and Implementation Methods Group.
Source: https://journals.sagepub.com/doi/full/10.1177/2632084320947559
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55. 55
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56. 1. Was there a clear statement of the aims of the
research?
• Yes
• There was a clear statement of the aims of the research.
Healthcare-associated infection (HAI) is costly and causes
substantial morbidity. The authors wanted to understand why
some hospitals were engaged in HAI prevention activities while
others were not. Because preliminary data indicated that hospital
leadership played an important role, they sought better to
understand which behaviors are exhibited by leaders who are
successful at implementing HAI prevention practices in US
hospitals. 56
6/22/2021

57. 2. Is a qualitative methodology appropriate?
• Yes.
• The authors use qualitative research to understand which behaviors
are exhibited by leaders who are successful at implementing HAI
prevention practices in US hospitals. As behavior is subjective and
not quantifiable. So, qualitative methodology is appropriate.
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58. 3. Was the research design appropriate to address the
aims of the research?
• Yes
• To determine which practices US hospitals are using to prevent
infection, the authors conducted a national, multicenter study that
entailed both quantitative and qualitative assessment.
• During the first phase of the project, they conducted a quantitative
survey at 719 hospitals in the United States and responses from 516
(72%) were received.
• On the basis of the survey data, they selected hospitals to participate in
the second and third phases of the study, during which they collected
and analyzed qualitative data to learn why hospitals are using certain
practices. 58
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59. 4. Was the recruitment strategy appropriate to the
aims of the research?
• Yes
• They chose 14 hospitals in Phase 2 , on the basis of their responses
to the survey, used or did not use various practices to prevent HAI
and that varied across a number of other characteristics (eg,
number of beds or VA or academic status).
• The first interviewee at each hospital was an infection
preventionist, who was then asked to recommend other
informants. Snowball sampling was used for recruitment of
interviwees. 59
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60. • For the third phase of the project, they identified 6 hospitals
that would make up a useful sample to elaborate themes that
were emerging. One such theme was the role of hospital
leadership in HAI prevention activities.
• They observed the hospitals’ environments and obtained
perspectives from additional staff, including senior executives,
mid-level managers, and front-line clinicians.
•
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61. 5. Was the data collected in a way that addressed the
research issue?
• Yes
• In phase 2, 14 purposefully sampled US hospitals were selected from among the
72% of 700 invited hospitals whose lead infection preventionist had completed a
quantitative survey on HAI prevention during phase 1.
• Qualitative data were collected during 38 semi-structured phone interviews with
key personnel at the 14 hospitals. During phase 3, they conducted 48 interviews
during 6 in-person site visits to identify recurrent themes that characterize
behaviors of successful leaders and to observe the hospitals’ environment. 61
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62. 6. . Has the relationship between researcher and
participants been adequately considered?
• No.
• The researcher has not mentioned about their own role, potential
bias and influence during
• (a) formulation of the research questions
• (b) data collection, including sample recruitment and choice of
location
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63. 7. Have ethical issues been taken into consideration?
• Yes
• Ethical clearance was obtained from Institutional review boards of
VA Ann Arbor Healthcare System and of each hospital visited.
• Anonymity of participants was also maintained.
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64. 8. Was the data analysis sufficiently rigorous?
• Yes
• Analyses were conducted with use of rigorous qualitative
procedures and included all of the phone and site visit interviews.
• Summaries were prepared after each interview, and the team met
at least monthly to identify and discuss emerging themes.
• Extensive summary reports, including one focused on leadership
were generated for each site by using all transcripts from phases 2
and 3.
• These summaries were prepared independently by 4 members of
the study team, and emerging themes were identified.
.
64
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65. 9. Is there a clear statement of findings?
• Yes
• Leadership plays an important role in infection prevention
activities. The behaviors of successful leaders could be adopted by
others who seek to prevent HAI.
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66. 10. How valuable is the result?
• The research is valuable.
• Every year, approximately 100,000 people die of healthcare associated infection
(HAI) in American hospitals. The substantial economic costs of HAI is very high.
• As the literature on the subject is replete with testaments to the importance of
leadership to an organization.
• Also, the role of leadership within a social sector, such as health care, is different
than that in a for-profit business and has received relatively little attention in the
peer-reviewed medical literature. 66
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67. THANK YOU!