Your hand hygiene data may soon go 'public'

Most organizations using secret observers

If Consumer Union, the nonprofit publisher of Consumer Reports has its way, all hospitals will soon begin publishing their hand-washing compliance rates — information that for most organizations, would not be flattering.

Only 35.6% of 1,256 hospitals surveyed by the Leapfrog Group, as part of its Hospital Quality and Safety Survey, have policies on compliance with the Centers for Disease Control and Prevention's hand hygiene guidelines.

"Hand washing, as we all know, is our best defense against infection," says Claire Davis, vice president of quality at Norwalk (CT) Hospital. "To that end, we have our hand washing dispensers appropriately installed. We also recently switched to a more expensive product, as we found that staff were more likely to use that particular product."

Compliance is monitored via visual surveillance by infection control, nursing staff, and "secret shoppers." "There is much to be done and it takes constant vigilance," says Davis. "The inclusion of infection reduction initiatives in the strategic plan of the hospital has been key in keeping focused on this and in resourcing the initiatives appropriately."

At Henry Ford Health System in Detroit, an infection prevention specialist observes staff for compliance, says Sue A. Lloyd, MT(ASCP), CHSP, CIC, the hospital's manager of infection prevention.

"The staff is re-educated at the time if lack of compliance is observed," she says. "Monthly rates are published and supplied to senior leadership, nursing, and our infection control committee."

At Mission Hospitals in Asheville, NC, hand hygiene compliance is currently around 85%. "We are utilizing secret observers and doing well with this," says Tom Knoebber, director of performance improvement. "We are able to break down data by skill type and location. We have also created public posting of the results and hope to improve what we measure."

Oakland, CA-based Kaiser Permanente implemented a National Hand Hygiene Program in 2001, with employee education, standardization of products and product placement, elimination of artificial nails, and widespread increase of alcohol degermer.

Compliance is measured through direct observation and soap and degermer product utilization rates. "This was found to be helpful as an adjunctive method of indirectly measuring hand hygiene compliance," says Alide L. Chase, senior vice president for quality and service. "It generally matched what was reflected in the observational studies when comparing one unit or department to another."

Cookies are incentives

At McKay-Dee Hospital in Ogden, UT, unit representatives from every department monitor hand hygiene compliance by conducting monthly monitoring of staff, usually done secretly, says Doe Kley, RN, BS, CIC, infection control coordinator.

"It typically only takes them 20 to 30 minutes per month to complete the compliance monitoring," she says. The observer documents the time frame, how many times the staff member actually performed hand hygiene, and the number of times they should have performed hand hygiene.

"Completed forms are turned in to me at month's end for tabulation," says Kley. "I then come up with a compliance percentage for each unit, and share the findings with the unit and hospital leadership."

Cookie coupons are given out as rewards when staff are caught in the act of performing good hand hygiene practices, especially when they think that no one was looking.

"Administration gave me several hundred dollars worth of the cookie coupons," says Kley. "The observers hand them out to staff who exemplify meticulous hand hygiene practices or who are good role models for the other staff. They have enough to give out one or two coupons per week. Staff and physicians love them."

A staff member from each unit is assigned to be the "secret observer" for that area, and completes hand hygiene education. "They will either sit at the nursing desk as if auditing charts where they can see patient rooms, or they roam about the unit with a clipboard as if conducting unit checks. They don't always go unnoticed," says Kley.

In fact, the observer will frequently approach staff and say something like, "I was noticing that you just missed an opportunity to perform hand hygiene. Why is that?" The secret observer role is alternated between various staff members several times per year.

Although there has been a steady increase in community-acquired MRSA cases seen in the ED at St. Joseph Medical Center in Towson, MD, over the last several years, the number of hospital-acquired cases remains steadily low. "This is due in large part to the staff practicing careful infection control measures," says Leigh Chapman, BSN, infection control practitioner.

"Our hospital policy is hand hygiene before and after every patient contact," says Chapman. "We have an outstanding hand hygiene program and have been statistically higher than the national average for hand hygiene for over two years."

Getting tougher

AT OSF Saint Francis Medical Center in Peoria, IL, both employees and medical staff are held accountable for performing hand hygiene before patient care. Monitoring is done through two processes: Each unit has identified individuals to anonymously observe and report 10 hand hygiene observations per month. Also, designated staff from throughout the medical center have volunteered or have been recruited to observe and report compliance with hand hygiene.

If hand hygiene was performed correctly, the staff member or physician is given acknowledgement. If hand hygiene was not performed, the manager or physician leader will follow-up with the employee or physician.

"The observations are entered into a database with the employee or physician name," says Patricia Ham, RN, MS, CIC, manager of epidemiology, infection prevention and control. "Repeated non-adherence to hand hygiene could result in disciplinary action."

In addition to using "secret shoppers" to monitor hand-washing in all patient care areas, a "stop the line" mentality exists at Baptist Hospital in Miami. "Anyone can intervene if they see someone not adhering to our hand hygiene guidelines," says Jill M. Szymanski, RN, MS, CHE, CPHQ, manager of quality.

"Since January 2006, we have consistently sustained hand hygiene compliance at or above 90%. However, we know that for patient safety we need to be at 100%," says Szymanski.

A new approach to hand hygiene was recently developed, created by a hospital-wide multidisciplinary task force. "Our monitoring data will no longer be blinded. Now, when we observe someone not washing their hands, we will internally report the data including the non-complier's name," says Szymanski.

If it's determined that there is not a process issue related to non-compliance, then there will be standardized, consistent consequences for any employee who does not wash their hands starting with corrective action and leading up to termination. "We also have non-compliance with hand hygiene as one of our clinical indicators for physician peer review," says Szymanski.

[For more information, contact:

Leigh Chapman, BSN, Infection Control Practitioner, St. Joseph Medical Center, Infection Control Department, 7601 Osler Dr., Towson, MD 21204. Phone: (410) 337-1396. E-mail:

Claire Davis, Vice President, Quality, Norwalk Hospital, 34 Maple St., Norwalk, CT 06856. Phone: (203) 852-2212. Fax: (203) 852-3436. E-mail:

Patricia Ham, RN, MS, CIC, Epidemiology, Infection Prevention & Control, OSF Saint Francis Medical Center, 530 NE Glen Oak, Peoria, IL 61637. Phone: (309) 655-4694. E-mail:

Doe Kley, RN, BS, CIC, Infection Control Coordinator, McKay-Dee Hospital Center, 4401 Harrison Blvd., Ogden, UT 84403. Phone: (801) 387-3294. Fax: (801) 387-3244. E-mail:

Tom Knoebber, Director, Performance Improvement, Mission Hospitals, 509 Biltmore Ave., Asheville, NC 28801. Phone: (828) 213-9194. E-mail:

Sue A. Lloyd, MT(ASCP), CHSP, CIC, Manager, Infection Prevention, Henry Ford Health System. Phone: (313) 874-4329. Fax: (313) 874-9515. E-mail: E-mail:

Jill M. Szymanski, RN, MS, CHE, CPHQ, Manager, Quality Management, 8900 North Kendall Dr., Miami, Florida 33176-2197. Phone: (786) 596-6049. Fax: (786) 596-2404. E-mail:]