Strategies to Achieve Hand Hygiene Compliance: Overcoming Challenges & Emphasizing Engagement
Results of a multimodal hand hygiene initiative
The following is an assessment of the impact of automated hand-hygiene monitoring on hand soap and sanitizer dispensing rates and healthcare worker compliance with hospital hand-hygiene policies. In addition, it describes a variety of performance improvement strategies employed to increase hand hygiene adherence. Finally, there is an exploration of the relationship between the incidence of infections and observed hand-hygiene improvements describing the impact of automated hand-hygiene monitoring on patient safety outcomes. These results describe the experience of 10 nursing units, six medical surgical and four critical care, in nine hospitals. The data combines 88 months of 24/7 automated hand hygiene monitoring, 1,009,735 patient/caregiver interactions and 3,476,808 hand cleansings. Methods of data collection and resulting hand hygiene compliance rates were standardized across all sites.
- Increase in hand hygiene solution dispensing: 51.6%
- Increase in hand hygiene compliance: 76.3%
- Decrease in healthcare associated infections: 26.8%
Direct cost savings: $1,506,683
Net loss savings: $778,362
Length of stay reduction: 1,173.3 days avoided
When considering the rate of mortality attributed to healthcare-associated infections (HAIs),1 nine deaths were prevented by these hospitals’ efforts through hand hygiene electronic monitoring.
Performing proper hand hygiene is a challenge: 150+ years without success
Healthcare-associated infections result in mortality, morbidity and increased healthcare costs worldwide.2 In the United States, approximately 90,000 patients die each year from HAIs and many more experience the consequences of such infections.1 Studies indicate sustained improvements in hand hygiene are attainable through the application of broad, multimodal programs that include a communications campaign, education, leadership engagement, environmental modifications, team performance measurement, and feedback.3 These facilities incorporated a similar approach but expanded upon it by using automated 24/7 monitoring which provided an extensive data set defined by an objective and comprehensive measure. This enabled us to overcome the difficulties of small sample size, observer bias and inter-rater reliability when interpreting results.
Automated hand hygiene monitoring
The automated hand hygiene technology utilizes a wireless radio-frequency identification (RFID) network to accurately assess caregiver movement and correlates it with individual caregiver hand hygiene activity. RFID badges communicate wirelessly with a network of sensors called Communication Units (CUs) that are connected to each hand hygiene solution dispenser. Active CU screens display clinical, personal and educational messages, and individual performance rates at the point of care.
The functionality is augmented with an experienced multidisciplinary clinical consultation team including infection preventionists, nurses, public health experts, microbiologists, and healthcare executives. This team provides support to ensure that the hand hygiene data is translated into improved care at the bedside.
Key components of the leadership communication package
Social and behavioral theories offer insight – and perhaps solutions – to the challenge of motivating caregivers to improve hand hygiene adherence. Hospitals combined elements of these theories with multimodal approaches previously described in the literature. This approach leveraged the concept that if an individual decides a suggested behavior is a) beneficial, b) expected by their peers and c) within their ability to perform, the result is increased motivation and an increased likelihood that they will engage in the prescribed behavior.4, 5, 6
The methods described below strengthen caregiver belief that hand hygiene, when done at the right time, is effective for increased patient safety. These methods establish peer expectations for participation, and convince the caregiver that they can be successful. In order to reinforce each of these components, hospitals deployed an approach consisting of the following elements:
1) Active 24/7 monitoring without disruption of workflow
2) An education and awareness campaign emphasizing individual and group baseline performance
3) Visible leadership commitment, active involvement and agreement that:
i) hand hygiene is important and non-negotiable4) Clear, reasonable and incremental goal setting
ii) hand hygiene is challenging
iii) we can do it together
5) Consistent, transparent communication of progress toward team goals
i) Posting individual compliance rates
ii) Point-of-care electronic feedback of individual compliance rates
Education and awareness
While healthcare workers generally acknowledge the importance of hand hygiene in preventing the spread of infection, they typically overestimate their own individual compliance. Caregivers frequently self-report compliance of greater than 90 percent while, in reality, they adhere to hand hygiene guidelines in less than 50 percent of encounters.6 The provision of comprehensive and objective data helps caregivers understand the reality of their personal and cohort performance. While most found it initially surprising, and some even found it difficult to hear, candid and open data sharing was a catalyst for improvement. The focus was on hand washing in close chronological proximity to key moments of care delivery. For example, educators recommended that hand cleansing be performed immediately before a patient interaction instead of 10 or 15 minutes prior to approaching the patient. When individuals are presented with valid performance data, they may reason and feel compelled to improve because they already believe that hand hygiene is an important step to protect their patients.
To demonstrate leadership commitment, executives were physically present to interact directly with staff. While not prohibitively time consuming, their personal availability was a powerful indicator of support. The leadership activities were multi-layered and included executives, head nurses, charge nurses, infection preventionists, and team leaders. Interactions consisted of routine rounding where leaders assessed progress by periodically asking caregivers their personal compliance rates and engaging in dialogue about their performance. Charge nurses performed as leaders to assess daily activity and provide immediate coaching. All leaders reinforced that the efforts to improve hand hygiene compliance were in the patients’ best interest.
Belief is a function of past success, so if goals are set allowing people to be successful, then they will continue to seek success in the same manner.6 Recognition of high performers is an effective and non-threatening strategy for global adoption. Positive reinforcement accelerates the rate of response. As small goals are met and rewarded, overall progress is accelerated. Over time, it can even surpass expectations created from a stretch goal.7
For example, if a unit’s overall compliance rate was 25 percent, they set the next goal at 40 percent (as opposed to the ultimate goal of greater than 90 percent) and worked aggressively to attain it. Some leaders incorporated the use of hand-written notes of recognition and/or appreciation while others publically recognized individual and team achievements. In other cases, a reward approach was used to stimulate interest and awareness.
After reaching their incremental goal and acknowledging the team accomplishment, the teams would reset their goals. While the next incremental goal, 50 percent overall compliance, for example, was not the ultimate objective, it was an attainable goal that fostered continuous improvement and teamwork. Even the smallest measurable improvement that can be positively reinforced can create more energy for the group.8
Performance feedback and competition
According to a study in PLOS ONE,9 individualized performance feedback doubles the likelihood a healthcare worker will cleanse their hands. This idea was combined with the understanding that an important component of behavior is peer expectation.6 Nursing leadership developed co-worker accountability by dividing staff into teams and establishing competitions. This provided an interesting element of play to the initiative and created peer expectations through the transparent posting of compliance rates. Team reports displayed team results and individual team member performance. The charge nurses, deemed team captains, were empowered to provide immediate coaching and education where necessary. Open display of individual compliance rates reinforced the peer expectation that, to be an accepted member of the group, everyone would have to participate in order to attain the team’s goal.
With clinical consultation and support, nursing leadership used themed hand-hygiene reports corresponding with holidays and major events to enhance feedback to participants. These included tips for improvement, individual and unit scores, progress toward goals and top compliers. Presentation formats were updated weekly with engaging cultural and holiday themes. Caregiver feedback was overwhelmingly positive and the overall hand-hygiene compliance rate across these sites increased 21.2% in the first month of the campaign.
Point-of-care electronic feedback of individual compliance rates
The ability to access personal hand-hygiene rates at the CU can be very informative and motivating. For example, one nurse became aware that her compliance rate hovered at 25 to 30 percent. She stated emphatically, "I am better than that and do not want to be the one at the bottom." Her rates improved to 55 percent the following week, to 76 percent the next, and to 96 percent by the end of the third week. Now, her rates are consistently between 95 and 97 percent. The individual point-of-care feedback allowed her to affect her own performance without management input. This gave her direct control and the ability to monitor her progress toward her self-assigned goal of 95 percent. The combination of objective performance feedback, peer opinion, her belief that hand hygiene is effective, and her realization that she could control her compliance rate provided the motivation she needed to improve.
These facilities adopted the idea that hand hygiene is a keystone behavior in promoting a broader culture of safety and quality. They agreed that a high level of hand hygiene is:
- important and not negotiable,
- challenging to maintain and
- dependent upon a team approach to achieve.
A multimodal approach that includes comprehensive and objective hygiene monitoring, active and visible leadership, clear goal setting, competition and transparent performance feedback increases hand hygiene performance and significantly improves clinical and financial outcomes.
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1 Klevens R, Edwards J, Richards C, Horan T, Gaynes R, Pollock D, Cardo D. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports. March–April 2007. 122:160-166.
2 Pittet D, Allegranzi B, Boyce J, World Health Organization World Alliance for Patient Safety First Global Patient Safety Challenge Core Group of Experts. The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations. Infect Control Hosp Epidemiol 2009.30:611–622.
3 Aboumatar, H, Ristaino P, Davis R, Thompson C, Maragakis L, Cosgrove S, Rosenstein B, Perl T. Infection prevention promotion program based on the PRECEDE model: improving hand hygiene behaviors among healthcare personnel. Infect Control Hosp Epidemiol 2012.33(2):144-151.
4 Nicol PW, Watkins RE, Donovan, Wynaden D, Cadwallader H. The power of vivid experience in hand hygiene compliance. J Hosp Infect 2009.72:36-42.
5 Sheppard BH, Hartwick J, Warshaw PR. The theory of reasoned action: A meta-analysis of past research with recommendations for modifications and future research. Journal of Consumer Research. 1988.15:325–343.
6 Ajzen I. From intentions to actions: A theory of planned behavior. In J. Kuhl & J. Beckman (Eds.), Action-control: from cognition to behavior. 1985.11-39. Heidelberg: Springer.
7 Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee (HICPAC)/Society for Healthcare Epidemiology of America (SHEA)/Association for Professionals in Infection Control (APIC)/Infectious Disease Society of America (IDSA) Hand Hygiene Task Force. 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. Infect Control Hosp Epidemiol 2002.23-S3-S-40.
8 Daniels, A. Rewarding things a dead man can do. Video based on Oops management practices that waste time and money and what to do about them. http://www.youtube.com/watch?feature=player_detailpage&v=GWZRgjnd3Rk. Aubrey Daniels International. Accessed 12/20/2012.
9 Fuller C, Michie S, Savage J, McAteer J, Besser S, et al. (2012) The Feedback Intervention Trial (FIT) — Improving Hand-Hygiene Compliance in UK Healthcare Workers: A Stepped Wedge Cluster Randomised Controlled Trial. PLoS ONE 7(10): e41617. doi:10.1371/journal.pone.0041617
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