The Performance Gap
Hand hygiene contributes significantly to keeping patients safe. While hand hygiene is not the only measure to counter HAI (for example effective environmental decontamination is essential), compliance with it alone can dramatically enhance patient safety \cite{Kelly_2016}, because there is much scientific evidence showing that microbes causing HAI are most frequently spread between patients on the hands of health- care workers. Many patients may carry microbes without any obvious signs or symptoms of an infection (colonized or sub clinically-infected). Microbes have an impressive ability to survive on the hands, sometimes for hours, if hands are not cleaned. This clearly reinforces the need for hand hygiene, regardless of the type of patient being cared for.
Health-care facilities which readily embrace strategies for improving hand hygiene also prove more open to a closer scrutiny of their infection control practices in general. Therefore, the impact of focusing on hand hygiene can lead to an overall improvement in patient safety across an entire organization \cite{Kelly_2016}. The hands of staff can become contaminated even after seemingly ‘clean’ procedures such as taking a pulse, blood pressure, or touching a patient’s hand \cite{world2009guidelines}.
A vital element of the Performance Gap is the accurate and reliable measurement of hand hygiene compliance which has typically been accomplished by Direct Observation (DO) by human observers sometimes known as "secret shoppers". It is clear from the research that DO and Secret Shoppers should no longer “measure” HH as they have been shown to consistently overstate compliance by as much as 300% giving a false sense of security and complacency that blocks the sense of urgency to improve \cite{25002555} \cite{19775774}. Further, allowing "secret shoppers" to observe the lack of HH compliance and do nothing to intervene enables a healthcare worker to provide care with potentially contaminated hands putting patients at unnecessary risk of harm. The solution is to measure hand hygiene compliance with an evidence-based and validated electronic hand hygiene compliance system - this is addressed in detail below in the Technology Plan.
CMS/CMMI and their Partnership for Patients are now promoting this approach around the deployment of electronic hand hygiene compliance systems to reduce infections and costs to the Hospital Improvement Innovation Networks (HIINs) via their web site and a web broadcast Pacing Event on May 25, 2017
Partnership for Patients Pacing Event - Hand Hygiene and HAIs.
Leadership Plan
The following is a practical guide for driving sustainable behavior change and results, starting with hospital leadership.
- Ensure top-down leadership engagement is authentic and known by all and that leaders model the expected behavior.
- Foster psychological safety and promote a "just" safety culture. It must be safe for everyone to be able to speak up and “stop the line” when hand hygiene does not occur as indicated.
- Use Direct Observation (DO) for Unit Based feedback (not the measurement of compliance) and real-time barrier identification - then develop and agree on an action plans to remove them. This approach has been proven effective in driving sustainable improvement.\cite{al2016a}.
- Agree on unit specific improvement goals & celebrate even small successes \cite{Son_2011} (The goal is progress vs. perfection)
- Give frequent feedback on performance – share the data daily and/or according to monitoring technology supplier’s recommendations. – frontline staff engagement is essential.
- Make HHC improvement part of performance evaluation with routine reporting of results to senior leadership for facility-wide feedback.
Practice Plan
Change management (that is changing the safety culture) is a critical element that must be included to sustain any improvements. Recognizing the needs and ideas of the people who are part of the process—and who are charged with implementing and sustaining a new solution—is critical in building the acceptance and accountability for change. A technical solution without acceptance of the proposed changes will not succeed. Building a strategy for acceptance and accountability of a change initiative greatly increase the opportunity for success and sustainability of improvements. “Facilitating Change,” the change management model The Joint Commission developed, contains four key elements to consider when working through a change initiative to address HAIs (Appendix A).
Hand hygiene improvement is not amenable to a “one size fits all” approach. It involves a complex set of interactions that requires an approach focused on measurement and understanding of root causes. The Joint Commission Center for Transforming Healthcare Targeted Solutions Tool (TST)® provides healthcare organizations this type of comprehensive approach and is proven to improve hand hygiene compliance \cite{commission2012}. However, when using the tool, measurement should only be accomplished with an evidence-based, validated electronic hand hygiene compliance system. This combination of electronic monitoring + DO has been proven to drive sustainable improvement \cite{al2016a}\cite{Boyce_2017}.
This involves a proven four-step process: 1. Identify barriers and obstacles unique to the unit using interventional Direct Observation as described above. 2. Work with unit leadership to put in place training and an action plan to remove the barriers. 3. Implement the training and action plan. 4. Measure improvement using an evidence-based, validated electronic hand hygiene compliance system and give appropriate feedback to ensure successes are acknowledged and that remaining barriers and obstacles are addressed \cite{al2016a}.