Tuesday, April 14, 2009

Good timing

A timely message from The Joint Commission arrived this afternoon:

Today, The Joint Commission is releasing “Measuring Hand Hygiene Adherence: Overcoming the Challenges,” to help health care organizations target their efforts in measuring hand hygiene performance. The monograph is designed to address “everything you ever wanted to know about hand hygiene measurement but were afraid to ask.” The aim of the monograph is to broaden understanding of the issues and provide practical solutions for strengthening measurement and improvement activities.

The monograph is the result of two-year collaboration with major infection control leadership organizations in the United States and abroad. . . . Free copies of the monograph are available on The Joint Commission Web site or by calling (630) 792-5800 (option 5), or sending an e-mail to customerservice@jointcommission.org.

I haven't had a chance to read all 200+ pages yet, but plan to, and you can bet it will be required reading here. Meanwhile, here is the forward:

Why would anyone write such a lengthy monograph about measuring adherence to hand hygiene guidelines? More importantly, why should anyone read it? The practice of hand hygiene has long been recognized as the most important way to reduce the transmission of pathogens in health care settings. Measuring adherence to hand hygiene practice is fundamental to demonstrating improvements both at an organization and a national level.

However, measuring health care worker adherence to hand hygiene guidelines is not a simple matter. Differing opinions and misinformation abound. We invite you to consider whether the following statements are true or false.

1. Everybody knows when to clean their hands.

False. While most of us know when to perform hand hygiene in our personal lives, health care workers who come in contact with patients or the patients’ environment are expected to perform hand hygiene many more times throughout the encounter. These indications for hand hygiene are described in professional guidelines and policies. Within a single encounter with a patient, there can be several times when hand hygiene should be performed. Studies show that continuing education is needed to inform and remind health care workers of the indications for hand hygiene.

2. It is easy to determine whether a person has cleaned his or her hands.

False. It may be obvious if someone is performing hand hygiene, but it is also important to consider how well the person performs hand hygiene and whether the person used the appropriate product. A quick rinse under the sink or brief rub between palms with alcohol-based hand rub may not be thorough enough to eliminate potential pathogens. Professional guidelines describe the proper techniques that should be used as well as when to use soap and water instead of hand rub.

It is also important to link the action of hand hygiene with the indications for hand hygiene described in the professional guidelines. It is possible that a person performed hand hygiene when he or she didn’t need to or that the person did not perform it when needed. Finally, even if you don’t see a health care worker performing hand hygiene, consider the fact that it may have been done prior to coming into the room or outside of your field of vision. You may want to consider asking a health care worker about it if you are unsure.

3. People who don’t perform hand hygiene when they should are careless or lazy or both.

Usually false. The vast majority of health care workers continually strive to do the right thing and try very hard to avoid harming patients. As described by Voss and Widmer, expecting perfection and 100% adherence is unrealistic, and we must “put an end to the reflex response that health care workers are neglectful of hand hygiene, which, far from helping, only demoralizes them further.” Studies have shown that organizational characteristics such as leadership involvement, reminders, convenient availability of products, and staff workload have a big influence on hand hygiene performance. Health care organizations need to integrate hand hygiene into routine procedures and have in place strong systems to support, monitor, and promote the correct behavior.

4. A hospital that reports a 95% rate of compliance with hand hygiene guidelines is better than a hospital that reports 75% compliance.

Unknown (could be true or false). Don’t be misled by statistics. Unfortunately, there is no standardized method for collecting and reporting rates of hand hygiene compliance. Organizations measure compliance in many different ways and in many different areas of an organization. Some organizations consider each indication for hand hygiene and sample groups of health care workers throughout the organization. Others measure more narrowly—for example, measuring whether hand hygiene was performed before and after care in the intensive care unit. The compliance rate is greatly influenced by what indications are chosen for measurement as well as where and how compliance is measured. As with any other performance measure rate, one should only compare rates to others that have defined, collected, and reported the same data in exactly the same way.

5. Observing care is the only way to get a valid assessment of hand hygiene guideline adherence rates.

Not necessarily true. Observation of care has important advantages, such as allowing you to directly link the activity of hand hygiene to the indication for hand hygiene. However, the observation method also has inherent limitations and potential biases (such as the Hawthorne effect, in which people change behavior because they know they are being observed). Collecting reliable observation data requires a highly structured method of both observing care and documenting data. Other methods, such as measuring product consumption, have different strengths and weaknesses. Using multiple measurement approaches helps to verify findings. Unfortunately, there is no perfect method for measuring hand hygiene adherence, and it is important to acknowledge the limitations of the measurement method used when rates are reported.

6. Excellent hand hygiene will reduce or eliminate health care–associated infections.

Partially true. In fact, the Centers for Disease Control and Prevention and the World Health Organization consider inadequate hand hygiene to be one of the most important contributors to infections. There are, however, many factors that influence whether a patient becomes infected. Other factors include such things as patient severity of illness, equipment and environmental sanitation practices, and adherence to recommended practices (for example, using maximal barrier precautions during central line insertions).

We hope these answers have piqued your interest in the content of this monograph. This monograph is designed to address the saying “everything you ever wanted to know about hand hygiene measurement but were afraid to ask”. Though easy answers are few, we hope this monograph will broaden your understanding of the issues and provide practical solutions for strengthening your measurement and improvement activities. We welcome your comments and suggestions for improvement.

The Consensus Measurement
in Hand Hygiene Project Team


catsandmusic said...

Hi Paul: I got a little chuckle out of #4 above. Those wily bacteria don't care if the compliance rate is 99%, as long as one of them survives in the right place at the right time. Infection control is one place where being perfectionistic is a really good thing. I am looking forward to participating in the forums we will be having.

Barbara Olson, MS, RN, FISMP said...

Hi Paul,

I started to draft a response to your post on Monday "Looking for your help," but got waylaid until today. I thought I'd share it here since the discussion has moved forward, and TJC guidance reinforces what I was thinking.

I think your inclination to dig deeper into the meaning behind (what on the surface looks like) non-compliance is correct. My brother is an engineer/project manager with an international company that walks, talks, speaks, thinks, and acts "safety." Their culture is far more safety-conscious than you and I will likely see healthcare become, given the number of years we can expect to remain "in the game" (or "here on earth.") :)

Here's a story about safety my brother passed along to me:
A group of die-hard, fully enculturated professionals (with responsibility for on-the-job safety) attended a safety conference where they were subjected to a mini-study about behavior. An extension cord--absent any fall-mitigating protection--had been deliberately strung across a walkway in the room that morning. The agenda moved forward, and breaks were taken. Around mid-day, the group was asked to perform a safety analysis of their conference room, identifying any egregious issues. The potential for fall posed by the cord was readily identified as a high risk by the majority of participants. Nothing further was said or done at that point. Following the lunch break, it was noted that a participant had re-routed the cord so that the fall potential was mitigated.

The take-away lesson: Even in safety-oriented cultures, knowledge does not translate into action unless safety is a visible priority that gets space on important agendas.

Thanks for helping keep safety visible on the "agenda" you host here. I blog about reliability in healthcare at http://florencedotcom.blogspot.com/and hope you'll consider adding my site to your blogroll.


Anonymous said...

On a side note, various departments are banning use of "department fleeces" and "cloth OR hats" because they are not laundered by the hospital and are at increased risk of infection -- our white coats, however, are not dry cleaned by the hospital (the only hospital I rotate through that does not provide this service) -- and yet white coats have yet to be banned. Should we also ban white coats, or start providing laundering services for physicians/medical staff's white coats?

Anonymous said...

One of the benefits of being retired is no longer having to read 200 page documents ((:), but I did skim p. 2, on "observed risk factors for poor adherence....", and Chapter 9, looking for information applying to physicians.
The first listed factor in the poor adherence chart is....physician status (as opposed to nurse.) Also among the top 10 is male gender.
In chapter 9, one hospital's system for dealing with poor physician adherence is presented:

"Non-adherent physicians were observed without initial
verbal intervention and were allowed three observations of
non-adherence every six months. Physicians reaching the third
observed episode of non-adherence were given a series of
letters: the first to the physician directly; the second to the
physician and to his or her department chair; and the third to
the physician, the department chair, and the credentials
committee. Further action with regard to any continued
physician non-adherence was the responsibility of the
credentials or executive committee, according to the medical
staff by-laws."

The time frame seems somewhat generous, but this suggests some interesting options, such as inserting into the bylaws a mandate for complying with hospital policies (or enforcing it if already present) to achieve re-credentialing.
Of course, this will only work if physician leadership is willing to actually follow the process all the way to its logical conclusion.

nonlocal MD

Paul Levy said...

This also seems to require some kind of observer corps. Does it explain how that is accomplished? Is everyone else deputized?

Anonymous said...

I can't answer your question since I didn't read the whole thing, but the table of contents indicates that the document spends a great deal of time on methods of data-gathering: observation and otherwise. I assume that the hospital in question (whose name escapes me, but it's somewhere around page 107-117) used one of the methods of observation discussed in the other chapters.

The document also mentions that physicians who were with a peer or superior who did not wash their hands during a patient encounter, were less likely to wash their hands themselves. This has obvious implications in an academic center with medica students, interns and residents.


Anonymous said...

OK, my OCD made me look it up - text box 9-3 on p. 115. In a hospital your size (as oppposed to 211 beds), a larger observation team would be necessary.


Paul Levy said...

Thanks. It's great to have an involved reader who is both OCD and retired -- has both inclination and time!


Anonymous said...

Yep, that's my side crusade while retired and now pursuing other interests - provide data and opinions on my former career field! Got any more 200 page documents??!! (:


Paul Levy said...

Nope, but my yard REALLY needs work . . .

Molly23 said...

This backs your comments re washing 2-3 times during a visit
Official report of the transfer of MRSA bacteria & germs etc in hospitals(curtains, bedrails, computer screens) have a look at the Report by Sydney University Microbiology Dept on a major Sydney Hospital.
Major Sydney Hospital Report on Transmitting MRSA on Hospital Surfaces by Sydney University Microbiology Department: