Achieving 95% Hand Hygiene Compliance: 5 Points From Dr. Al Connors, CMO of MetroHealth

This is the first article in a series of five articles focused on the most pressing issues in patient safety and infection control, published during International Infection Control Week. The series is sponsored by X-Static.

In 2010, MetroHealth in Cleveland started noticing an upswing in infections with resistant bacteria — a problem plaguing many hospitals across the country. In response, chief medical officer Al Connors, MD, piloted a program to decrease infection rates in the hospital, starting with a push for greater hand hygiene compliance. When the hospital first started tracking hand-washing rates, they were at about 65 percent compliance — higher than the national average, but, in Dr. Connors' words, "not as good as it could be."

Here, he discusses several tactics the hospital used to increase hand hygiene compliance to an average of 95 percent at MetroHealth.

1. Require all employees to undergo training. Dr. Connors borrowed a video on hand-washing from the CDC and required all employees at MetroHealth to watch it. The video was only 20 minutes and made the cash for why all employees needed to wash their hands. "Of all our employees, only about 150 people didn't attend the training, and those people got a little note in their employee file that they missed the hand-washing video," Dr. Connors says.

He says the video helped get everyone at the health system on the same page on hand-washing; while everyone seemed to think it was a good idea, few people understood how serious the problem was. "When you asked people how often they washed their hands, they'd say, 'I think about 100 percent,'" he says. "It turned out to bea around 65 percent, and people just didn't know that."

2. Hire people to track compliance. MetroHealth educated its employees in Nov. 2010 and installed four handwashing monitors at the health system in December. The monitors were all high school graduates — smart people, but not highly-trained specialists — who worked approximately 20 hours a week and cost the hospital less than $100,000 a year total. They wore white coats and carried clipboards and went around to every unit to report whether employees were following the policy. The theme of the campaign was "wash in, wash out": Every time an employee entered or left a room, they were expected to wash their hands.

Once the hospital had achieved a steady success rate for about a year, they decreased the number of monitors to two, in order to save money. In addition, they distributed a report every eight weeks rather than every four weeks to cut costs.

3. Increase your goal as you improve. After the monitors had been with the hospital for a month, MetroHealth analyzed four weeks of data and found that their compliance rate had increased from 65 to 83 percent. "It was pretty good and people were feeling pretty happy about themselves, but I wanted to set our goal higher," Dr. Connors says. The health system's original goal was to improve from 65 percent. Once they had reached 83 percent, Dr. Connors decided to set a new goal of 90 percent compliance.

"We're aiming for optimally protecting our patients, and nine times out of ten sounds much better than seven times out of ten," he says. He spoke to the hospital's inpatient units and explained that five of the hospital's units were already above 90 percent. "I said to the others, 'Let's get out there — if they can do it, you can do it. They're not any smarter or better than you are.'"

4. Publicize information on progress. Dr. Connors says MetroHealth put information on hand hygiene compliance on the internal website for the hospital so that every employee could see it. "It didn't identify individuals, but rather said how each unit was doing," he says. When the next report came out, there were 12 units above 90 percent and 21 units below 90 percent.

Dr. Connors sent out an email to all units, letting them know of the progress. Five weeks later, all but one unit was over 90 percent and many were over 95 percent. Every week, the hospital posted the updated results so that every floor could tell how they were doing. Dr. Connors says the program simply came down to diligence from the program monitors, himself and the staff — everyone had to keep the results in mind at all times. Dr. Connors sent out regular emails to remind staff that he was "still watching," he says, to make sure no one became complacent and stopped following the guidelines.

5. Speak to outlier employees individually.
Occasionally, your surgical facility may run into a particular nurse or physician who has issues with remembering to wash their hands. For the most part, Dr. Connors says the non-compliance is accidental — they think they've been washing their hands, but they aren't up to the level expected by the facility. He says he asked the handwashing monitors to report any employees who protested when told to wash their hands. For every physician mentioned, he called the provider individually and asked them about the instance. "I'd tell them that they needed to be a role model," he says. "If someone sees a doctor come into the room without washing their hands, they're confused about what to do." He says the physicians frequently had an excuse for non-compliance — for example, they were just going into the room to tell the patient one thing and left again quickly — but he made sure to restate the policy of "wash in, wash out."

Since implementing the program, MetroHealth has maintained a hand hygiene compliance rate of between 95 and 97 percent for over a year. For any unit that falls below the 95 percent threshold (as reported every eight weeks), Dr. Connors send s an email reminding them to stay on top of hand-washing. He says the best thing about the program was that it was cheap and easy to implement; any surgical facility in the country could do it with little cost and effort.

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