All Eyes on Hand Hygiene
Date: November 16, 2012
When Sibley Memorial Hospital adopted a program last July that assigns specially trained staff to secretly monitor whether or not clinicians use Purell or wash their hands when entering and exiting patient rooms, only slightly more than half of those observed met the strict rules.
One year later, however, their compliance rate
is 94 percent—among the highest within Johns Hopkins Medicine.
Others across the system are striving to replicate these results through similar “secret shopper” programs, most of which rely on entry-and-exit methodology and training tools developed by The Johns Hopkins Hospital. Although hand hygiene improvement programs vary by hospital and even by unit, an institution-wide task force is looking at ways to boost scores across the board to protect patients from hospital-acquired infections.
“Secret shopping programs are one of the best models out there to get data on hand hygiene,” says Polly Trexler, associate director of hospital epidemiology and infection control (HEIC) at Hopkins Hospital. “These observations tell us a lot about barriers that caregivers may be facing and help us understand where we need to focus our efforts.”
Milena Walker, director of infection control and prevention, says Sibley initially struggled to improve its score after implementing the Hopkins Hospital model. When she discovered that many staff members did not follow the new rules nor understand the reasoning behind them, her team personally visited each unit. Training included a well-received video that showed how one patient suffered harm because of poor hand hygiene practices.
While scores increased in most areas, hand hygiene compliance rates in the D.C. hospital’s inpatient units still remained below the Johns Hopkins Medicine goal of 85 percent, set this year by a board of trustees committee that oversees the Armstrong Institute for Patient Safety and Quality and includes hospital executives and other safety and quality leaders across the health system.
Staff cited the harshness of the gel product in dispensers as an explanation for low scores, Walker says. When a more gentle product was tried, compliance exceeded the goal in just one month. A hospital-wide switch to the preferred sanitizer is under way.
After a drop this spring, hand hygiene compliance rates at Hopkins Hospital are rising. HEIC attributes the 61 percent rate of compliance in May to the massive effort needed to open the Sheikh Zayed Tower and The Charlotte R. Bloomberg Children’s Center. “People may have lost their focus with the move to the new clinical buildings,” Trexler says. “We got the word out, and people are responding,” she adds, noting that scores climbed back up to 81 percent in September.
To nudge compliance even higher, HEIC is exploring electronic monitoring around the clock to track how often an employee enters and exits a patient’s room and whether he cleans his hands. A pilot of the system is under way in the Simulation Center and will be tested on a clinical unit next.
Other efforts to encourage clinicians to keep their hands clean abound. They range from soliciting feedback from patients and family members at All Children’s Hospital and Johns Hopkins Community Physicians practices to recognizing top performers with such honors as Sibley Hospital’s Golden Hands Award.
At Hopkins Hospital, the medical board has adopted an accountability model aimed at improving hand hygiene compliance among medical staff, a group that’s traditionally scored the lowest, says Redonda Miller, vice president of medical affairs. Miller says the program uses a set of tiered interventions that include a reminder from the department director and individual improvement plans documented by the medical board for repeat offenders. Physicians and midlevel providers will receive direct feedback on their hand hygiene performance from trained observers, who will share the results with their leaders.
“If we can hold individuals accountable,” says Miller, “then we can really push our scores higher.” All hand-washing experts at Hopkins hospitals report that their best-scoring areas have one thing in common: unit-based peer monitoring programs. “You need a peer-to-peer reminder program for hand hygiene to really become a part of the culture of the unit,” says Rita Smith, nurse epidemiologist at Suburban Hospital. “The units that have adopted their own programs have done the best and are able to sustain their scores.”
A system-wide task force that comprises infection control representatives from each entity is pooling its resources and expertise to support hand hygiene initiatives. One effort is adapting a Hopkins Hospital hand hygiene toolkit for broader circulation. The goal is to ensure that the toolkit, which will include data-reporting tools, educational resources and a leader guide and checklist, will be “generic enough to be used across the institution but flexible enough that it can be customized to meet each member’s needs,” says Jon Teter, a health system HEIC analyst.
Another institution-wide effort is an upcoming employee communications campaign that will spotlight hand hygiene role models. Additionally, member institutions can soon compare their compliance rates on a hand hygiene report card. “Publicizing score cards and rank is a good way of fostering friendly competition,” Teter says. “We can all improve by sharing.”