JCAHO to hospitals: Hand hygiene counts

Compliance will affect accreditation

How well your employees comply with proper hand hygiene may affect not only hospital-based infections, but accreditation ratings as well.

As of Jan. 1, hand hygiene/infection control becomes one of the seven National Patient Safety Goals of the Joint Commission on Accreditation of Healthcare Organizations, which means it will be a focus of both announced and unannounced surveys. Employee health will be working closely with infection control practitioners to demonstrate effective training of staff and volunteers and compliance with guidelines of the Centers for Disease Control and Prevention.

"The adherence of health care workers to recommended hand washing practices has been unacceptably low for decades," says John M. Boyce, MD, chief of the section of infectious diseases at the Hospital of Saint Raphael in New Haven, CT, and clinical professor at Yale Univer-sity School of Medicine. Boyce was one of the authors of the CDC hand hygiene guidelines.

"I’m very optimistic that having the Joint Com-mission make hand hygiene an important issue is going to really help improve hand hygiene practices among health care workers," he says.

Health care workers use proper hand hygiene only about 40% of the time, a review of studies has shown.1 Meanwhile, more than 2 million patients acquire nosocomial infections every year, resulting in some 88,000 related deaths.2

This year’s outbreak of SARS, which affected hundreds of health care workers, patients, and hospital visitors, added to the spotlight on hand hygiene. The Joint Commission also has made infection control one of three "highest priority focus areas" for random unannounced surveys in 2004.

Joint Commission surveyors will ask hospital administration about their hand hygiene practices and their choice of product. Then they actually will observe compliance as they follow the care of individual patients, says Rick Croteau, MD, the Joint Commission executive director for strategic initiatives.

"We will be conducting our survey process primarily where the care is delivered," he says. "We will be talking to caregivers and observing them as they provide care."

Hospitals have long sought to improve hand hygiene. The Joint Commission action not only gives weight to those efforts — the accreditation agency has advised specific actions.

In a Sentinel Event Alert issued earlier in the year, the Joint Commission recommended the use of alcohol-based rubs. The organization also noted that patient death or permanent injury or loss of function due to a nosocomial infection meets the criteria for a "reviewable sentinel event" and should be the focus of root-cause analysis to determine "risk reduction strategies."3 (For more information on conducting a root-cause analysis, see Hospital Employee Health, September 2003, p. 116.)

At some hospitals, those strategies include revising competency assessments, defining supervisory expectations, and implementing tracking systems, the Joint Commission says.

But JCAHO doesn’t require specific activities or even the use of alcohol-based products, Croteau says. "We want to know what their policies are, but the bottom line is, Are they doing it?’"

The Joint Commission action is sure to get the attention of hospital leadership — and that in itself may give a boost to employee health and infection control professionals who seek to improve hand hygiene, Boyce notes.

"I think for so many years, something as low tech as hand washing or other ways of cleaning your hands just didn’t receive enough attention," he says. "If you’re going to really modify behavior in a hospital setting, you need to get the hospital administration behind it."

Hospitals may need additional resources, such as the purchase of new alcohol-based products as well as staff training. But lack of knowledge isn’t the major impediment to better hand hygiene, notes Elaine Larson, RN, PhD, a hand hygiene expert who is associate dean for research at Columbia University School of Nursing in New York City. What hospitals need are performance improvement projects that help change behavior, she says. "Infection prevention is really as much a behavioral challenge as it is a biologic challenge," she says. "We know a lot about how to prevent infections. Most people feel it’s not an educational deficit; it’s a motivational deficit."

Hand hygiene experts know some factors that improve compliance with hand hygiene. Alcohol-based rubs can be more convenient and less irritating to employees’ hands, but they also have different characteristics that may affect their acceptance.

At the Hospital of Saint Raphael, compliance with hand hygiene improved by 20% with the use of an alcohol-based rub that was favored by employees. Employee involvement in the selection of the product played a role in that success, Boyce says. "We tested a variety of different products before we selected one. The one we selected is very well liked. It’s very well tolerated. It doesn’t have a strong smell. Importantly, the dispensers work well."

Education and motivational campaigns should accompany the introduction of new hand hygiene products, he says. But the efforts don’t end there. Boyce advises hospitals to monitor hand hygiene and provide reports to units about compliance. "In fact, feedback is one of the measures that appears to have been most helpful in modifying behavior in an organizational setting."

Health care workers may not always make a connection between their hand hygiene and potential risks to their patients. But it turns out that gaps in hand hygiene also may present some risks to the employees themselves.

Larson and her colleagues took hand cultures of nurses every three months for two years. Her finding: The longer someone had worked as a nurse, the more antibiotic-resistant flora they had on their hands.

While that flora may not affect them while they’re healthy, it could put them at risk for infections if they have surgery or other procedures, she notes. So hand hygiene has a direct benefit not just to patients, but to employees, says Larson, who has not yet published her data.

"You’re protecting not only the patient, you’re protecting yourself from picking up antibiotic resistance," she says.


1. Boyce JM, Pittet D. Guideline for hand hygiene in health care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51(RR16):1-44

2. Centers for Disease Control and Prevention. Monitoring hospital-acquired infections to promote patient safety — United States, 1990-1999. MMWR 2000; 49:149-153.

3. Joint Commission on Accreditation of Healthcare Organizations. Infection control-related sentinel events. Sentinel Event Alert Jan. 22, 2003.