Facility finds new ways to improve hand hygiene success rates
After reading this article, you will be able to:
- Discuss challenges inherent in using multiple measurement methods for hand hygiene
- Identify key units to involve in improving hand hygiene compliance measurement
- Describe simple methods for adding to the number of observations per unit for tracking hand hygiene compliance
- Identify options for compliance measures related to hand hygiene
Of all the challenges U.S. hospitals face, few are as unifying as hand hygiene-extremely important and, as many facilities struggle with compliance, extremely difficult to get right.
At Alamance Regional Medical Center (ARMC) in Burlington, NC, a reexamination of how hand hygiene compliance was measured has led to an improved and better overall process for supporting good hand hygiene practices.
The effort began with a serious look at ARMC's previous measurement practices.
"We had had two ways of measuring hand hygiene compliance," says Sara Wall, RN, MSN, infection preventionist at ARMC. "When I first came [to ARMC], we had one way of measuring hand hygiene that had really good results, much better than what I was hearing that other organizations were getting, so we wanted to verify it."
Parallel to this tracking method, a second method was put in place with results that conflicted with the initial high-scoring numbers.
"We decided there was something wrong," says Wall. "We couldn't be doing so well with one monitor and not as well with the other."
Additionally, these statistics ended up in a bit of a vacuum-there was not a good feedback loop for providing information back to the staff.
"We were getting the numbers but not getting improvements," says Wall.
In an effort to correct this imbalance, a team comprising representatives from nursing, training and development, quality resources, and infection prevention undertook the task of looking for ways to improve not only their measurement methods, but the facility's overall performance as well.
"We wanted to measure and report this data accurately and in a timely manner so that the information would be useful to departmental leadership, who could then in turn communicate with their staff," says Wall. "We also wanted to be able to provide immediate feedback to the person who is not doing hand hygiene right to help them improve."
This meant finding a way to respond in real time-not just queuing up issues to discuss in a staff meeting, but identifying a teaching style that could be applied immediately upon witnessing noncompliance.
The team visited some other organizations to look at various programs and their effectiveness before proceeding to develop their own.
The new method was called Take Five.
It's a simple idea with a visual cue-five fingers, five minutes.
"We started out educating leadership about the concept-and beyond that, we then embarked on observer training," says Wall.
The plan was a pyramid scheme, she explains.
They first targeted inpatient nursing units and procedural areas. The plan was to have each observer take five minutes per day five days a week to do at least five observations each day.
"That would give us, assuming a month had four weeks, for example, 100 observations a month per unit," says Wall.
One of the problems with the old system was that there was not enough data to be representative of the facility's actual compliance.
"Our observations were too skinny," says Wall. "But if you've got 100 observations a month with 14 units, that's 1,400 observations a month-and much more representative of reality."
And this was just the beginning.
It isn't just about doing the right number of observations-ARMC also needed to do the right kind of observations. To this end, it invested in proper training for observers.
A one-hour class taught by an infection preventionist with very specific content for the prospective observers set the tone for the new process.
The organization rolled out training on a monthly basis-first it trained the observers who would be on the floor in this capacity for the first month, and when they hit the units running, a second set of observers were initiated into the training program.
"Ultimately we'll have observers for every unit with up to 12 observers per unit fully trained within a year," says Wall.
ARMC did not overreach by training observers for every unit right off the bat-it began with key departments first and expanded incrementally.
"Because of the training, observations, and coaching, we have an increased awareness of how hand hygiene should be performed, and a good number of observers also coaching and serving as role models for others," says Wall.
Boosting the number of observers not only improves the accuracy of compliance numbers, but also prevents burnout. Once a number of observers are trained in a specific unit, that unit can then rotate observational duties on whatever schedule works best for the department, rather than setting a fixed monthly rotation.
Observers are chosen through different methods depending on the unit. Some are volunteers; others are chosen because they are recognized leaders among their peers. Originally, the only stipulation was that the observer had to be a licensed individual so that they would be comfortable coaching nurses and physicians. However, that condition has been removed and some excellent unlicensed observers have been trained.
For benchmarking purposes, ARMC uses the Centers for Disease Control and Prevention (CDC) hand hygiene guidelines (rather than World Health Organization guidelines). Observers monitor compliance with the indicators laid out by the CDC.
With regard to coaching, there are two methods observers employ, depending on the situation. Observers are trained through role-playing scenarios during the class and are encouraged to come up with their own ideas for scenarios to make them more lifelike.
These scenarios, which then enter into practice in the units, are of two types: either to prevent patient harm or to give immediate feedback and improve future performance.
When the first type is used, the process stops and feedback is given on the spot. Situations like central line insertion, where the first check mark on the bundle is hand hygiene, is one such case.
"If you have a physician who is about to put on his gown and gloves and has not performed proper hand hygiene, how do you stop that process without making the patient lose confidence in the physician?" asks Wall. Such scenarios are discussed, with suggestions such as offering the physician an application of pocket hand sanitizer. A simple "Doctor, I have sanitizer for you" can be an easy method to make sure hands are washed without causing a scene.
For the latter type of observation, ARMC developed a script to minimize accusatory tones and make the interaction more educational and conversational. Coaching should be private, objective, and nonargumentative. It is not about trying to embarrass anyone. For example, the observer might say, "I saw you go in and take vitals without washing your hands. Did I miss that?"
"It's possible to miss them washing their hands," says Wall. "If they say that they did perform hand hygiene, but we did not see it, we do not record the observation. We take their word for it." That way, if physicians did wash their hands, they are not unjustly penalized. On the other hand, if they are being less than honest and really did not wash their hands, the encounter serves as a reminder that they are being monitored and they need to do better. Monitors are educated to be nonconfrontational in the interactions.
"If they say that they forgot, we do record it as noncompliant and use it as an opportunity to teach about that situation as a CDC-indicated opportunity for hand hygiene," says Wall.
All of these observations are input into a database; data entry is expected of observers. The database is set up to take less than five minutes to enter a day's observations.
ARMC does not currently have palm-sized devices, which some other facilities use; instead, it uses an intranet-based system with a simple user interface. This system is updated in real time, meaning observations are immediately accessible. That way, if the team needs up-to-date figures for a 3 p.m. meeting, the stats entered earlier in the day would already be part of the ongoing data collection.
In terms of tracking, observers also complete manager feedback forms. These forms, officially known as Take Five Manager Report Forms, give the observer a chance to not only document coaching moments, but also document non-observers doing an exemplary job by setting an example or even providing coaching to other staff members.
These forms serve a few other purposes as well. For starters, they help track trends. With multiple observers, it is possible that the same person might receive coaching from separate observers during separate incidents. Using the manager form, a unit leader can identify staff who may need more help achieving compliance.
The forms also allow managers to speak with staff who were not coached at the time of the observation. "We don't want it done that way all the time, but there are times when you have to," says Wall. "And if you're going to do it that way, you have to be specific." For example, if the observer is uncomfortable approaching a specific noncompliant individual, he or she indicates "not coached" on the form and includes details of the observation. The manager or other appropriate person then assumes the coaching function.
A third benefit is the ability to track staff between departments. Some staff members move between floors, while observers are unit-based. The manager report forms provide an opportunity to get a big-picture look at how these non-unit-based staff perform from department to department.
The database allows managers to look not only at the big picture, but to narrow the search by any number of parameters, including date, location, and profession. This allows managers to determine where their departments need the most work in terms of performance improvement. The real benefit of the database, though, is giving those who manage it a way to make this information accessible to all levels of the organization.
"I send it to administration, department directors, assistant directors, and a number of other places. I want them to share the information about how we are doing with staff," says Wall.
Interest in the classes has continued at a healthy pace. Generally ARMC hosts three new hand hygiene monitor training courses per month. Staff are taught during orientation about the importance of hand hygiene and the fact that monitoring occurs.
"Our compliance isn't perfect, but it is good and steadily improving. It really is all about doing the right thing and, by doing so, increasing the safety of both patients and staff," says Wall.