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 firstname.lastname@example.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