Hand hygiene compliance: Why hospitals aren't getting it right
Hand hygiene compliance: Why hospitals aren't getting it right
Barriers to and methods of hand hygiene compliance
If clean hands can save lives, why aren't more health care workers complying with hand hygiene guidelines? The answer isn't singular in nature and neither are the methods suggested for improvement, but one thing is certain: Compliance is lacking. In response, The Joint Commission recently published a 262-page monograph, "Measuring hand hygiene adherence: Overcoming the challenges," to identify best practices for measuring adherence.
Elaine Larson, RN, PhD, FAAN, CIC, professor of epidemiology at Columbia University's Mailman School of Public Health, served as scientific advisor and chair of the panel that produced the paper. Asked by Hospital Peer Review what the answer is to encourage 100% hand hygiene compliance, Larson says, "If we knew that.... It's been something we've been working on for ages. I think it requires a culture change for the entire place."
By that she means encouraging and empowering all staff to speak up when a peer doesn't wash his or her hands. "There's no way in general a nurse would tell a physician to do hand hygiene 'right now.' But we know from work that Peter Provonost and others have done that if you enable and empower people to do it, then I think it becomes a cultural expectation and people help each other rather than perceiving it as spying on each other."
Infection prevention vs. quality assurance
To quality improvement directors, she says, collaborate with your infection prevention (IP) department. She sees a vacuum in identifying who exactly "owns" the hand hygiene issue. "My observation is that when I look from place to place that it's either the quality assurance [QA] department or the infection prevention department, and they don't seem to work together as much. And that's kind of a shame. Sometimes it almost feels like it's a little competitive.
"I do sense in a lot of places a sort of tension between infection prevention and QA, and obviously infection prevention is part of QA... But I think it may have to do with who owns this, instead of just working together and figuring out what's the best way to make it work combining our joint strategies. I think this would be part of the culture change for hospitals, where we are really working together on this."
She says the "tension" between IP and QA might in part be because infection prevention "has been around since 1970 or so and has done a huge amount in terms of methods for data collection and data interpretation and applying epidemiology. So, I think QA, as an entity, a department, if you will, is a little bit newer. And maybe there was a sense from infection prevention that maybe, 'They're going to take us over or something.'"
Acknowledging this is part of the cultural shift toward making true changes in compliance she sees as crucial.
Barbara Braun, PhD, project director in The Joint Commission's division of quality measurement and research, agrees that collaboration between IPs and QA is key. From a resource standpoint, she says, infection prevention can't do it all on its own. "Quality improvement staff can really engage the leaders and the board," so the hospital prioritizes hand washing from the top down.
She notes another barrier to compliance: People are not clear on what the guidelines call for with regard to when hand hygiene should occur.
"Everybody thinks they know — before and after patient contact — but in fact the guidelines are much more complicated, and people are either not aware or they forget the indications such as from [the World Health Organization] about before patient contact, before an aseptic task, after body fluid exposure, after patient contact, and after contact with surroundings in the environment," she says.
She suggests reviewing recently updated guidelines from WHO (www.who.int/patientsafety/en/). "Those are a little more updated than the [Centers for Disease Control and Prevention] guidelines, but they're very closely related."
Three improvement methods
The monograph touts three methods for measuring hand-washing compliance — suggested methods meant to be used in tandem and not as a simple fix-it-all answer. The paper examines the advantages and disadvantages of each method: direct observation, measuring product use, and conducting surveys.
Braun points out that each has strengths and weaknesses. "There are a lot of things that you can measure with observation that you can't get at with product [measurement]... With product measurement, you can't tell who's using what and if they're using it at the appropriate times (unless you have a very sophisticated electronic monitoring system). Observation is the only way to do that... Now observation is considered direct measurement; product measurement is considered indirect, and then surveys really don't do a good job at all of measuring adherence to the guidelines. They're really more useful for measuring knowledge and attitudes and beliefs and things like that, which are very important to measure, but they're not useful for asking people how well they adhere because the data have shown to be an overestimate."
"Surveys, I think, are worthless," Larson says. Echoing Braun's statement, she continues, "Most people don't intentionally lie, but we overestimate how much we do hand hygiene. So that's pretty useless.
"I think a really promising way to monitor hand hygiene is to look at amount of product use... The problem is that you still don't know unless you get it per unit and per patient bed. [Otherwise] you don't really know whether a hand hygiene episode occurred... So there are some disadvantages." Over time, she says, you could establish standards given, perhaps, the patient population on the unit. "Right now the sort of gold standard is observation, and it's terribly difficult because it's extremely expensive."
Pairing monitoring and feedback
Monitoring without feedback is "not that useful," Larson says.
Indeed, Braun says one of the strategies that has seen more success is implementing education and training, plus auditing and feedback. She's seen examples of organizations doing a good job at measuring and "then they share the information back to the unit levels, to the department level, and they post it," turning it into a competition. "You can really boost your rates by having a healthy internal reporting [system] and competition."
Engaging staff
"I really, truly think that the only thing that's going to work is a long-term commitment on the part of an institution or a unit. It can't be from individual to individual. It's got to be the unit culture," Larson says.
Braun says the level of compliance often depends on staff beliefs and attitudes, and she stresses the importance of role models and clinical champions. "I think there's some research on physicians that really demonstrates that the role models, the mentors, the senior folks have to be role models; otherwise people will not adhere."
In order to empower staff to get buy-in for improvement, Braun suggests forming a multidisciplinary team focused on the initiative, including "people from housekeeping up to the C-suite and physicians, because they know best what the obstacles are among their peers."
[Editor's note: The monograph is available at www.jointcommission.org/NR/rdonlyres. For more information on The Joint Commission requirements regarding hand hygiene visit www.jointcommission.org/AccreditationPrograms.]
If clean hands can save lives, why aren't more health care workers complying with hand hygiene guidelines? The answer isn't singular in nature and neither are the methods suggested for improvement, but one thing is certain: Compliance is lacking. In response, The Joint Commission recently published a 262-page monograph, "Measuring hand hygiene adherence: Overcoming the challenges," to identify best practices for measuring adherence.Subscribe Now for Access
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