As healthcare reform focuses more on value for patients, many hospitals are making quality and patient safety top goals. However patient safety is a broad category of important issues. Here, Gina Pugliese, RN, MS, vice president of the Premier healthcare alliance's Safety Institute, explains why hand hygiene should be a patient safety priority, and how healthcare organizations can succeed in improving hand hygiene compliance.
Question: Patient safety includes a wide range of issues, from patient falls to medication errors and hospital-acquired infections. What one patient safety issue do you think should be a priority in hospitals and health systems?
Gina Pugliese: Hand hygiene is one of the most important patient safety issues today. And, it is the single most important factor in preventing the spread of pathogens and healthcare-associated infections. Low compliance with this basic patient safety measure may represent a lack of compliance with other patient safety practices. Despite attention to public reporting, reduced reimbursement initiatives for certain healthcare-associated infections, and international attention by public health, professional and accreditation organizations, it has been a challenge to reach and sustain hand hygiene rates over 80 percent in many healthcare facilities.
Q: What are the biggest barriers to improving hand hygiene?
GP: All the systems must be in place to support hand hygiene and make it easy for staff to adhere. This includes staff education on the importance and indications for hand hygiene; convenient location of sinks and dispensers; all dispensers in working order and filled with hand hygiene products that are not drying or irritating to the skin and [that are] acceptable to staff.
Q: How can healthcare leaders overcome these barriers?
GP: To support compliance, staff feedback and visual and auditory reminders can reinforce key messages and maintain awareness. Strategies to empower patients to remind caregivers have also been successful. A recent study conducted by the Premier Safety Institute in collaboration with the CDC and Catholic Health Partners found that patients were twice as likely to ask their caregiver to wash their hands after viewing a video that provided education and encouragement. Research has also shown us the importance of role modeling from superiors or peers as a strong influence on appropriate hand hygiene. It is also important to promote a culture that does not tolerate intimidation and empowers staff to speak up when nonadherence is observed.
Q: What are the biggest opportunities for improving hand hygiene?
GP: The organizational culture must have the right balance between no-blame and individual accountability for noncompliance with safety practices. In most high reliability industries, such as the airline industry, once a reasonable safety rule has been scrutinized for strong evidence to support it, found to have no unintended consequences and then becomes implemented, a worker who fails to follow the rule becomes accountable for failure to comply. There needs to be a consistent, fair and transparent method to monitor adherence to recommended practices for hand hygiene and the behaviors for which staff will be held accountable.
Some hospitals have been very successful with incentives and rewards to improve hand hygiene compliance. Any penalties for failure to adhere to patient safety standards must be understood by all staff and applied fairly and proportional to the infraction. Penalties are not intended for a busy or distracted caregiver that may forget to wash their hands, but rather habitual and intentional failure to perform hand hygiene despite education, repeat counseling and corrections of any identified systems issues. Penalties for failure to adhere to appropriate hand hygiene vary, and have included the linking of compliance to merit increases for salaried staff and temporary loss of clinical privileges for physicians.
Q: How can leaders spread successful strategies to create widespread improvement in hand hygiene?
GP: A strong visible support for a safety culture, led by the board and C-suite, reflects the commitment to safety that is evident at all levels of the organization and is the key to sustainable change at the front lines of patient care. As part of that culture, leadership helps set expectations for the staff by determining the priorities and level of focus on hand hygiene, providing resources, removing barriers and setting expectations for compliance and accountability.
A strong leadership with visible support for a safety culture that promotes hand hygiene can influence a culture change and increase compliance. Staff perception of organization culture has been found to be associated with improved hand hygiene compliance. One study showed that those hospitals with top management and medical and nursing leaders visibly supporting a culture [of frequent hand hygiene to lower infection rates] had a significant and sustained increase [in] hand hygiene frequency with reduced rates of antibiotic-resistant organisms, specifically [methicillin-resistant Staphylococcus aureus] and [vancomycin-resistant enterococci].
Supporting a multidisciplinary team and the use of a systematic quality improvement model will help with understanding the reasons for nonadherence to guidelines and identifying and prioritizing additional strategies for sustained improvement. Finally, visibly celebrate success throughout the organization.
Evidence-Based Approaches to Hand Hygiene: Best Practices for Collaboration
Patient Safety Tool: 3 Videos on Hand Hygiene
Question: Patient safety includes a wide range of issues, from patient falls to medication errors and hospital-acquired infections. What one patient safety issue do you think should be a priority in hospitals and health systems? Gina Pugliese: Hand hygiene is one of the most important patient safety issues today. And, it is the single most important factor in preventing the spread of pathogens and healthcare-associated infections. Low compliance with this basic patient safety measure may represent a lack of compliance with other patient safety practices. Despite attention to public reporting, reduced reimbursement initiatives for certain healthcare-associated infections, and international attention by public health, professional and accreditation organizations, it has been a challenge to reach and sustain hand hygiene rates over 80 percent in many healthcare facilities.
Q: What are the biggest barriers to improving hand hygiene?
GP: All the systems must be in place to support hand hygiene and make it easy for staff to adhere. This includes staff education on the importance and indications for hand hygiene; convenient location of sinks and dispensers; all dispensers in working order and filled with hand hygiene products that are not drying or irritating to the skin and [that are] acceptable to staff.
Q: How can healthcare leaders overcome these barriers?
GP: To support compliance, staff feedback and visual and auditory reminders can reinforce key messages and maintain awareness. Strategies to empower patients to remind caregivers have also been successful. A recent study conducted by the Premier Safety Institute in collaboration with the CDC and Catholic Health Partners found that patients were twice as likely to ask their caregiver to wash their hands after viewing a video that provided education and encouragement. Research has also shown us the importance of role modeling from superiors or peers as a strong influence on appropriate hand hygiene. It is also important to promote a culture that does not tolerate intimidation and empowers staff to speak up when nonadherence is observed.
Q: What are the biggest opportunities for improving hand hygiene?
GP: The organizational culture must have the right balance between no-blame and individual accountability for noncompliance with safety practices. In most high reliability industries, such as the airline industry, once a reasonable safety rule has been scrutinized for strong evidence to support it, found to have no unintended consequences and then becomes implemented, a worker who fails to follow the rule becomes accountable for failure to comply. There needs to be a consistent, fair and transparent method to monitor adherence to recommended practices for hand hygiene and the behaviors for which staff will be held accountable.
Some hospitals have been very successful with incentives and rewards to improve hand hygiene compliance. Any penalties for failure to adhere to patient safety standards must be understood by all staff and applied fairly and proportional to the infraction. Penalties are not intended for a busy or distracted caregiver that may forget to wash their hands, but rather habitual and intentional failure to perform hand hygiene despite education, repeat counseling and corrections of any identified systems issues. Penalties for failure to adhere to appropriate hand hygiene vary, and have included the linking of compliance to merit increases for salaried staff and temporary loss of clinical privileges for physicians.
Q: How can leaders spread successful strategies to create widespread improvement in hand hygiene?
GP: A strong visible support for a safety culture, led by the board and C-suite, reflects the commitment to safety that is evident at all levels of the organization and is the key to sustainable change at the front lines of patient care. As part of that culture, leadership helps set expectations for the staff by determining the priorities and level of focus on hand hygiene, providing resources, removing barriers and setting expectations for compliance and accountability.
A strong leadership with visible support for a safety culture that promotes hand hygiene can influence a culture change and increase compliance. Staff perception of organization culture has been found to be associated with improved hand hygiene compliance. One study showed that those hospitals with top management and medical and nursing leaders visibly supporting a culture [of frequent hand hygiene to lower infection rates] had a significant and sustained increase [in] hand hygiene frequency with reduced rates of antibiotic-resistant organisms, specifically [methicillin-resistant Staphylococcus aureus] and [vancomycin-resistant enterococci].
Supporting a multidisciplinary team and the use of a systematic quality improvement model will help with understanding the reasons for nonadherence to guidelines and identifying and prioritizing additional strategies for sustained improvement. Finally, visibly celebrate success throughout the organization.
More Articles on Hand Hygiene:
20 Ohio Hospitals' Hand Hygiene Compliance Rate Nearly TripledEvidence-Based Approaches to Hand Hygiene: Best Practices for Collaboration
Patient Safety Tool: 3 Videos on Hand Hygiene