JCAHO Update for Infection Control

JCAHO tip: Make HCWs 'accountable' on hand hygiene

Kentucky hospital achieving amazing results

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) continues to emphasize that the historic lack of compliance with hand hygiene practices by health care workers will no longer wash. Compliance with Centers for Disease Control and Prevention (CDC) hand hygiene guidelines remains a JCAHO National Patient Safety Goal — lucky No. 7, to be precise.

The CDC shifted its traditional emphasis on sinks and soaps in 2002 with guidelines based on the European model of using alcohol-based hand rubs. As part of those guidelines, the CDC urges clinicians to monitor health care workers' adherence with recommended hand hygiene practices and provide personnel with information regarding their performance.

In updating frequently asked questions about patient safety goals on its web site, the Joint Commission reiterates that "compliance with Goal #7 will be surveyed through interviews with caregiver staff and direct observation. Caregivers should know what is expected of them with regard to hand hygiene and should practice it consistently. It is expected that noncompliance will be quite low, so that any pattern of noncompliance, i.e., more than a sporadic miss, will be scored as noncompliance. During tracer activity, if surveyors observe three or more instances of noncompliance, either through observation of practice or staff interview, a Recommendation for Improvement (RFI) will result.

In addition, the Joint Commission is listed as a co-authoring agency on a recently published book that urges patients to demand that health care workers wash their hands. "Hand washing is mandatory," the book — You: The Smart Patient — emphasizes. "This is not a joke. They should wash their hands after they touch you and before they head to the next patient. It's understandable that harried nurses and doctors occasionally forget to do this, but it's not acceptable."

Yet when it comes to getting health care workers to comply with hand hygiene practices to protect themselves and patients, much has been tried to remarkably little avail. Hand washing compliance typically falls below 50% in most studies, with more than half of medical workers ignoring the cardinal principle of infection control on any given patient encounter. That is the reality despite widespread knowledge that the transiently colonized hands of health care workers can lead to cross-transmission of pathogens between patients. As a result, some will become sicker and others will die. It's time, one epidemiologist urges, to make health care workers accountable.

'It is time for accountability'

A program based on the straightforward, time-honored concept of accountability is producing remarkable results at the Medical Center in Bowling Green, KY, where observed hand hygiene compliance rates have been in the 98% to 100% range for the last two years.

"I keep expecting it to fall off," says Rebecca Shadowen, MD, hospital epidemiologist. "Month after month, it is just a little too overwhelming to me to be true, but it is clearly true."

Shadowen received a strong reaction from her audience when she outlined her program recently in Chicago at a meeting of the Society for Healthcare Epidemiology of America (SHEA). "I think this is a seminal, profound paper that represents a breakthrough in infection control," said Donald Goldmann, MD, professor in the department of immunology and infectious diseases at Harvard University School of Public Health. Speaking as a SHEA audience member after Shadowen's presentation, Goldmann said he expects her message to be heard far and wide by the nation's infection prevention programs.

"Coming from a quality improvement organization I am obviously very interested in systems improvement," he told SHEA attendees. "However, once the system has met the needs of the caregiver — by having alcohol available at the point of care, having the dispensers filled, having people educated and competent — it is time for accountability. This is the first time I have ever seen anybody get up at this meeting and talk about the accountability of the individual with punitive consequences. I think everybody is going to look at this and go back to their institution and say if they did it in Kentucky, we can do it in Michigan or wherever. I just think this is absolutely outstanding."

Faced with abysmal hand hygiene compliance, Shadowen convinced hospital administration to back an effort to dramatically change things. As a result, during the years 2003 to 2005, direct observation of hand hygiene practices among health care workers (physicians included) with interventions for noncompliance was implemented. Fifteen-minute, direct observations were done on a daily basis.

Punishment fits the crime

Noncompliant health care workers face the following consequences in order: verbal correction; computer-based learning module; verbal counseling/warning; written counseling/warning; referral to human resources for disciplinary action or dismissal. Physicians are not exempt, underscoring the fact that full administrative support is behind the ongoing program.

"We did have one physician who has been caught twice in the last two months, and who was counseled by the department of medicine," she says. "There has been a lot of activity of counseling of docs in the department of medicine. The chairman does [the counseling] and we have not had to go any further. A culture change has happened over the last two years here, and it is sustainable. It's just amazing."

Taking organizational ownership

Of course, the key to the success is administrative support — just don't call it a "buy-in" from the suits. "I call it ownership," Shadowen tells JCAHO Update. "I don't call it 'buy-in' because that has a connotation to it that over the years has not been very good. Because truly I want you to own it — this is your job. Knowing your role is a big deal, and of course we had to get higher-level administration first to understand that they owned the responsibility for holding others accountable. This ownership/accountability thing is a very important detail."

In other words, you can't buy into something you already own.

"We actually had to [convince] some of our nurse managers because they didn't have ownership," she says. "They didn't really get it that it was their job to take care of this problem. The majority of people have come into the 'culture' now and changed their behavior."

That doesn't mean the sailing has been smooth. Shadowen had the experience and clout to undertake such an effort and show that extraordinary hand hygiene compliance is possible.

"Part of this has a lot to do with the bridges you have built over the years — how long you have been in the facility, how well you are respected — and how much you can tolerate," she says. "I have been here for 17 years and built a lot of bridges, but I am not going to tell you that everybody thought kindly about me. But the door and the phone were always open for any conversation. I think in your heart if you are trying to do the right thing, you've got the literature to back it up, and you're honest and open about it, it is a little easier."


1. Roizen MF, Oz MC, with the Joint Commission and Joint Commission Resources. You: The Smart Patient. New York City: Free Press; 2006.