The evolution of a checklist into an infection prevention and control process.

Clostridium difficile (C.difficile) infection (CDI) has the potential to be a severe or fatal
infection, occurring predominantly in the elderly and other vulnerable patients (NHS England,
2014, a). Since 2010, the Infection Prevention and Control Team in association with staff
across an acute Trust have undertaken a collaborative daily checklist review which later
became known as the daily review checklist process (DRCP) for all CDI patients. This review
included feedback at ward and organisational levels. The DRCP incorporated completion of
a checklist through contemporaneous clinical patient assessment and ward level
examination of infection prevention and control practices.
A grounded theory approach was used to explore the influence of the DRCP on the care and
management of patients with CDI. The study consisted of two distinct phases. Phase 1
included a retrospective documentary analysis that examined all checklists (n=928)
completed between July 2010 and December 2011. Phase 2 explored the perceptions of
different groups of staff (Infection prevention and control practitioners [IPCPs], matrons,
ward based staff and senior managers) concerning the influence the DRCP had on the care
and management of patients with CDI.
The findings from Phase 1 highlighted that the DRCP was used as a form of real time
monitoring, providing organisational surveillance to assure safe and effective infection
prevention and control practice for inpatients and appropriate and timely responses when
care or standards of infection prevention and control may have been suboptimal.
Phase 2 findings indicated that staff perceived that the DRCP had been influential in the care
and management of patients with CDI. Three main themes were developed: education and
learning, developing and sustaining relationships and leadership and change management
that offer an explanatory framework for understanding the interactive processes that may
have contributed to the care and management of patients with CDI. In terms of education
and learning, ward staff valued the situated nature of learning provided by the review
process. The DRCP also appeared to conceptualise CDI as an illness suggesting
embodiment. Traits such as approachability and helpfulness of the key players involved in
the DRCP (IPCPs and matrons) appeared to be fundamental to the DRCP and were
particularly significant for developing and sustaining relationships and team work between
staff. Finally the DRCP illustrated clinical leadership in practice with the IPCP and matron
providing leadership and assistance in the care and management of patients with CDI.
The DRCP evolved from a checklist serving as an instrument of surveillance and monitoring
to an interactive educative facilitative process assisting staff in the care and management of
patients with CDI and in compliance with general infection prevention and control practice.
What emerged during the evolution of the DRCP was the influence of a human factors
approach and the impact that communication, teamwork, situated learning and leadership
had on the process.
The key implication that emerged from this study included the contribution of human factors
theory to behavioural change and improved patient outcomes. Incorporated within this was
the influence situated learning can make to effecting change in knowledge and compliance
and the impact relationship development can have on infection prevention and control
practices and potentially processes that require different professionals to work together to
improve patient outcomes.