“Top Down” Theory of Policy Implementation: A Critical Analysis

Successful policy implementation is a daunting task, but there are several steps that may be taken in order to implement a policy successfully.  First, one needs to identify the need for a policy. Once the need is established, then the goal(s) must also be clearly defined so that they can be understood by all.  In order to do so, the necessary political , administrative, technical and financial resources must be available, i.e. there is adequate support, staff, equipment and funds. The chain of command must also be  established.  This goal may act as reason why the policy should be implemented, and may provide the legitimacy necessary to ensure that others follow the policy.  During the development and formulation of the policy, it should be decided how the policy will be implemented, but the latter is not always the case.  Consideration of the implementation process is an important characteristic of the ‘top down’ theory of policy implementation, as opposed to other implementation theories, including but not limited to the ‘bottom up’ theory.

This essay will focus on the ‘top down’ theory, and by way of a critical analysis of it, the example of a hand hygiene policy in hospitals will be provided.Introduction: ‘Top Down’ Theory of Policy ImplementationThe top down theory of policy implementation is the implementation of a policy that originated from ones in the highest positions of the organization (associated with rational approach , stages model and lead to prescriptive conclusion).  New policies are frequently implemented according to the top-down principle. Suggestions for the necessity of new policies originate at the senior level of management and are then passed down the line.

These suggestions may include the planning and development of conceptions, a guiding principle or goals of an organization.  Under the top down implementation theory, it is generally understood that senior level management has the responsibility to influence their areas of responsibilities comprehensively to the effect that goals are achieved via the best, most effective means.The management level is burdened with the responsibility to see that the desired outcome of certain goals (by way of policy implementation and evaluation) is achieved.  To better exemplify the top down theory of policy implementation, hand hygiene policy in hospitals will be used as an example.

Hand Hygiene in HospitalsOn the 2nd of September 2008, the National Patient Safety Agency reissued an Alert on hand hygiene.  The Alert was reissued because the executive summary of health care associated infection (HCAI) believes that the hospital infection cost to the National Health Service is at least one million pounds annually and that it causes at least 5000 deaths.  An economic evaluation suggested that 30% of the latter infections are preventablen3 , thus the reason this alert was issued, so that it could reinforce the fact that hand washing plays a significant role in the reduction, or on the converse, the increase of infection, particularly at hospitals.  It is important to wash hands because germs are spread easily from unclean hands.

The kinds of germs that cause diseases come from people.  These germs are microbes that can live in the human body and grow and multiply.  We pass these germs along by infecting our hands with them and then touching other people or objects that other people touch.Germs do not die off when they are outside the body. They survive for a time on one’s fingers, or on towels, or drinking cups, or elsewhere.  That said, when outside the body, germs do grow less.  In order for communicable disease to spread, germs must be carried quickly from one person to another.  There are three ways which such germs can be carried, and that is by  food and drink,  insects,  or personal contact.

In the hospital and with regard to personal contact, germs are transferred from one patient to another often via the health care worker (upon contact, the germs present on the patient’s skin are transferred to the health worker’s hands and are capable of surviving for several minutes, and if the health worker does not wash her/his hands or the hand washing is done inappropriately, the care giver will transfer the germs to another patient via her/his contaminated hands).[6]  It is the third cause of transmission that concerns this essay, and which is also the most important way that disease germs are spread in hospitals and elsewhere.  It is not necessary for people to see each other or to be with each other in order for germs to spread via hand, it is only necessary that a person with the germs touch something that the other person soon touches and then touches their mouth.  In the context of the hospital, this is a serious issue.

Germs are everywhere, and certain germs can be fatal for certain people whose immune systems are weak.  To reduce the latter risks, it is imperative that germs be reduced and limited as much as possible.  “Hand hygiene is the simplest, most effective measure for preventing … infections.” Health-care workers’ adherence to hand hygiene has been very poor, so there is definitely a need, or rather a responsibility, for a policy on hand hygiene in the healthcare systems in the U. When such a policy is created, the implementation of it must be considered as well.  This top down method is necessary to ensure the utmost adherence to such an important and lifesaving topic.  Indeed, the U.K. campaign for hand hygiene is for that very reason, that is saves lives. Hand Hygiene Policy, Its Implementation & EvaluationThe World Health Organization (WHO) has developed guidelines on hand hygiene in health care. Throughout the undertaking of this project, WHO has consulted more than 100 international experts and they are involved in the testing and implementation phases throughout the world, both in modern, high-technological hospitals in developed countries and less advanced hospitals in developing countries.

This exemplifies the high importance of hand hygiene.  It is not only a national issue, but an international issue, for everyone in developing and developed countries.  That is why the National Health System has a national hand hygiene policy.The National Health System’s national hand hygiene policy is directed mostly at hospitals. Each policy instructs on the proper hand hygiene, and this includes the type of soap, the length of the wash, the technique of hand wash, the use of alcohol gel and the hand drying method.  It was the top level health officials who devised the policy, and they are implementing it from the top down.  Top down is necessary because it provides the support necessary to create the work culture that will promote good hand hygiene.  The policy itself is clear.

The policy also outlines that proper hand hygiene facilities must be available, i.e. clean enamel sinks with no chipping, no overflow of water, touchless taps, among other things are necessary.  Only the top management can plan for and provide those things, not the bottom up. Returning back to the policy, there is also a procedure given that details how to perform adequate hand hygiene.  For something of which has been called by the National Health System as “social hand hygiene”, the procedure includes simply plain or antimicrobial soap, preferable liquid.  This is key to cleanliness.  It is also suggested that if hands are not soiled, then mere alcohol based hand rub is acceptable.

One step above that hand cleansing procedure is if one will be performing aseptic techniques or surgery.  In such cases, stronger antibacterial soap is required.  Further, hand washing should be endured for 15 seconds, unless it’s a surgical scrub, which means that hands should be scrubbed for 2-3 minutes.  A hand wash with an approved antiseptic hand cleanser is necessary, followed by an alcohol-based rub. Drying hands is also a part of the process, and there is one strong caveat that jewelry should never be worn in the hospital, if a healthcare worker.How does such a policy get implemented and maintained when most healthcare workers do not wash their hands regularly and are unaccustomed or thoughtless in doing so?  As already mentioned, instruction must come from the top down.  This instruction adds a sort of legitimacy and urgency to the issue.  It “officializes” it and makes it clear that part of the job is to undertake the policies of the organization seriously.

There is also the implicit notion that consequences could result from nonparticipation and/or disregard for the policy.  That said, the management levels of organisations are indeed confronted with particular challenges with regard to the implementation of certain healthcare policies.  The policies must be implemented from top, to middle to bottom, such that each level has its particular role in implementing the policy and ensuring its success. The top management must in the first place represent hand hygiene as a goal internally and externally and define the policy as a strategy for cleaner hospital environments.

To implement this goal internally, there are three things that must be done from the top down: There must be visible support for the implementation of a hand hygiene policy from top management down in order to establish credibility, Distribution of the necessary resources must be made available to implement the policy from the top down, such that the finances, staff and equipment needed are made available, and The understanding of the importance for such a policy must be made known; therefore top management must create informational pamphlets, posters, etc, or hold workshops, meetings, etc. , in order to get the message across to everyone in the organization, from the top down, as to why hand hygiene is vital with respect to healthcare issues.Overall the implementation of a hand hygiene policy can be promoted through senior management commitment, such as, internally, participation in and initiation of awareness.

As mentioned, however, there must be external acknowledgement of the policy.  In this case, public statements of specific aspects of hand hygiene may be provided to the public, so that they know their stake in the policy as well, such that its benefits of a safer hospital visit if a hand hygiene policy is undertaken and the consequences if it is not adhered to properly. On the basis of instructions from senior management, it is a middle management task to undertake precise planning for the creation of the framework for the implementation of a hand hygiene policy.  The U.K. National Health System has a hygiene policy, but it is up to the management of the hospitals (or rather middle management by way of analogy) to frame that policy accordingly.

These “middle management” sectors, or the management of the hospitals, must: Allocate the resources that have been provided, Organise a meeting or discussion of the policy so that all staff from top down are verbally/orally made aware of the policy and then provide a written document of the policy, and in some cases the written form may provide an acknowledgement sheet where the staff member must read, sign, and return it to confirm their understanding and acceptance to follow the given policy, and New implementation procedures should be developed and/or ways should be founded to integrate hand hygiene processes into existing procedures.Coordination of the implementation of the hand hygiene policy, which should also include evaluation of the process, must therefore be the responsibility of middle management, or in this case, hospital management.  The goal here is to mobilise staff by communicating hand hygiene goals.  To mobilize staff members, certain actions may be taken.

For instance, communication with staff may be done by means of work agreements (e.g. agreement of goals employer and staff member) or by means of intensive internal communication.  Various elements may be used in the internal communication by addressing the issue in official meetings, or addressing it in interviews with staff members. Such knowledge and acknowledgement from management will foster the possibility of achieving a wide impact on all in the hospital, and this will trickle down to the patients and their families and visitors.Continuing down the line – from top to bottom, it is now important for the implementation of the hand hygiene policy to be a goal of the general staff.  As a prerequisite, the senior and middle management levels must have been successful at making the hand hygiene policy credible as a requirement for good job performance.  Hand hygiene must be stated here as a necessary and regular activity that cannot be ignored or overlooked.

In many organizations, there are employees who have been committed to hand hygiene, but overall, and as mentioned, hand hygiene is most often ignored by the majority of the staff, thus, leading to the consequences that result from the spread of germs in an already germ infected environment where immune systems are already potentially weak.A hand hygiene policy is further complicated more so than other policies because it is about behavior.  Given that most healthcare workers do not wash their hands regularly,[15] changing a behavior that is already well ingrained is difficult indeed.  But behavior can be learned and/or changed if good leadership is provided, thus the importance of a top down policy.

Leaders must provide the leadership necessary to ensure that staff members are complying with the policies given to improve the health of the hospital environment.  Good leaders may do so through interventions to enforce or implement the hand hygiene policy.  The interventions are obviously “aimed at improving compliance with hand hygiene [and] must be based on the various levels of behavior interaction.” Furthermore, it is noted that “[f]actors influencing compliance at the group level include lack of education and performance feedback; working in critical care (high workload); downsizing and understaffing; and lack of encouragement or role models from key staff.

These factors are reason why it is imperative to have good leadership, one that is active and well-respected by those in the “bottom”.  These factors that influence the poor adherence to good hand hygiene can be countered if indeed the leadership and the support of the senior and middle management levels are there.  It cannot happen from the bottom up.Successes ; Failures: My OpinionThough the top down is necessary to bring legitimacy and a sense of requirement to the policy, it does have its faults. Frequently, many of the elements of top down implementation oriented to hand hygiene outlined here are not present and must therefore be supplemented by bottom-up approaches.  Top down approaches cannot counter situations where there is high stress, urgency and lack of staff.  There is no time to wash hands under the procedures mentioned; there isn’t time to think about it.  Humans are humans and take their chances.

Further, the top down approach neglects or rather ignores the initial voice and opinion of those at the so-called ‘bottom’.  It is those persons at the ‘bottom’ who are the real implementers of the policy.  Their opinions matter, and they may have better suggestions than those at the top, because they are the ones who are at the center of the policy and know firsthand the situations and circumstances that may help or make problematic the policy’s implementation.Top down, to reiterate, does not fail at implementation, but it is not wholly successful too.

This may be reason why the national policy suggests that patients take an active role and ask their doctors and nurses to wash their hands before touching them.[20]  The patients are at the very bottom, so to speak, of the line.  Their participation and involvement in the implementation of the hand hygiene policy may be vital, and indeed it is their welfare at risk.  It could be said that they are the biggest stakeholders in the successful implementation of the policy.

If those who are the biggest stakeholders are at the bottom and not given the room to voice their opinion, then how is a policy legitimated?  Therefore, if a top down approach is implemented in a hand hygiene policy endeavor, which it is in this case, then the means to implement the policy must be carried out in the planning.  That is a key characteristic of top down approaches.  The senior and middle management must work it into the policy planning just how they will implement it to the biggest stakeholders.  In this case, posters and pamphlets are released.

In hospitals there are posters everywhere, but in addition to posters hospitals can move one step further, and that is by having health care givers wear a pin with the question: ask me did I wash my hands?.  This simple strategy could do wonders, as it will involve the patients, instigate them to ask the healthcare givers if indeed they did wash their hands properly, and it will be a constant reminder to the healthcare givers themselves.  Finally, it will increase patient awareness.  Alcohol gel boxes should also be available in front of each patient room.

Education on the matter is important, and these visual educational pieces help inform patients of the necessity to ensure that not only their hands be cleaned, but most importantly their doctors and/or nurses or any other personnel in the hospital.ConclusionOverall, it is a matter senior management convincing others of the necessity of paying attention to the cross-sectional goal of “hand hygiene”.  If senior management does not support the implementation of a strong hand hygiene policy and if hand hygiene is not credibly established as a goal of the organisation, then increased participation of patients, their families, and other interested parties by means of bottom-up processes will be needed.  Truly, a top down approach is necessary, but if it is couples with a bottom up approach, where staff members and patients can provide their own suggestions and ideas, then it may make for a win-win situation. In fact, it is more inclusive that way, and by including everyone in the process, they feel as though they ‘own’ the policy, it is a part of their making, and will become a part of their procedure, their daily routine, and their habit.  Behavior can change, but it takes support, evaluation and inclusion to make it happen.

References

1. nhs.uk/cleanyourhands/frequently-asked-questions/;.Bibliography;Blackpool, Fylde ; Wyre Hospitals NHS Trust retrieved on 15 October 2008, at ;http://www.bfwhospitals.
2. nhs.uk/about/foi/part_two/cat8/documents/ic_docs/Corp_Pol_056.pdf;.C.
3. Ham, ‘Improving the performance of health services: the role of clinical leadership,’ The Lancet, vol. 361, iss. 9373, 2003, pp. 1978-1980.
4. D. Pittet, ‘Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach’, Special Issue, vol. .7, no.
5. 2, March-April 2001, pp. 234-240.East Kent Hospitals University NHS Trust retrieved on 15 October 2008, at ;http://www.ekht.
6. nhs.uk/home-page/for-staff/a-z-departments/pathology/infection-prevention-and-control/hand-hygiene-policy/;.How disease germs are spread, retrieved on 15 October 2008 at ;http://www.oldandsold.
7. com/articles10/healthy-living-20.shtml;.Ian Sanderson, ‘Evaluation in Complex Policy Systems,’ Evaluation, Leeds Metropolitant University: UK, vol. 6, no.
8. 4, 2000, pp. 433-454.Nassera Touati, Danièle Roberge, Jean-Louis Denis, Raynald Pineault, Linda Cazale, ; Dominique Tremblay, ‘Governance, Health Policy Implementation and the Added Value of Regionalisation,’ Healthcare Policy / Politiques de Santé, vol. 2(3), 2007, pp.
9. 97-114.National Patient Safety Agency, Clean Your Hands Campaign, retrieved 14 October 2008 at ;http://www.npsa.nhs.
10. uk/cleanyourhands/frequently-asked-questions/;.Richard E. Matland, ‘Synthesizing the Implementation Literature: The Ambiguity-Conflict Model of Policy Implementation,’ Journal of Public Administration Research and Theory, vol. 5, no.
11. 2, 1995, pp. 145-174.Royal Devon and Exeter NHS Foundation Trust, retrieved on 15 October 2008, at ;http://www.rdehospital.
12. nhs.uk/docs/patients/services/infection_control/Hand_Hygiene_Policy%20-%20approved%20January%202008.pdf;.Stuart S.
13. Nagel (Ed.), Policy Analysis Methods, New Science Publishers, Inc., 1999.Thomas R.
14. Dye, Top Down Policymaking, Chatham House Title: Florida, September 2000.World Alliance for Patient Safety. ‘WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft),’ WHO Press: Geneva, 2005.[1] Ian Sanderson, ‘Evaluation in Complex Policy Systems,’ Evaluation, Leeds Metropolitant University: UK, vol.
15. 6, no. 4, 2000, pp. 433-454.[2] Buse, Kent, Nicholas Mays and Gill Walt.
16. ‘Making Health Policy (Understanding Public Health),’ Open University Press: England, 2005.[3] Richard E. Matland, ‘Synthesizing the Implementation Literature: The Ambiguity-Conflict Model of Policy Implementation,’ Journal of Public Administration Research and Theory, vol. 5, no.
17. 2, 1995, pp. 145-174.[4] World Alliance for Patient Safety. ‘WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft),’ WHO Press: Geneva, 2005.
18. [6] National Patient Safety Agency, Clean Your Hands Campaign, retrieved on 14 October 2008 at;http://www.npsa.nhs.uk/cleanyourhands/frequently-asked-questions/;.
19. [7] D. Pittet, ‘Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach’, Special Issue, vol. .7, no.
20. 2, March-April 2001, pp. 234-240.[8] Pittet, p. 234.
21. [9] See How disease germs are spread, retrieved on 15 October 2008 at ;http://www.oldandsold.com/articles10/healthy-living-20.shtml;.
22. [10] National Patient Safety Agency, ;http://www.npsa.nhs.uk/cleanyourhands/frequently-asked-questions/;.
23. [11] World Alliance for Patient Safety. ‘WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft),’ WHO Press: Geneva, 2005.[12] There are many examples of policies on hand hygiene at each hospital in the U.K.
24. to choose from, and each vary somewhat in the style and visual policy handbook, but the substance remains pretty much the same.  See for example Central and North West London, Mental Health NHS Foundation Trust, issue Nov. 2001, reviewed Nov. 2006, or Royal Devon and Exeter NHS Foundation Trust found at http://www.
25. rdehospital.nhs.uk/docs/patients/services/infection_control/Hand_Hygiene_Policy%20-%20approved%20January%202008.pdf, or Blackpool, Fylde ; Wyre Hospitals NHS Trust found at http://www.
26. bfwhospitals.nhs.uk/about/foi/part_two/cat8/documents/ic_docs/Corp_Pol_056.pdf, or East Kent Hospitals University NHS Trust found at http://www.
27. ekht.nhs.uk/home-page/for-staff/a-z-departments/pathology/infection-prevention-and-control/hand-hygiene-policy/.[13] Nassera Touati, Danièle Roberge, Jean-Louis Denis, Raynald Pineault, Linda Cazale, ; Dominique Tremblay, ‘Governance, Health Policy Implementation and the Added Value of Regionalisation,’ Healthcare Policy / Politiques de Santé, vol.
28. 2(3), 2007, pp. 97-114.[14] Nassera et al, pp. 97-98.
29. [15] Pittet, p. 234.[16] C. Ham, ‘Improving the performance of health services: the role of clinical leadership,’ The Lancet, vol.
30. 361, iss. 9373, 2003, pp. 1978-1980.[17] Ham, p.
31. 1978.[18] Pittet, p. 237.[19] PIttet, p.
32. 237.[20] National Patient Safety Agency, Clean Your Hands Campaign, retrieved 14 October 2008 at ;http://www.npsa.nhs.uk/cleanyourhands/frequently-asked-questions/;.