Why It Matters
"There is no 'one size fits all' approach [to improving hand hygiene]. It needs to be individualized to the culture and organization."
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Hand Hygiene Matters

By Frank Federico | Monday, July 22, 2013

The following is an interview IHI Communications Specialist Jo Ann Endo conducted with IHI Director Diane Jacobsen.

Q: Why is it that something like hand hygiene—that can seem so simple—is so challenging in practice?

A: This is a really big question. As an epidemiologist, I spent many years in hospitals in infection prevention at a time when it was hard to make a case for focusing on hand hygiene. To a great extent, this has changed and the importance of hand hygiene is now more widely embraced. A key challenge, however, can be perception. Often there’s a significant gap for staff, physicians, nurses, and other caregivers between perception and reality. On the planning calls we had with [our faculty] from both Johns Hopkins and Vanderbilt who are going to contribute to the Impacting Hand Hygiene at the Front Line Expedition, they both commented that—when they informed people in their organizations of their rates of hand hygiene practice—they were often surprised [by their baseline data].

Another obstacle to hand hygiene can be the physical environment. If hand sanitizer or soap and water are readily accessible to people when they enter the room, it’s much more likely that staff will [wash their hands] than if they need to search out a sink or look for a dispenser. Designing the physical environment to ensure hand washing is convenient upon entry into a patient room can significantly improve compliance.

I think culture and practice within an organization are also important. One person [on our planning call] compared it to using seat belts—how the use of seatbelts has become “habit” and something almost everyone does without thinking about or questioning. I personally wasn’t someone who used seat belts. I hadn’t made a conscious decision not to use them. I would describe it as a bad “non-habit.” I had not integrated it into what I did when I got into the car. You know what changed me? When I got a new car, it had an annoying buzzer if I didn’t buckle my seat belt. I think hand hygiene can also be a non-habit. I don’t believe it is, or rarely is, “I just don’t want to do it.” It may not be habitual or built in.

Q: So, if people tend to be surprised by the data on their actual hand hygiene compliance versus what they think they are doing, does that mean that getting observation data, for instance, is a key to getting buy-in?

A: Yes, I believe—and many hospitals have demonstrated—that  having an objective way to assess or measure how reliably staff are washing their hands and providing feedback to staff is really important for keeping things visible and “top of mind.”

Q: What are some of the keys to improving hand hygiene throughout an organization?

A: I think there are some overarching themes that apply across most improvement initiatives: having a strong leadership focus, organizational commitment, and accountability are really important. People I have talked with about their experience with hand hygiene always reflect on the time it has taken to engrain hand hygiene into their culture. They’ll say, “We spent a year or more just working on culture change in our hospital.”

Q: You mentioned accountability as a being one of the keys to success. What does that mean to you?

A: To me it means we are all in this as a team and we have a shared accountability for our practice. With that, we commit to providing each other with gentle reminders, such as “I noticed you might have missed washing your hands.”

Q: A number of organizations that have improved their hand hygiene have had hand hygiene campaigns.  Do you think that organizations need to formally declare it as a campaign to make significant improvement?

A: I don’t think a campaign per se is necessary. I do think that visible reminders and making adjustments in the environment to promote hand washing—which could be under the campaign umbrella—are important. I also personally think that making reminders visible to patients and family and visitors can be incredibly helpful. As a patient, I would not hesitate to remind someone to wash their hands. Others may not be as comfortable doing that. Making things visible, reminding both staff and visitors of the importance of hand hygiene can really change the behavior and culture within hospitals.

It isn’t necessary to spend a lot of money [on an official campaign]. Finding ways to keep hand hygiene in front of busy people who have many things on their minds can enhance hand hygiene. Hand hygiene is one thing on a long list of priorities people have, so the key is to think about how we can make it easier.

Q: There are differing opinions about the role of patients when it comes to hand hygiene. Some initiatives have focused specifically on encouraging patients to ask careproviders to wash their hands and others argue that patients should not be put in that position. What is your perspective on that?

A: I can see it from both sides. I don’t think we can put the onus on patients. At the same time, I think we can develop a shared accountability in which patients are informed and feel comfortable raising it with staff and providers rather than an expectation that patients and families remind us. To the extent that they are comfortable and willing, patients should certainly have a voice and be invited to be part of the reminder system. 

Q: How do you think tools like the Joint Commission's Targeted Solutions Tool (that will be part of the upcoming Impacting Hand Hygiene at the Front Line Expedition) can support teams that are working on hand hygiene?

A: Some type of measurement system or objective assessment of compliance with hand hygiene is very important. The Joint Commission Targeted Solutions Tool is one approach that many organizations have found useful and supportive. Organizations benefit greatly by using some objective way to assess and gather data.  Measurement on some level needs to be a foundational component of improving hand hygiene.

Q: There is research indicating that if the attending physician or first person in a group entering a room washes their hands, others in the group are more likely to follow suit. Would you comment on the behavioral aspect of improving hand hygiene?

A: I really think so much of hand hygiene is behavioral. We influence each other with our behavior and our practice. If I am with a physician in a hurry and they don’t stop to wash their hands, I am more likely to do the same. If, however, [I’m with] a team that is very diligent about that step, it is much more likely I am going to follow the team.

Q: There was a recent New York Times article that asserted that hospitals were being driven by financial pressures related to healthcare-associated infections to focus on hand hygiene.  How do you see financial pressure influencing efforts to improve hand hygiene?

A: The increased emphasis on health care-associated infections clearly raises the stakes on ensuring hand hygiene to interrupt transmission. There is more pressure to do the very best we can to prevent the transmission of healthcare-associated infections and the financial incentives certainly heighten awareness. However, I like to believe it’s not just the financial incentive but also ensuring we provide safe care to our patients.

Q: Is there anything else you would like to add?

A: There is no “one size fits all” approach [to improving hand hygiene]. It needs to be individualized to the culture and organization. I think it’s important to create a dialogue that encourages hospitals to talk with each other and share ideas about what has been successful and where they have faced obstacles. “This approach worked really well in one hospital. It might be something we could do here.” You can’t say, however, “Here is the recipe that will work everywhere.” It’s just not feasible.

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