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"Haven't we failed our patients if we accept that there's good hand hygiene in one area, but not everywhere?"
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Going Beyond Hand Hygiene Compliance

By Thomas Talbot | Monday, April 6, 2015

Vanderbilt University Medical Center’s hand hygiene compliance rate has been in the 90 percent range for the last four years. In an interview with IHI, Vanderbilt's Chief Hospital Epidemiologist Dr. Tom Talbot credits their success to building a strong culture of shared accountability.

Q: What are the main barriers to consistently following recommended hand hygiene practices? 

Handwashing is a reflexive behavior — we don’t tend to think about it; we think it just “happens.” It’s like if we use seatbelts. We get into a car and put on the seatbelt without really thinking about it because we’ve become accustomed to this behavior. But anything that impedes these kinds of behaviors — if you don’t have ready access to [hand sanitizer], for example — will keep you from doing them if they’re not ingrained in your workflow. Another common issue is accountability. There needs to be an expectation that [good hand hygiene] is part of the foundational professional behavior we should all have as health care workers.

Q: What have been keys to your organization’s success in maintaining hand hygiene compliance? 

Vanderbilt’s current compliance rate is 96 percent, but I’ll put an asterisk on that because any time you directly observe people, there is going to be a Hawthorne Effect (that is, they know they are being observed so they correct behavior in real time). We’ve used “secret shoppers” to monitor hand hygiene practices, and our compliance rate has been well in the 90 percent range for about four years through a lot of hard work. One challenge of comparing and benchmarking [hand hygiene compliance] data is that everyone measures it a little differently. There’s a great deal of subjectivity.

About six years ago, Vanderbilt amplified our handwashing efforts because it was important to do more than just improve the hand hygiene compliance rate. Improving hand hygiene itself is important, but we wanted to make it a core foundational behavioral and cultural practice. We wanted staff to work together, develop a culture of shared accountability, and create an environment in which they feel comfortable reminding each other about practices that may seem basic, such as handwashing.

We also elevated hand hygiene compliance to our highest level of quality measures for the institution. There was a lot of discussion about what numbers we were going to use [for measurement]. We decided to hold everyone accountable to a single number. In other words, we measure the hand hygiene compliance rate of the entire medical center, both inpatient and outpatient.

Some folks didn’t like using a single, overall number because they didn’t think it was fair. Some expressed concern about not being able to “control” consulting doctors or traveling nurses or that they could be in a clinic that [has good compliance], but the overall number might be lowered by another clinic that doesn’t. Some people said, “Just tell me our rate, and I’ll be accountable for that.” But haven’t we failed our patients if we accept that there’s good hand hygiene in one area, but not everywhere? So, we chose to use [an overall compliance rate] because it is important for all staff to feel responsible for all of our patients, and to have a culture where, if there’s an area not [following good hand hygiene practice], we have a conversation about that just like we do when there’s any other kind of unsafe practice. 

There was some initial resistance, but most pushback against handwashing really starts to fall apart once you have a conversation. For example, “I’m so busy. You want me to wash my hands before every single patient?” Well, if I was the patient, yeah! Wouldn’t you? We’ve now hardwired a shared accountability for hand hygiene into our culture.

Q: It seems that some organizations have some initial success with improving hand hygiene – the result of a special campaign or initiative, for example – but they’re not always able to maintain those results. How has your organization sustained success over time?

I think we’ve been successful because we made everyone rely upon each other. For example, every clinical unit, clinic, or procedural area designates a person from their area to be a hand hygiene observer [of another part of the organization] every month. (They can’t observe themselves.) They spend about 20 to 30 minutes observing, capturing that data, and hopefully gaining some insights they can take back to their own area. And someone is also doing that same observation for their area, so they’re all interdependent — every area provides and receives compliance data. If there’s a month when an area doesn’t receive data, they’ll tell us. We really don’t get pushback anymore. It’s taken a long time, but now we hear, “How can we improve?”

We’ve also tried to infuse hand hygiene practices with other infection prevention programs. As we said from the start, if we can’t get handwashing right, then everything we’re trying to do for pneumonia, or urinary tract infections, or central line infections is not going to be as effective because hand hygiene is such a foundational practice.
Q: Have you been able to apply lessons learned from hand hygiene to other infection prevention efforts? 

We have, and not just for infection prevention, but for other improvement efforts. It makes me proud when we’re working on a new program — whether it’s falls prevention or mislabeled specimens or ID badges — and I hear, “We’ve got to hardwire this like handwashing.” What we’ve learned from the hand hygiene work really lends itself to other behavioral practices that involve monitoring and having peer-to-peer conversations.

We borrowed another practice from a program that one of my mentors, Dr. Hickson, uses with patient complaint data. We used handwashing performance data to provide feedback and build awareness in areas where compliance was well below our organizational goals. We used formal “awareness letters” — that basically say, “We know that you know that infection prevention is important. Here are our institutional goals. Here’s how you’re performing, and it is below where we want you to be, so we’re going to give you some target reminders and work with your team to improve. We’ll keep doing that until you reach the goals we want you to attain.” The letters reinforce the message, “We’re watching, but we’re all in this together, and we’ll help you.”

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Q: How else have you applied that kind of respectful engagement?

Before we started collecting hand hygiene compliance data, we had a huge discussion with [various stakeholders] about exactly how we should measure and count. It was a tedious exercise, but really important because everybody provided their input and it helped us reaffirm as a group that hand hygiene is important.

Also, when we share the data, we don’t say, “Why is your compliance so horrible?” We open a discussion. For example, we have a unit with a somewhat unusual layout — it’s divided in half and there’s a door between the two sides. When we first started the hand hygiene observation program, the observer for this unit (who had never been there before) kept seeing people going through that door and not washing their hands, counting that as a [handwashing] opportunity. She didn’t realize there was another nurse’s station on the other side of the door (and that it did not go directly to a patient room), so she was counting that as a patient area and counting it as non-compliant. When the unit saw their data, they asked if we could take another look. That’s how we found we were measuring incorrectly. You can’t assume your data are absolutely correct. You need to listen and take a closer look sometimes.

We also had another instance in which a unit thought we were counting incorrectly. They said, “Sometimes we step in the room for a minute and give people a status update, but we don’t go in and touch anything. I’m sure that’s why we’re seen as [non-compliant], because we’re just going in and out really quickly.” Talking to our observers, we confirmed that wasn’t the case.

But we decided to give them two minutes in the room. We agreed not to count any time under two minutes. But their data stayed the same, and after that we got their buy-in. If we hadn’t been flexible, they might have continued to assume that the only problem the numbers represented was inaccurate counting and not their hand hygiene practices.

We’re all professionals, so we treat everyone respectfully. Our approach is to figure out together with each unit why data suggests there are opportunities for improvement.
Q: What role does technology play in monitoring hand hygiene compliance? 

Technology might work very well for other organizations, but at Vanderbilt, we’re at a place now where we’ve sustained [a high compliance rate] and feel that technology is not going to add anything for us. It may actually do some harm in terms of the culture-building we are doing. By relying too heavily on technology, we wouldn’t have the peer-to-peer dialogue that we value.

One thing that drives our culture is how we train observers to have conversations that are not silly or demeaning when they remind people to wash their hands. Those skills apply to any topic because a culture that supports open, respectful discussions about hand hygiene also helps people say things like, “You didn’t prep your sterile field quite right.” We call them “cup-of-coffee moments” because we want them to feel like you’re chatting over a cup of coffee with a peer. That’s very different than a badge buzzing when I forget to wash my hands or a “Big Brother” sort of monitoring system.
Q: How has the focus on preventing healthcare-acquired infections, especially the penalties for avoidable readmissions, influenced attention on hand hygiene practices? 

It has helped because hand hygiene is such a foundational practice that applies to any healthcare-associated transmission. If you approach it the right away, it has broader impact than just infection prevention. I’m not naïve enough to think that if we weren’t in an era where central line infection data were publicly reported, people would be as interested in handwashing, but that’s just part of the evolution of health care and we’ve all become more interested in quality.

Q: What has surprised you most as you’ve worked on hand hygiene over the years? 

This has been the most fascinating program I’ve been involved with. When I started, I kind of shrugged my shoulders and said, “I have to be in charge of handwashing?” But it’s been fascinating because it’s a very simple concept — wash your hands, prevent infections — but to hardwire behavior and change practice, particularly in a large medical center with microcosms of cultures within the organization, is extremely difficult. I was really surprised at how difficult.
A unit’s hand hygiene compliance is like a biopsy of their culture — the factors that contribute to problems with handwashing also factor into other problems. People weren’t surprised when some areas found hand hygiene challenging because they had other issues. Units with good hand hygiene practices had leadership that worked well together, and had a great team and great communication. For these units, handwashing was no problem. That kind of learning has been fascinating.

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