Changing from Passive to Active Surveillance and Intervention to Increase Hand Hygiene Compliance
Background: With the implementation of hand hygiene (HH) as a national patient safety goal and the Joint Commission's expected compliance of 90%, health care institutions are under pressure to develop HH programs and to demonstrate improved adherence. Health care providers need continuous reminders, encouragement and monitoring to maintain adequate HH. To meet the Joint Commission's expected compliance rate, the University of Michigan Health System (UMHS) has used many approaches such as education, posting of signs, dissemination of videos, and monthly feedback reports on HH compliance.
Objective: To increase HH compliance of health care workers to 100% throughout the UMHS.
Methods: The UMHS relies primarily on nurse observers to collect HH compliance data. Currently, 79 observers collect observation data from 46 different inpatient floors and outpatient clinics. When UMHS began collecting HH data, observers were asked to watch staff and indicate on a data collection tool whether or not health care workers washed their hands or used alcohol-based hand sanitizer appropriately. Beginning on March 1, 2009 the nurse observers were asked to change their practice. Instead of only watching and recording data, they were asked to intervene when they saw someone not cleanse their hands appropriately. The observers would provide immediate feedback and reinforcement at the moment when staff were not compliant. They would then record their observations and report monthly data with notes indicating when interventions were needed. All observers were trained by Infection Control & Epidemiology staff members with specific expectations for HH, when observers should intervene, and how to record intervention data using a specially designed data collection tool.
Results: Prior to the change in procedure, the three month average for HH adherence was 86.5%. Following the implementation of the new observer protocol, the UMHS surpassed 90% HH compliance for the first time since the initiation of nurse observer HH data collection. In May 2009, following two months of active intervention by nurse observers, the HH adherence rate was 91.5%. The adherence rate reached 94.2% in September. In March 2009 nurse observers intervened 219 times out of 1,948 observations. In September 2009 observers intervened 80 times out of 1,410observations.
Conclusions: Providing reinforcement at the moment of non-compliance had a positive effect on HH adherence within UMHS. Immediate individual feedback and education may be a stronger learning tool than monthly feedback reports to managers and scheduled educational sessions. In addition to regular education, reminder signs, and other forms of HH education, we believe feedback and reinforcement at the time of noncompliance played an important role in increasing HH adherence within our institution.