JCAHO Update for Infection Control

Joint Commission effect’: Awareness of looming JCAHO survey increases hand hygiene compliance

Manager effect’ also found in observational study

An impending visit by surveyors from the Joint Commission improved hand hygiene compliance rates, which remained higher than baseline even after the inspection, an epidemiologist reports.

An 18-month observational study, which included thousands of hand hygiene opportunities, documented the "Joint Commission effect" on compliance, says SeJean Sohn-Tuma, MPH, an epidemiologist at Memorial Sloan-Kettering Cancer Center in New York City. JCAHO has come on strongly in the infection control area in recent years, including an emphasis on compliance with hand hygiene guidelines by the Centers for Disease Control and Prevention.

"We knew the JCAHO would be looking at hand hygiene with the issuance of the hand hygiene guidelines," she says. "It was definitely something they were going to be looking at."

Forewarned is forearmed. Knowing a JCAHO survey was slated for December 2004, the infection control teams at the hospitals started a prospective, interventional study of hand hygiene in June 2003. Trained members of the infection control staff recorded whether workers performed hand hygiene before (HH Pre) and after (HH Post) a patient care episode. "We looked at hand hygiene at two points, before patient care and after patient care," Sohn-Tuma explains.

Twenty observation sessions per week were distributed randomly during the hours of 7 a.m. to 5 p.m., Monday through Friday. Each observation session lasted approximately 30 minutes. Palm Pilots were used to collect the data. An introduction of alcohol hand rubs was timed to coincide with the beginning of the study.

"The course of this study was about 18 months long, and so the interventions were staggered," she adds. "With the introduction of the alcohol product, we had an introductory education — your traditional inservice, which was kind of interactive. We had also a poster campaign so it was multifactorial. After three months, we went back to the same group and we would refresh them, and we would also [feed] back baseline compliance data. Three months after that, we initiated a monthly feedback to nurse leadership."

Compliance rates for HH Pre increased significantly with each passing week of November 2004, from 9.1% to 24.8%. Similar results were observed for rates of HH Post: 41.8% to 61.9%. Hand hygiene compliance reached record levels in the weeks before the JCAHO inspection, suggesting health care workers are capable of rapid change given the right incentive, Sohn-Tuma notes. "It was funny that there was a temporal association. The Joint Commission effect was basically [seen during] the weeks before and after the JCAHO was supposed to come and visit. What we found was that though the compliance had steadily been creeping up over time, the Joint Commission period was quite dramatic. The data looked pretty, with a nice line [toward] the highest rates."

The study raises the question of whether the traditional ramp-up for an accreditation survey may have more impact on worker behavior than the threat of surprise visits, which the Joint Commission increasingly favors.

"It’s true that the element of surprise does add something [different]," she says. "But one of the strong points of our observational study was that the observation sessions were quite intensive and constant and had been going on for a long time. We had [some] 14,000 opportunities for hand hygiene that we observed over time. We think that our findings are real."

Indeed, in looking at compliance in January — a month after the JCAHO inspection — rates had fallen but were still well beyond the baseline rates. "The hand hygiene [post-patient care] did decrease from week to week from about 63% to about 40%," Sohn-Tuma continues. "They were still much higher than our baseline rates. Unfortunately, we had to end the hand hygiene observation. It was time- and resource-intensive, with each ICP doing quite a few half-hour observation sessions."

Losing the observers may have diminished compliance. Awareness that they are being observed may change test subjects’ behavior, a phenomenon commonly called the Hawthorne effect. Sohn-Tuma found it is not just whether a person is being watched, but by whom. The epidemiologist called it "the manager effect" in presenting her hand hygiene study recently in Los Angeles at the annual meeting of the Society for Health Care Epidemiology of America.

"Throughout the whole course of the study, when a manager was watching the hand hygiene [compliance] was significantly higher than if infection control staff [were observing]," Sohn-Tuma tells JCAHO Update for Infection Control. "It does seem as if there were occupational differences. Nurses consistently had higher hand hygiene [rates] if they saw a manager observing. Initially, physicians [washed hands] like 90% when a manager was watching and 0% when the ICP was watching. That finding did change over time. That was just during the baseline."

Though Hawthorne effects typically wane, she notes that the manager effect lasted for the 18-month study period over thousands of observed hand hygiene opportunities. The study included guest observers from hospital administration. The data suggest associations between worker hierarchy and hand hygiene compliance, meaning the perceived power of the observer influences behavior in the observed.

Compliance rates for both HH Pre and HH Post were significantly higher during every study phase when the infection control manager performed observations. HH Pre compliance also was higher when guest observers from hospital administration were present compared to other observations recorded during the same two-week period (35.7% vs. 24.6%). Similar results were observed for HH Post (78.6% vs. 59.4%).