Using Financial Incentives to Improve Hand Hygiene Adherence

Background:  Since 2004 Vanderbilt University Medical Center (VUMC) has actively promoted hand hygiene adherence through education and awareness, enhanced availability of alcohol-based hand gel, and direct observations of hand hygiene practice.  Despite these efforts, hand hygiene adherence remained low with institutional adherence rates of 55%, 53%, and 54% for fiscal years 2007, 2008, and 2009.  In 2009 VUMC leadership considered new strategies to improve adherence.  VUMC is self-insured for malpractice claims against its professionals and facilities.  Funding for a self-insurance trust occurs through facility and medical group premiums.  Due to favorable claims experience, a self-insurance rebate program was created in fiscal year 2008 encouraging the medical group and facilities (hospitals) to reclaim up to 10% of their yearly premiums based on meeting four safety and risk prevention goals (all with associated metrics).  In June 2009 VUMC leadership elected to establish hand hygiene adherence as one of the four goals.  In coordination with the rebate program, an enhanced Hand Hygiene Campaign was then launched with expanded direct observation teams in both inpatient and outpatient settings.

Objective:  To improve hand hygiene adherence using a multi-faceted hand hygiene program coupled with a self-insurance trust premium rebate program.

Methods:  In July 2009, VUMC leaders established institutional quality goals for hand hygiene adherence (70% threshold, 80% target, and 90% reach) based on direct observations.  In October 2009, VUMC launched the enhanced Hand Hygiene Campaign which consisted of faculty and staff education, marketing, expanded direct observation of hand hygiene practice, and both electronic and in person feedback to chairmen, clinic and hospital leaders.  Unit managers conducted observations in locations for which they had no direct supervisory role.  Hand hygiene adherence data were recorded via a web-based data-entry system and were stratified according to patient care unit and job description. Data were aggregated and reported monthly to the VUMC Quality Council for evaluation against target adherence goals and consideration of feedback interventions to improve hand hygiene adherence.  

Results:  Baseline hand hygiene adherence varied prior to the campaign, with rates ranging from 31% to 80% (Figure 1).  Following enhancement of the program, hand hygiene adherence was sustained above 77% from February through September 2010.  Improved adherence rates allowed the medical group and facility leadership to claim 75% of the rebate dollars allocated for the hand hygiene metric.

Conclusions:  Hand hygiene is an important risk reduction and patient safety strategy.  Use of a self-insurance trust rebate within a multi-faceted hand hygiene campaign and direct feedback to leaders was associated with sustained improvement in hand hygiene adherence.