Hand washing: You must measure compliance

Best practices will be identified

Lack of consensus on how to measure hand hygiene compliance has made this a daunting challenge for quality professionals. To address this, the Joint Commission has partnered with infection control organizations to identify how to measure compliance with hand hygiene guidelines. The final product of the 18-month project will be an educational monograph that recommends best practices for measuring hand hygiene compliance.

Effective measurement will help health care organizations target interventions, which in turn should improve hand hygiene practices by health care workers and ultimately result in fewer health care-associated infections, says Jerod M. Loeb, PhD, executive vice president of the Joint Commission's division of research.

Measuring compliance with hand hygiene practices during the delivery of care is difficult, mainly because of the resources needed to monitor the practices of many different care providers in numerous locations for meaningful periods of time. Since there is no unified approach to measuring hand hygiene performance, it's impossible to determine whether overall performance is improving, deteriorating, or staying unchanged as new strategic interventions are introduced.

The Joint Commission's National Patient Safety Goals require accredited organizations to follow the Centers for Disease Control and Prevention's hand hygiene guidelines, but many studies have shown poor compliance. In addition, the Joint Commission's infection control standards require continuous strategic surveillance for infection and infection-related risks, and this is a key focus during surveys.

Hospitals using observation, patient education

At Covenant HealthCare in Saginaw, MI, a hospitalwide hand hygiene committee has improved compliance by using daily rounding by infection control nurses to observe compliance, using a unit-based data retrieval form to monitor universal precautions. "We will be using a tracking monitor that can be installed on a soap or alcohol dispenser," says BJ Helton, MPH, CIC, infection prevention and control program administrator.

The nurse manager or a designee from each nursing unit is required to monitor at least 30 staff members every year, and the completed observation is sent to infection control. The information is shared at individual unit conferences and also will be presented at quarterly outcomes report meetings.

At these meetings, all of the clinical nurse specialists report what accomplishments have taken place, and the nursing dashboard and regulatory dashboard are presented. "By presenting the hand washing and universal precautions data, there will be more room for housewide discussion," says Ann D. Law, RN, Covenant's outcomes specialist.

In addition, a patient education brochure on hand hygiene is placed on patient tray place mats. "A collaborative effort with organizational development led to a computer program with our new infection prevention logo, SqWash Leo the Bug," adds Helton. "The VP of nursing made it a mandatory requirement for everyone to participate in seeing this program."

At OSF St. Joseph Medical Center in Blooming-ton, IL, patients are educated about hand hygiene via the hospital's Get Well Network, which is accessible on every TV. The program includes a segment on hand hygiene and how it can reduce the spread of infection. The hospital's patient satisfaction survey includes a question to get the patient's viewpoint on whether hospital staff and physicians are practicing good hand hygiene.

To obtain additional data, an observation program is being implemented. "Of course, this brings about its own measurement problems," says Kathy Haig, director of quality resource management. "Human resources in most health care settings is a limited and valuable commodity, so is it the best use of our resources to have them observe?"

Without observing, though, there is no valid way to determine compliance, says Haig. Another concern with the observation methodology is the validity of the data, since they can be very subjective. "For example, if the door to the patient's room is closed, how do you know if the staff member practiced hand hygiene?" she says.

The observer must be kept secret to prevent a "Hawthorne effect," people doing what they are supposed to because they know they are being watched, says Haig. "It is also important to prevent the observer from being perceived negatively by peers," she adds.

The aggregate data will be shared with the various unit managers as improvement opportunities. "I expect that we will, at some point, compare our results to the infection rate, although our infection rate currently is very low," says Haig.

The fact that different departments in the hospital have different opportunities for hand washing presents another challenge. "When you measure by observation, how do you watch for all of the opportunities specific to the area?" she asks. "Admittedly, our process is not perfect, as we cannot measure all the times when hand hygiene should be done, but we feel it is a start."