Improving hand hygiene is a perennial problem for hospitals, but some are finding the strategies that work best depend on knowing your true rate of handwashing before trying to improve it. The rate may not be as high as one would think, and the traditional approaches to improving hand hygiene may not be the most effective.
Hospitals use a variety of approaches to improve hand hygiene — signs, inservices, secret observers, people watching each other, and various technological monitors. All of them can have a place in a hand hygiene quality improvement program, but there is no single strategy that gets the job done, experts say.
However, there are some common denominators across successful initiatives. One is constantly reminding clinicians about the importance of handwashing, says Aaron E. Glatt, MD, FACP, FIDSA, FSHEA, chair of medicine, chief of infectious diseases, and hospital epidemiologist at South Nassau Communities Hospital in Hewlett, NY.
“One can never get complacent. We have to constantly, constantly reiterate this to the point that it’s second nature, as opposed to something that you have to remember to do,” Glatt says. “Just as people typically wash their hands before coming out of the bathroom without having to put much thought into it, so we need to make it as second nature and obvious that you wash your hands every time you enter and leave a patient’s room.”
The goal must be to achieve a 100% compliance rate with handwashing, Glatt says. Eighty percent will not do. Glatt’s hospital has used secret observers to watch staff handwashing habits, with good results even though the staff’s hand hygiene rates are never at the desired 100% mark.
He compares the expectations in hospitals to those regarding sterility in computer microchip manufacturing facilities, where anyone entering must be covered completely and unable to contaminate the delicate materials. Human bodies are more fragile and important than a computer disk, so it is not unreasonable to expect complete compliance with hand hygiene, he says.
“Nobody would think of doing surgery without scrubbing and gowning, but it’s just as important to wash when moving from one patient room to another because you could be transporting potentially fatal infections from bed A to bed B and causing a community outbreak of resistant organisms because of your carelessness,” Glatt says. “Unfortunately, nothing happens right away, so it’s easy for people to say, ‘What’s the big deal if I didn’t wash my hands?’ Hospitals must constantly reinforce why it is important.”
Low-tech Can Work
Many high-tech solutions are available and continuing to be developed, but Glatt says some of the most effective approaches are simple and low-tech. Simply monitoring how much of the soap or sanitizer is used in dispensers will give you a rough idea of how much people are washing their hands, he says.
It also is critical to empower anyone in the hospital to call for proper hand hygiene, Glatt says.
“If the CEO of the hospital walks into a room without washing his hands, an orderly can tell them to go please wash their hands and they will not get any flak,” Glatt says.
Education must be ongoing, especially for those staff who may not be as aware of some of the clinical research and why it is crucial to wash your hands every single time you enter and leave a patient room, he says.
“It can seem entirely reasonable for them to say, ‘It’s OK because I washed my hands a few minutes ago’ or ‘It’s OK because I’m wearing gloves,’” he says. “It takes time to get the message across and create that culture in which the importance of hand hygiene is common knowledge and people are expecting each other to comply.”
Multiple Approaches Needed
Improving hand hygiene will require a multipronged approach, Glatt says, and it is important to not depend on simple steps or one-time solutions. Giving a grand rounds on handwashing on time is a worthwhile effort, but simply doing that one time will not improve handwashing for more than a few days, he says.
That strategy should be combined with other efforts to build a longer-lasting and more comprehensive change in how people think about hand hygiene, Glatt says.
“If people say they did their job by educating people in a grand rounds or providing an educational packet, they are going to be disappointed in the results,” he says. “One-time things are in general a very poor way of changing people’s habits. We have to realize those things have a limited ability to change habits even though it is tempting to make a big show of educating people on hand hygiene and then sitting back to wait for better results.”
Find the Impediments
Sharp HealthCare in San Diego used The Joint Commission’s Targeted Solutions Tool (TST) to improve hand hygiene, with good results, says Patty Atkins, MS, RN, FACHE, CPPS, vice president of quality and patient safety. (TST information is available at: https://bit.ly/2Jsluln.)
The health system used the TST to work through the five phases of a Six Sigma project focusing on hand hygiene. The first step was collecting good data.
“The whole idea is that you don’t just start trying to improve things willy-nilly. You define what you want to focus on, collect data on your baseline of not only how much you’re washing your hands but also the contributing factors for why we’re not washing our hands,” Atkins says. “Those defects drive where the quality improvement efforts go.”
Hand hygiene is one of the health system’s seven critical patient safety practices that it expects to happen for every patient, every time. Sharp measures compliance with “wash in/wash out,” meaning handwashing is performed each time a clinician enters or exits a patient room.
Sharp began the effort in 2013, employing “secret observers” to obtain the data that would drive future improvements. The health system uses staff from a wide variety of positions, including nurses, social workers, chaplains, physical therapists, and administrators, to secretly observe hand hygiene practices.
“The secret observers are like flies on the wall as they go about their business in the hospital,” Atkins says. “They collect data on a form we provide them, noting when they see a person washing or not washing their hands when entering a room and the type of role for that person. It’s all very discreet, looking like they’re making notations on their regular paperwork, so we don’t get any influence from people knowing they’re being watched.”
Low Compliance With Physicians
The initial compliance rate from those observations was 48%, averaged across the health system, Atkins says. Some units had higher compliance rates, like the 80% in oncology where staff were more finely attuned to the infection risk for immunosuppressed patients.
Physicians and certified nursing assistants both had lower-than-average rates of compliance with the wash in/wash out rule.
From that baseline measurement, Sharp encouraged units to develop their own methods for reminding staff to wash in and wash out. Some developed nonverbal cues such as flashing a green card at a co-worker who had not washed, and others simply encouraged team members to speak up when necessary.
The goal was to create a social norm in which people expected their co-workers to do the right thing, just because it is the right thing to do, Atkins says.
“It’s one thing when your supervisor tells you to wash your hands, but when a peer reminds you, that feels different,” she says. “When it becomes an expectation among your peer group rather than something your boss told you to do, that can be real progress.”
The health system also promoted an “It’s OK to Ask” campaign that reassures staff they can ask anyone about handwashing, regardless of status.
Coaches Look for Reasons
Sharp also trained “just in time coaches” who look for opportunities to remind people to wash their hands but also to investigate why people were not washing.
“The coaches engage people and try to learn why they didn’t wash, and the answers can be revealing. The nurse might say that to clean her hands, she has to walk down the hallway to a sink and, though it doesn’t seem like a big deal, it interrupts her workflow, and she doesn’t need that when she’s so busy,” Atkins says. “One of the first things we learned was that we needed more hand gel outside patient rooms and throughout the hospital.”
However, making hand sanitizer more available was not as simple as it first seemed.
Atkins and her team had to carefully consider fire safety concerns regarding much alcohol-based hand sanitizer could be exposed in a particular area, as well as the need to keep it away from children and some patients on locked units. Units and groups with lower-than-average compliance, including physicians, were targeted for additional education.
“Physicians often say, ‘Oh, I’m just going to pop in and say hello. I won’t touch anything,’” Atkins explains. “But before you know it, they’re shaking hands, or the patient asks to hand them a glass of water. So that was part of the message to physicians: Even if you think you’re not going to touch anything, we still want you to wash your hands. Getting physicians more in that mindset has really brought up their compliance.”
Sharp also put the onus on medical staff leaders to address the low compliance. The message was that hand hygiene is not a quality issue on which the medical staff is being asked to help, but rather it is a medical issue for which they were responsible.
Medical staff leaders at three of the four Sharp hospitals decided to make educational videos featuring their chiefs of staff and chief medical officers encouraging better hand hygiene.
“They had fun with it. It was kind of corny, but it was a strong message from their own leaders saying basically, ‘You have to do this,’” Atkins says. “The message was coming from their fellow physicians and physician leaders, so it had more impact than someone else telling them they should wash their hands more.”
Handwashing Tied to Bonuses
By 2016, there still were compliance gaps, so Sharp began requiring all clinical units to conduct 30 hand hygiene observations per month to improve data collection and identify possible barriers to handwashing. That effort yielded some improvement, but units relaxed again, and some failed to make their required observations. Compliance even fell in some units.
To improve accountability, the next step was to make hand hygiene a system performance target, added to other report card items like sepsis, mortality, and readmissions.
“That meant that people’s incentives and bonuses were affected by the results. That was the tipping point,” Atkins says. “We couldn’t have done that until we had the whole program in place with education, measurement, and the initial improvements. But once we did, we had CEOs looking at their dashboards and asking what was going on in a particular unit with low compliance. We had accountability.”
That was effective in improving compliance, and now Sharp plans to remove the connection to bonuses for 2019 while still leaving the data on the dashboard.
The improvements have been hardwired into the system and the culture has changed enough that the compliance rate should be sustainable without that leverage, Atkins says.
Electronic Monitoring Considered
Sharp plans to incorporate an electronic monitoring system soon, one that will use technology to keep track of whether people wash in and wash out of patient rooms, but Atkins says they are still assessing the options from various vendors. Implementing such a tool is no easy task, she notes.
“Every year, we take a look at the vendors and see if we think the technology is ready. They’re very expensive, and it takes a tremendous amount of IT resources to put all the sensors in at every sink, in every patient’s room,” Atkins says. “I still hope we can get there and get away from the paper-and-pencil data collection, which is not so efficient. In the meantime, we’re thinking of moving to data collection on mobile devices, but we don’t want that to give away our secret observers. We’re trying to lay the groundwork for them to be used for other data collection as well, so they’re not just associated with hand hygiene.”
An electronic monitoring system helped Atlantic Health System in Morristown, NJ, improve hand hygiene, but the effort started with obtaining an accurate baseline on handwashing practices. It turned out that the system’s compliance rates were not as good as they thought, says Laura Anderson, MSN, RN, CIC, director of infection prevention.
Atlantic had been collecting hand hygiene data through direct observation, and some units also used an electronic badge system that monitored the use of handwashing sinks. Anderson and her colleagues were concerned that the compliance rates had been exaggerated by people washing more when they knew they were being watched, along with small sample sizes.
“Everyone always wanted their scores to be good, and overall, our scores were very high, but we weren’t sure that was where we really were,” Anderson says. “People wanted their units to be good, so they would report the good practices they saw and may not have chosen to report what they saw on the negative side.”
System Monitors Group Compliance
The electronic badging overcame some of those problems, but it only measured wash in and wash out for patient rooms — not other situations in which proper hand hygiene was expected. Anderson notes that research has shown that about half of hand hygiene opportunities occur in the patient room, leaving the other half unmonitored in other areas. (An abstract of a study assessing hand hygiene opportunities is available online at: https://bit.ly/2CO5M2G.)
Atlantic implemented a new compliance monitoring system in 2015 that tracks the World Health Organization’s “Five Moments for Hand Hygiene” guidelines. (The guidelines are available online at: https://bit.ly/1fJGgf5.) They call for healthcare worker (HCW) hand hygiene in the following situations:
- before the HCW touches a patient;
- before conducting clean or aseptic procedures;
- after HCW exposure or risk of exposure to body fluids;
- after the HCW touches a patient;
- after the HCW touches a patient’s surroundings.
The new monitoring system monitors groups of people rather than individuals, which Anderson says builds on the hand hygiene culture in which people watch and encourage each other.
“It was a lot of education and reinforcement of good hand hygiene, along with information on how this system uses algorithms to calculate the compliance of a group,” Anderson says.
“We also spent a lot of time praising units that were doing well and paying more attention to units that weren’t doing so well, trying to figure out what was holding them back and finding solutions.”
After three years with the new program, Atlantic has seen a 69.5% increase in hand hygiene compliance, nearing 90% compliance with the WHO guidelines and the Centers for Disease Control and Prevention’s hand hygiene standards. When the program was expanded to all six Atlantic medical centers, there was a 57% overall improvement.
Patient safety was improved as a result. Catheter-associated urinary tract infections were reduced 47%, surgical site infections by 58%, C. difficile infections by 64%, and methicillin-resistant Staphylococcus aureus infections by 82%.
“The group monitoring was key to getting us the real data on compliance and not the false impression we had before,” Anderson says.
“We can’t work to improve our compliance rates and address the problems if we don’t know what our compliance rates truly are.”
- Laura Anderson, MSN, RN, CIC, Director, Infection Prevention, Atlantic Health System, Morristown, NJ. Email: firstname.lastname@example.org.
- Patty Atkins, MS, RN, FACHE, CPPS, Vice President, Quality and Patient Safety, Sharp HealthCare, San Diego. Phone: (858) 499-4000. Email: email@example.com.
- Aaron E. Glatt, MD, FACP, FIDSA, FSHEA, Chair of Medicine, Chief of Infectious Diseases, Hospital Epidemiologist, South Nassau Communities Hospital in Hewlett, NY. Phone: (516) 497-7422.