Secret shoppers help improve hand hygiene compliance

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If you want to see someone’s true behavior, watch what they do when they think no one is looking, says Brian Hudson, MT (ASCP), CIC, an infection preventionist (IP) at Cleveland Regional Medical Center in Shelby, NC.

This is the idea behind secret shopper programs at various hospitals, which try to get a better picture of staff members’ hand hygiene compliance by observing them when they don’t think they’re being watched.

“It’s impossible for the infection control professional to do [accurate hand hygiene observation] when they’re rounding. People tend to run screaming to the closest sink when they see us,” says Gayle Lovato, MS, RN, an IP at Inova Loudoun Hospital in Leesburg, VA.

The numbers support her observation. Research has shown that people are more likely to wash their hands after using the bathroom if someone else is in the bathroom with them than if they are alone, says Hudson.

Cleveland’s secret shopper program found striking differences in compliance: Staff members are 90%–95% compliant with hand hygiene guidelines when they know they are being observed, but those numbers dip when the secret shopper is watching, Hudson says.

How secret shopper programs work

Secret shopper programs vary, but at Inova and Cleveland, staff members are used to being secretly monitored for hand hygiene compliance.

Inova’s secret shopper program has been in place for several years, using infection control trainers to perform the surveillance. One trainer on each unit monitors staff compliance with hand hygiene regulations and documents the findings on a standardized report form. Each trainer performs an average of 10 observations per month, says Lovato.

Currently, Cleveland has only one shopper because it has been difficult finding volunteers to fill additional positions, but the hope is to expand the program, says Hudson.

To entice volunteers, Inova offers a step increase for secret shoppers. This gives staff members a small incremental pay increase, similar to what they would get for participating on a hospital committee, says Lovato.

Every month, Inova issues a report card listing the compliance rates for each unit. “The observations are not scientific—they’re random—but overall I think they give us a pretty good snapshot,” says Lovato.

The hospital uses these hand hygiene figures to spot trends and identify problem areas.

For example, if a particular unit has a high incidence of noncompliance, Lovato looks for opportunities to perform staff education or improve systems issues, such as making alcohol-based hand sanitizer more readily available.

Dividing data

Officials have broken up the data at Inova into two categories: compliance with hand hygiene prior to patient care and after patient care.

Hand hygiene compliance tends to be higher after a healthcare worker touches a patient than before. “This is almost a universal finding,” says Lovato. Healthcare workers are more likely to wash their hands to protect themselves from patient germs they may have encountered during contact than they are to protect the patient from their own germs, she says.

“One of the things we say in orientation is ‘We’re here to protect you from the patient and to protect the patient from you,’ ” says Lovato. “Hand hygiene goes two ways.”

There is currently a debate at Inova about whether observers have a moral obligation to protect patients by stopping healthcare workers who fail to comply with hand hygiene guidelines before they touch a patient. Officials don’t require secret shoppers to step in, primarily because they don’t want to blow the shopper’s cover.

If Inova decides to require shoppers to intervene in the future, it will need to provide training to help shoppers administer this guidance diplomatically, says Lovato.

Focusing on noncompliance

To encourage compliance at Inova, the names of noncompliant staff members are reported to their managers. This is primarily designed to target chronic offenders. Information about individuals with multiple offenses goes into their files, Lovato says.

Recently, the program was expanded to include physicians. Physicians had been excluded because they weren’t hospital staff members, says Lovato. But physician hand hygiene rates have been a problem.

Hospital observations at Inova target three categories of workers: physicians, nurses, and “others,” a group that includes patient care techs and respiratory technicians. Physicians are always the worst offenders, with nurses coming in second, says Lovato.

“Month after month after month, the ‘others’ are at 100%,” she says. “I wish I knew why.”

Enlist the help of a physician champion when addressing physician noncompliance. “It doesn’t do much if it’s just me fussing at doctors; it needs to be a doctor fussing at other doctors,” says Lovato.

Changing the culture

Gaining compliance also requires a culture shift.

“Hand washing is the first thing you learn the first week of medical or nursing school, and it’s the first thing to go because it’s too pedestrian,” says Lovato. “People have all these devices with bells and whistles and monitors and flashing lights. They think, ‘We have all this stuff. Why do we still need to wash our hands?’ ”

However, Lovato says she’s hopeful that will change in coming years. “Nurses coming through school now are being educated very differently than those that came before them,” she says. “In five, six, eight years from now, people will be saying, ‘I can’t believe we didn’t wash our hands.’ ”

Tips for a solid program

There are several barriers hospitals must overcome to start a secret shopper program. Hudson says his biggest challenge has been recruiting people to take the job. “Nobody wants to be thought of as a rat,” he says. “It’s viewed as tattling. That’s why we’re stuck right now.”

However, there is no reason for staff members to view the job as a negative, Lovato says. Shoppers should know that they are performing an important service by protecting patient safety. Offering an incentive, such as the step increase, is one way of overcoming an individual’s unwillingness to take the position, she says.

Some potential volunteers also balk because they’re afraid other staff members will be angry if they find out a coworker is a secret shopper.

That has not been the case at Inova. Many of the trainers have participated in the program since the outset, and as a result, staff members on the floors have outed them as secret shoppers, says Lovato. “I’d say maybe 30% of them have been outed,” she says. “But I don’t think it affects data collection.”

Staff members tend to get caught up in their daily routines and forget that the shoppers are there. “They just become wallpaper,” says Lovato. “I don’t think the other staff members think, ‘That person is watching me.’ ”

To encourage participation, it’s also important to let shoppers know they’re appreciated. Lovato meets with the secret shoppers monthly, sometimes at a catered breakfast meeting. “We try to make it a fun role,” she says. “We bring in speakers. Sometimes, drug reps will do a presentation on infectious diseases or issues.”

The facility also hosts a holiday party for secret shoppers and thanks them for their work in the hospital newsletter.

“We need to let them know how important their role is, we can’t just burden them with collecting data,” says Lovato.

Always put a positive spin on your program. “As you roll it out, let [staff members] know that this [secret shopper program] is beginning. It’s not a dirty, sneaky, ratting-out thing. It’s designed to help staff do the right thing. You need to play it as positively as you can,” says Lovato.

Educating people on the importance of hand hygiene can sometimes convince them to join your effort.

“People reach a certain point where a lightbulb goes off and they say to themselves, ‘We’re giving these people infections.’ At that point, generally you’ve won them over,” says Hudson.

You also need administrative support for a secret shopper program to be effective.

“If the program isn’t important to the administration and it’s not important to the unit directors, it’s hard to get it started,” says Hudson. “The key is to get the nursing unit to take ownership. You need to get individuals who are willing to look their coworkers in the eye and say, ‘We need to do the right thing for the patient.’ ”