Establishing a Hand Hygiene Culture of Accountability

A hospital established a “culture of accountability” by identifying and removing barriers to hand hygiene, one of which was the hesitancy to remind coworkers they need to wash their hands, said Hannah Battey, BS, MS, CIC, infection preventionist at City of Hope National Medical Center in Pasadena, CA. “A big part of our intervention was bringing the departments together and trying to bridge those gaps, to make sure people feel comfortable speaking to each other, and that we’re really fostering a culture of accountability here,” she said recently in Indianapolis at the 2022 conference of the Association for Professionals in Infection Control and Epidemiology (APIC).

In a survey of hospital staff, 25% said they had observed colleagues not washing their hands at appropriate times. A follow-up question was, did they prompt them to do so? “Of that 25%, only 28% always speak up and remind [the coworker to wash their hands],” Battey said. “There’s an opportunity here for just-in-time coaching.”

Hospitals are hierarchal institutions, and 34% said they feel comfortable speaking up about a missed hand hygiene moment if it is on a peer level, for example, nurse to nurse.

“We really pushed the just-in-time coaching,” she said. “We got our chief medical officer and our head of infectious disease to bring up the barriers specific to physicians to their meetings. They talked to them and said, ‘if someone reminds you [to wash hands] they’re looking out for the best interest of the patient — please receive it well.’”

To avoid this process in front of patients, the acronym for the hospital, “COH” was used as the code reminder for hand disinfection. This also made it easier for staff to speak up in front of patients and family members.

“Units really liked it because they could just say COH, which stands for City of Hope, but it also stands for ‘cleaner hands,’” she said.

Based on a performance improvement tool developed by the Joint Commission, the hand hygiene project consisted of two rounds of focused, unit-specific cohorts, spanning the course of 15 months in 2020-2021.¹

Staff barriers were assessed through survey and direct observation. Each participating unit appointed a team of bedside nurses and managers to assist with data collection and solution implementation. Staff were engaged through tailored educational presentations, unit-specific advertising, and a video competition.

The top three hand hygiene barriers identified were:

• Distracted or forgot

• Hands full of supplies

• Frequent entry/exit

“In terms of frequent entry or exit, this is a challenging one because, of course, it can be chaotic and busy on the floors and the last thing we want to do is make people’s lives more difficult,” she said. “But also, at the same time, we want to make sure we’re being safe and that we are clear on the expectations of what’s required of us as healthcare workers on the care team.”

This is somewhat similar to “distracted or forgot,” and if a coworker speaks up, their colleague is reminded. If no colleague is there and the caregiver is heading toward the patient with unwashed hands, the final safety net is the patients themselves.

“We also did some patient education, and if they noticed that their healthcare provider didn’t clean their hands, that were empowered to speak up,” Battey said.

For “hands full of supplies,” there was an emphasis on establishing the work flow and knowing the difference between “clean” vs. “dirty.” If the equipment has been properly disinfected and stored, then healthcare workers should wash their hands before retrieving it to avoid fomite contamination, she said. “Clean your hands so you’re not cross-contaminating your supplies and the patient,” she said.

Another key step toward building a culture of hand hygiene accountability — and sustaining it — was creating a hand hygiene committee that includes frontline staff. “Putting some of the accountability on the front-line staff is huge,” she said. “When you offer up some of that power and that opportunity to staff, they will really take it and run with it.”

Inpatient units designated a representative, and IPs explained the expectations on providing information to colleagues, how they could help gather data, and provide just-in-time coaching.

In the survey, workers noted that dispensers of soap and sanitizers too often were empty. “To remedy this, we talked to our environmental services department — one of our strong allies here — and created a contact tree of who to make sure empty dispensers are filled within 15 to 20 minutes,” Battey said.

Battey and colleagues also provided resources on how to mitigate skin irritation and referred some workers to employee health if they had an apparent allergy to the hand hygiene products.

Participating units maintained consistent hand hygiene compliance around the 85% mark throughout the course of the project. This sustainability coincided with a reduction in central-line bloodstream infections and Clostridium difficile cases, she said.

Although falling short of the Joint Commission goal of at least a 90% hand hygiene compliance rate, Batty said many important issues were addressed in the project. “I think we’re getting closer to our true compliance here,” she said. “We have a very robust data set and we wanted to understand where we’re at. If you see something like this, do not get discouraged, because we’re also trying to shift culture here and that might take some time. When we look at our compliance since this project, it is at or above what we [report] here — so it is sustaining.”

REFERENCE

1. Joint Commission Center for Transforming Healthcare. Targeted Solutions Tool (TST): Hand hygiene. https://www.centerfortransforminghealthcare.org/-/media/cth/documents/what-we-offer/hand-hygiene-tst-fact-sheet-8-15.pdf