Boosting hand washing with monitors, feedback
Novant uses internal marketing to get staff on board
In the photograph, a young boy in a hospital bed looks unflinchingly at you, one hand on his chest. And in big type it reads, "You could kill me with your bare hands." Novant Health's message to its staff in 2005 was clear. Hand hygiene compliance is a matter of life and death.
The hospital system knew what it was talking about. In 2004, there was an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) in one of its NICU units. "And with the subsequent associated death to MRSA of a small baby and some transmission within the unit, it was really the president of the system's call to arms — 'This can't be,'" says Jim Lederer, MD, medical director for Novant Health's clinical improvement department.
So with upper-level support from management and administration, the health system set out to raise hand hygiene compliance to 90%. And after about a dozen failed hand hygiene compliance efforts, this one took, garnering the health system The Joint Commission's 2008 Ernest Armory Codman Award. Novant is now at 98% for hand hygiene compliance, and its MRSA rate is 0.16 per 1,000 patient days, a 68% reduction.
The effort was systemwide, and the steering committee included "everyone from infection prevention to nursing to senior leadership," says Lederer, an infectious disease doctor who works with occupational health and the clinical improvement department, which houses both infection control and quality.
Monitors hired for observation, feedback
The guiding light became accountability, and in order to "hold you accountable for something, I need to be able to to have measurement," Lederer says. So Novant hired two monitors for each region to rotate through the facilities and observe staff for hand hygiene compliance.
The monitors were full-time, newly created positions under infection control. "Initially, they were LPNs," Lederer says, "but we found that LPNs had a difficult time challenging and correcting RNs. So we moved it up a notch to RNs." Their primary job was monitoring but also reporting feedback and providing education to staff.
He says the system used the methodology proposed by the Centers for Disease Control and Prevention and the World Health Organization's five steps. But placing two monitors to observe every hand-washing opportunity was a challenge. For the most part, Lederer says, they were placed in the general medical/surgical units upon entrance and exit, as well as the ICUs. "Because of the way our ICUs are laid out with windows into the room" monitors could observe compliance between sterile sites.
When monitors see a lapse in hand hygiene, they immediately speak to the noncompliant individual and then to the manager of the unit. But for physicians, Lederer says, the system found it was more effective to have physician-to-physician communication. So monitors would report lapses to the vice president of medical affairs in each facility who talked to noncompliant individuals.
Not only was monitoring and reporting real time, but data flowed automatically into the health system's electronic performance score card, "which is seen by all," Lederer says. "Any facility can look at any other facility and you can actually drill down to the noncompliant individual and if you click on their name, it'll pull up their name tag.
"You can't make it totally nonpunitive," he adds. "We have alcohol dispensers everywhere. There's no reason for you not to spend 10 seconds [washing your hands]. We can understand you not wanting to go into a patient's private bathroom, which may be internal inside the [patient's] room without a foyer or anteroom... We have lots of excuses, but there's not an excuse not to use a hand hygiene dispenser that's in the hall right outside the door."
When physicians are noncompliant, the incident is put into their credentialing file. For other staff, it's part of the system's progressive discipline policy. "If we catch you once, obviously you're going to get counseled, and you would follow the progressive discipline course if you got caught multiple times," Lederer says.
The system tied observation, direct feedback, and unit-based education to an internal marketing campaign. Posters, desktop wallpapers, cling stickers, and even billboards on major roadways near the facilities were used to home in on the message — washed hands can literally save lives. Messages about the importance of hand sanitization were posted at the entrances to each facility, in front of doctors' offices, on patients' tray mats, and computer pop ups.
The campaign, Lederer says, was "really meant to show employees that this is the degree to which we'll go." (All of the signage Novant used is available for hospitals' use at www.washinghandssaveslives.org.)
Barriers to compliance
Lederer sees two significant barriers to compliance. One, he says, is "the mindset and the culture that's dictated from the top. And that's why we had 12 failed prior hand hygiene [initiatives]. If you don't have that level [of support], you'll get nowhere."
And the second thing he points to is resources: making those readily available to make compliance easier. The system had to go through a learning curve after introducing dispensers at facilities in 1998. "[O]ver time," Lederer says, "we've learned that different fire marshals have different approaches." He says they've had no problems with The Joint Commission or the Centers for Medicaid & Medicare Services as far as dispenser placement but suggests learning what your local fire marshal is looking for.
He also acknowledges that once staff knew who the monitors were, they might consciously change their practices and that monitors were mostly staffed during the day — a different culture than nights and weekends. "So even today we realize there's still a challenge because it's not unconscious competency." So measurement and feedback continues, and as it does Lederer hopes it will become less of a corporate responsibility and more of an individual unit one — with managers measuring locally and continuing to cultivate the culture of hand hygiene.
In the photograph, a young boy in a hospital bed looks unflinchingly at you, one hand on his chest. And in big type it reads, "You could kill me with your bare hands." Novant Health's message to its staff in 2005 was clear. Hand hygiene compliance is a matter of life and death.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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