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Be seen and heard being clean: A novel patient-centered approach to hand hygiene
ARTICLE IN PRESS American Journal of Infection Control ■■ (2015) ■■-■■
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Practice forum
Be seen and heard being clean: A novel patient-centered approach to hand hygiene Lynda Z. Caine MPH, RN a,*, Ashley M. Pinkham MSN, RN b, James T. Noble MD c a
Infection Prevention, Concord Hospital, Concord, NH Internal Medicine, Concord Hospital Medical Group, Concord, NH c Infectious Disease, Concord Hospital Medical Group, Concord, NH b
Key Words: Hand hygiene Patient-as-observer Quality improvement
A quasiexperimental pre- and posttest design was used to evaluate hand hygiene (HH) rates on a medical– surgical unit. Data were collected by asking patients if they had seen or heard staff members cleaning their hands. Sixty-five percent of patients reported seeing or hearing staff perform HH preintervention and 93% reported observations postintervention (P < .001). Through incorporating an auditory cue we engaged patients while removing the burden placed on them to question health care worker behavior, and increased both staff and patient awareness of personal HH behavior. © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
It is commonly known that hand hygiene (HH) is the most important way to prevent the transmission of infection and is a priority for all health care workers (HCWs). The World Health Organization and Centers for Disease Control and Prevention developed programs to increase HCW HH compliance in efforts to reduce the number of hospital-acquired infections (HAIs). These initiatives in conjunction with advancement in the development of alcoholbased handrubs (ABHRs) have reduced transmission of HAIs and reduced infection rates globally.1 However, HAIs are still prevalent in health care facilities worldwide, indicating that there is discrepancy between actual practice and behavior. In 2001 the Institute of Medicine published Crossing the Quality Chasm: A New Health System for the 21st Century,2 which established 6 aims to improve preventable unsafe practices and errors occurring in medicine. One aim in this model, patient-centered care (PCC), revolves around patient and families, ensures patient values guide all clinical decisions, and works on improving patient outcomes. Using PCC as a guide, The Joint Commission, Centers for Disease Control and Prevention, and World Health Organization launched campaigns urging patients to take a role in preventing health care errors by becoming actively involved and informed participants in the health care team.1 “Speak Up” and “It’s OK to Ask” are two programs developed to instruct patients to ask HCWs to clean their hands.
Although these campaigns have made progress, there is undue pressure placed on patients to question HCW practices. This creates tension and potential mistrust. Studies have shown that patients are willing to be engaged; however, patients tend to be uncomfortable speaking up due to the vertical provider–patient relationship.3 Kim et al,3 as well as previous researchers, found discrepancies between patients’ perceptions, their actions, and their willingness to ask, stating that patients feared repercussions related to their health if they questioned HCWs’ HH practices. To engage patients, Kim et al3 found that indirect methods of patient feedback, such as assessment cards, were favored over direct methods. The results of Concord Hospital’s approach to incorporate HCW HH and PCC are detailed here. METHODOLOGY Setting Concord Hospital is an acute-care, 238-bed facility in central New Hampshire with approximately 11,000 discharges a year. The site of this study was a 32-bed medical-surgical unit with 2 wings. All rooms are equipped with a patient sink and ABHR; however, most are not in direct sight of the patient. Local problem
* Address correspondence to Lynda Z. Caine, MPH, RN, Concord Hospital, 250 Pleasant St, Concord, NH 03301. E-mail address: [email protected] (L.Z. Caine). Conflicts of Interest: None to report.
In 2008 the New Hampshire Healthcare Quality Assurance Commission (Commission) with the Foundation for Healthy Communities sponsored a statewide campaign to improve HH practices among
0196-6553/© 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.11.027
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L.Z. Caine et al. / American Journal of Infection Control ■■ (2015) ■■-■■
HCWs in New Hampshire hospitals, with the aim of reducing the risk of HAIs.4 In the “High Five for a Healthy NH” campaign, observed HH compliance data are collected each month by trained auditors hospitalwide and submitted to the infection prevention department to be aggregated, then forwarded to the Commission. Following the implementation of this campaign, hospitals throughout the state significantly increased their HH compliance rates from approximately 82% in 2008 to 93% in 2014 (P < .0001).4 In 2014 members of the Commission and infection preventionists throughout New Hampshire became concerned with the validity of the data collected. Specifically they were concerned with the variance in surveillance and collection methods. Direct observation in
which auditors monitor the HH compliance of HCWs is the most commonly used method of measurement; however, this method is subject to biases, including observer bias.5 The Commission formed a subcommittee to meet and discuss other ways to approach standardizing audit methods and data collection. During the deliberation data reporting was no longer required, but the continuance of tracking and delivering ongoing reminders to staff was recommended. At Concord Hospital senior leadership voted to continue HH observation tracking and launched an investigation into the culture of HH behavior. During a process-and-pattern observation it was noted that on days when HH auditors were present, gelling or handwashing behaviors increased and staff made sure to catch the eye
Fig 1. Staff- and patient-targeted campaign posters.
ARTICLE IN PRESS L.Z. Caine et al. / American Journal of Infection Control ■■ (2015) ■■-■■
3
of the auditor. When auditors were not present this behavior was not observed. Approach To improve HH behaviors the campaign slogan “Be seen and heard being clean” was implemented. This slogan reminds staff to clean their hands and to inform patients of the action before providing care. The auditory cue not only informed patients of the act, but also stimulated the auditory cortex of the brain, potentially leading to memory formation and increased ability to recall the event at a later date.6 Once the behavior was established on the unit, the patient-as-observer approach was used to monitor staff HH. Data collection and analysis Before implementation of the intervention, data were collected for 30 days from patients on the unit by asking them if they had seen or heard staff cleaning their hands. Patients included in the study were on the unit for 1 day and were alert and oriented times 4 (person, place, time, and situation). These parameters permitted increased reliability in patient observation reports. Data were presented to leadership and staff on the unit, which began the process of reexamining HH practices. A pre- and posttest comparative analysis was performed on patient observation rates before and after implementation. A 2-sample t test was used to generate statistical significance of the intervention. A critical value of α = 0.01 or <0.01 was identified as the level of statistical significance. A total of 3 data collectors were used to validate observations made by the primary investigator. Staff education A week of staff education on the new campaign was conducted. Three sessions were held each day to educate staff on all shifts. Staff included registered nurses, licensed nursing assistants, patient care coordinators, hospitalists, nutritionists, and physical therapists. A PowerPoint (Microsoft, Redmond WA) presentation and educational video were presented to generate discussion. Five to 8 members of the staff attended each session. Staff discussed situations when an auditory cue would be appropriate and understood the importance of using a patient-centered approach to HH. Staff practiced using different sayings through role play. It was stressed that messages were not to be scripted; instead, they were to be naturally derived (ie, I am sorry my hands are cold; I just washed my hands). These personal, in-themoment sayings are more sincere when being delivered to a patient. Auditors served as champions for the initiative while continuing staff HH audits. Staff practiced for 1 month before postintervention data were collected. Staff- and patient-targeted posters were hung in the hallways and on patient bathroom doors (Fig 1). Two roundtable discussions were conducted to discuss the results. Staff provided feedback and input on ways to improve the initiative. This hands-on approach empowered staff to have a voice in the change process, which helped to solidify the new behavior. RESULTS A total of 161 out of 166 and 153 out of 166 patients were asked if they had seen or heard staff members cleaning their hands during pre- and posttest data collection, respectively. Sixty-five percent of patients reported seeing or hearing staff members perform HH before the intervention, whereas 93% reported these observations after the intervention (P < .001) (Fig 2).
Fig 2. Percent of patients who reported seeing or hearing staff clean their hands preintervention and postimplementation.
Qualitatively during roundtable discussions, staff disclosed they were more aware of HH practices and used the message at high-touch times. Staff stated they were more engaged with patients in their care postimplementation. Increased frequency in refilling ABHR or soap dispensers was an unexpected result reported by staff. Importantly, patients became more engaged with staff around HH. DISCUSSION The results indicate a change in behavior occurred by adding an auditory message. The change was significant enough to be reflected in patient feedback. Patients were enthused and receptive of the auditor being present on the unit, stating, “It feels very reassuring to see employees protecting my safety,” and “A weight has been lifted off my shoulders when staff tell me they washed their hands—I would never ask.” The nurse manager stated: “The message was easily added to staff HH routines.” During the roundtable debriefing, 3 significant findings were identified. First, during shift change patients picked up on the message not being delivered and asked: “Why didn’t you tell me you washed your hands
ARTICLE IN PRESS 4
L.Z. Caine et al. / American Journal of Infection Control ■■ (2015) ■■-■■
like the other staff did?” This was eye-opening because the HCW did not know how intently patients were engaged. The second finding came when a staff member realized that he “knew when his hands were clean but the patient did not.” The final and most significant discovery was that staff reported increased patient participation in HH. One staff member stated, “I can’t remember when so many patients requested personal ABHR at the bedside.” These findings suggest an increased awareness in both staff and patient personal HH behavior. Similar to previous studies7,8 the patient-as-observer approach was used to track HCW HH through using survey cards during outpatient visits. In these studies, cards unintentionally provided a visual cue to staff. In the Concord Hospital inpatient model staff did not know which patients were being audited because they had no visual cue, removing observation bias. Limitations to the study include a nonrandomized sample population. Another limitation was that patients gave qualitative—not quantitative—results. Additional limitations to the study include the scale and distribution of the effort. Intensive efforts were focused on HCWs who spent the majority of time with patients, whereas others received less in-depth training. Finally, the patient-asobserver approach is less applicable in intensive care units because patients are unable to provide feedback due to critical conditions. Staff members are trained to use the message because family members may be present and patients may be unconsciously aware. In these settings auditors should use the original auditing tool to monitor staff HH. Based on a literature review, we believe this is the first study that attempts to modify the behavior of inpatient HCW HH through incorporating a verbal message. Patients were engaged as observers of HH, removing the observation bias seen with previous methods. Pressure placed on patients to ask about or challenge HCW action was eliminated, which strengthened the HCW–patient re-
lationship. Patients inadvertently became more aware of both HCW and personal HH. Auditory messaging could be a significant step toward patient HH in hospital settings. This is critical because patients’ hands are vehicles of infection transmission and are frequently found to be colonized with pathogenic bacteria. Using an auditory cue resonated with staff and elicited behavior change, while also creating a memorable PCC experience for patients.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at doi:10.1016/j.ajic.2015.11.027.
References 1. Landers T, Abusalem S, Coty M, Bingham J. Patient centered hand hygiene: the next step in infection prevention. Am J Infect Control 2012;40:11-7. 2. Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academy Press; 2001. 3. Kim M, Nam EY, Na SH, Shin M, Lee HS, Kim N, et al. Major article: discrepancy in perceptions regarding patient participation in hand hygiene between patients and health care workers. AJIC. Am J Infect Control 2015;43:510-5. 4. Kirkland K. A qualitative analysis of facilitators and barriers to hand hygiene improvement at New Hampshire hospitals during a statewide hand hygiene campaign. Concord (NH): Foundation for Healthy Communities; 2011 Available from: http://www.healthynh.com/. Accessed January 26, 2016. 5. Sringly J, Furness C, Baker G, Gardam M. Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf 2014;23:974-80. 6. Wheeler ME, Petersen SE, Buckner RL. Memory’s echo: vivid remembering reactivates sensory-specific cortex. Proc Natl Acad Sci U S A 2000;97:11125-9. 7. Bittle M, LaMarche S. Engaging the patient as observer to promote hand hygiene compliance in ambulatory care. Jt Comm J Qual Patient Saf 2009;35:519-25. 8. Le-Abuyen S, Ng J, Kim S, De La Franier A, Khan B, Mosley J, et al. Patient-asobserver approach: an alternative method for hand hygiene auditing in an ambulatory care setting. Am J Infect Control 2014;42:439-42.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Practice forum
Be seen and heard being clean: A novel patient-centered approach to hand hygiene Lynda Z. Caine MPH, RN a,*, Ashley M. Pinkham MSN, RN b, James T. Noble MD c a
Infection Prevention, Concord Hospital, Concord, NH Internal Medicine, Concord Hospital Medical Group, Concord, NH c Infectious Disease, Concord Hospital Medical Group, Concord, NH b
Key Words: Hand hygiene Patient-as-observer Quality improvement
A quasiexperimental pre- and posttest design was used to evaluate hand hygiene (HH) rates on a medical– surgical unit. Data were collected by asking patients if they had seen or heard staff members cleaning their hands. Sixty-five percent of patients reported seeing or hearing staff perform HH preintervention and 93% reported observations postintervention (P < .001). Through incorporating an auditory cue we engaged patients while removing the burden placed on them to question health care worker behavior, and increased both staff and patient awareness of personal HH behavior. © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
It is commonly known that hand hygiene (HH) is the most important way to prevent the transmission of infection and is a priority for all health care workers (HCWs). The World Health Organization and Centers for Disease Control and Prevention developed programs to increase HCW HH compliance in efforts to reduce the number of hospital-acquired infections (HAIs). These initiatives in conjunction with advancement in the development of alcoholbased handrubs (ABHRs) have reduced transmission of HAIs and reduced infection rates globally.1 However, HAIs are still prevalent in health care facilities worldwide, indicating that there is discrepancy between actual practice and behavior. In 2001 the Institute of Medicine published Crossing the Quality Chasm: A New Health System for the 21st Century,2 which established 6 aims to improve preventable unsafe practices and errors occurring in medicine. One aim in this model, patient-centered care (PCC), revolves around patient and families, ensures patient values guide all clinical decisions, and works on improving patient outcomes. Using PCC as a guide, The Joint Commission, Centers for Disease Control and Prevention, and World Health Organization launched campaigns urging patients to take a role in preventing health care errors by becoming actively involved and informed participants in the health care team.1 “Speak Up” and “It’s OK to Ask” are two programs developed to instruct patients to ask HCWs to clean their hands.
Although these campaigns have made progress, there is undue pressure placed on patients to question HCW practices. This creates tension and potential mistrust. Studies have shown that patients are willing to be engaged; however, patients tend to be uncomfortable speaking up due to the vertical provider–patient relationship.3 Kim et al,3 as well as previous researchers, found discrepancies between patients’ perceptions, their actions, and their willingness to ask, stating that patients feared repercussions related to their health if they questioned HCWs’ HH practices. To engage patients, Kim et al3 found that indirect methods of patient feedback, such as assessment cards, were favored over direct methods. The results of Concord Hospital’s approach to incorporate HCW HH and PCC are detailed here. METHODOLOGY Setting Concord Hospital is an acute-care, 238-bed facility in central New Hampshire with approximately 11,000 discharges a year. The site of this study was a 32-bed medical-surgical unit with 2 wings. All rooms are equipped with a patient sink and ABHR; however, most are not in direct sight of the patient. Local problem
* Address correspondence to Lynda Z. Caine, MPH, RN, Concord Hospital, 250 Pleasant St, Concord, NH 03301. E-mail address: [email protected] (L.Z. Caine). Conflicts of Interest: None to report.
In 2008 the New Hampshire Healthcare Quality Assurance Commission (Commission) with the Foundation for Healthy Communities sponsored a statewide campaign to improve HH practices among
0196-6553/© 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.11.027
ARTICLE IN PRESS 2
L.Z. Caine et al. / American Journal of Infection Control ■■ (2015) ■■-■■
HCWs in New Hampshire hospitals, with the aim of reducing the risk of HAIs.4 In the “High Five for a Healthy NH” campaign, observed HH compliance data are collected each month by trained auditors hospitalwide and submitted to the infection prevention department to be aggregated, then forwarded to the Commission. Following the implementation of this campaign, hospitals throughout the state significantly increased their HH compliance rates from approximately 82% in 2008 to 93% in 2014 (P < .0001).4 In 2014 members of the Commission and infection preventionists throughout New Hampshire became concerned with the validity of the data collected. Specifically they were concerned with the variance in surveillance and collection methods. Direct observation in
which auditors monitor the HH compliance of HCWs is the most commonly used method of measurement; however, this method is subject to biases, including observer bias.5 The Commission formed a subcommittee to meet and discuss other ways to approach standardizing audit methods and data collection. During the deliberation data reporting was no longer required, but the continuance of tracking and delivering ongoing reminders to staff was recommended. At Concord Hospital senior leadership voted to continue HH observation tracking and launched an investigation into the culture of HH behavior. During a process-and-pattern observation it was noted that on days when HH auditors were present, gelling or handwashing behaviors increased and staff made sure to catch the eye
Fig 1. Staff- and patient-targeted campaign posters.
ARTICLE IN PRESS L.Z. Caine et al. / American Journal of Infection Control ■■ (2015) ■■-■■
3
of the auditor. When auditors were not present this behavior was not observed. Approach To improve HH behaviors the campaign slogan “Be seen and heard being clean” was implemented. This slogan reminds staff to clean their hands and to inform patients of the action before providing care. The auditory cue not only informed patients of the act, but also stimulated the auditory cortex of the brain, potentially leading to memory formation and increased ability to recall the event at a later date.6 Once the behavior was established on the unit, the patient-as-observer approach was used to monitor staff HH. Data collection and analysis Before implementation of the intervention, data were collected for 30 days from patients on the unit by asking them if they had seen or heard staff cleaning their hands. Patients included in the study were on the unit for 1 day and were alert and oriented times 4 (person, place, time, and situation). These parameters permitted increased reliability in patient observation reports. Data were presented to leadership and staff on the unit, which began the process of reexamining HH practices. A pre- and posttest comparative analysis was performed on patient observation rates before and after implementation. A 2-sample t test was used to generate statistical significance of the intervention. A critical value of α = 0.01 or <0.01 was identified as the level of statistical significance. A total of 3 data collectors were used to validate observations made by the primary investigator. Staff education A week of staff education on the new campaign was conducted. Three sessions were held each day to educate staff on all shifts. Staff included registered nurses, licensed nursing assistants, patient care coordinators, hospitalists, nutritionists, and physical therapists. A PowerPoint (Microsoft, Redmond WA) presentation and educational video were presented to generate discussion. Five to 8 members of the staff attended each session. Staff discussed situations when an auditory cue would be appropriate and understood the importance of using a patient-centered approach to HH. Staff practiced using different sayings through role play. It was stressed that messages were not to be scripted; instead, they were to be naturally derived (ie, I am sorry my hands are cold; I just washed my hands). These personal, in-themoment sayings are more sincere when being delivered to a patient. Auditors served as champions for the initiative while continuing staff HH audits. Staff practiced for 1 month before postintervention data were collected. Staff- and patient-targeted posters were hung in the hallways and on patient bathroom doors (Fig 1). Two roundtable discussions were conducted to discuss the results. Staff provided feedback and input on ways to improve the initiative. This hands-on approach empowered staff to have a voice in the change process, which helped to solidify the new behavior. RESULTS A total of 161 out of 166 and 153 out of 166 patients were asked if they had seen or heard staff members cleaning their hands during pre- and posttest data collection, respectively. Sixty-five percent of patients reported seeing or hearing staff members perform HH before the intervention, whereas 93% reported these observations after the intervention (P < .001) (Fig 2).
Fig 2. Percent of patients who reported seeing or hearing staff clean their hands preintervention and postimplementation.
Qualitatively during roundtable discussions, staff disclosed they were more aware of HH practices and used the message at high-touch times. Staff stated they were more engaged with patients in their care postimplementation. Increased frequency in refilling ABHR or soap dispensers was an unexpected result reported by staff. Importantly, patients became more engaged with staff around HH. DISCUSSION The results indicate a change in behavior occurred by adding an auditory message. The change was significant enough to be reflected in patient feedback. Patients were enthused and receptive of the auditor being present on the unit, stating, “It feels very reassuring to see employees protecting my safety,” and “A weight has been lifted off my shoulders when staff tell me they washed their hands—I would never ask.” The nurse manager stated: “The message was easily added to staff HH routines.” During the roundtable debriefing, 3 significant findings were identified. First, during shift change patients picked up on the message not being delivered and asked: “Why didn’t you tell me you washed your hands
ARTICLE IN PRESS 4
L.Z. Caine et al. / American Journal of Infection Control ■■ (2015) ■■-■■
like the other staff did?” This was eye-opening because the HCW did not know how intently patients were engaged. The second finding came when a staff member realized that he “knew when his hands were clean but the patient did not.” The final and most significant discovery was that staff reported increased patient participation in HH. One staff member stated, “I can’t remember when so many patients requested personal ABHR at the bedside.” These findings suggest an increased awareness in both staff and patient personal HH behavior. Similar to previous studies7,8 the patient-as-observer approach was used to track HCW HH through using survey cards during outpatient visits. In these studies, cards unintentionally provided a visual cue to staff. In the Concord Hospital inpatient model staff did not know which patients were being audited because they had no visual cue, removing observation bias. Limitations to the study include a nonrandomized sample population. Another limitation was that patients gave qualitative—not quantitative—results. Additional limitations to the study include the scale and distribution of the effort. Intensive efforts were focused on HCWs who spent the majority of time with patients, whereas others received less in-depth training. Finally, the patient-asobserver approach is less applicable in intensive care units because patients are unable to provide feedback due to critical conditions. Staff members are trained to use the message because family members may be present and patients may be unconsciously aware. In these settings auditors should use the original auditing tool to monitor staff HH. Based on a literature review, we believe this is the first study that attempts to modify the behavior of inpatient HCW HH through incorporating a verbal message. Patients were engaged as observers of HH, removing the observation bias seen with previous methods. Pressure placed on patients to ask about or challenge HCW action was eliminated, which strengthened the HCW–patient re-
lationship. Patients inadvertently became more aware of both HCW and personal HH. Auditory messaging could be a significant step toward patient HH in hospital settings. This is critical because patients’ hands are vehicles of infection transmission and are frequently found to be colonized with pathogenic bacteria. Using an auditory cue resonated with staff and elicited behavior change, while also creating a memorable PCC experience for patients.
SUPPLEMENTARY DATA Supplementary data related to this article can be found at doi:10.1016/j.ajic.2015.11.027.
References 1. Landers T, Abusalem S, Coty M, Bingham J. Patient centered hand hygiene: the next step in infection prevention. Am J Infect Control 2012;40:11-7. 2. Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academy Press; 2001. 3. Kim M, Nam EY, Na SH, Shin M, Lee HS, Kim N, et al. Major article: discrepancy in perceptions regarding patient participation in hand hygiene between patients and health care workers. AJIC. Am J Infect Control 2015;43:510-5. 4. Kirkland K. A qualitative analysis of facilitators and barriers to hand hygiene improvement at New Hampshire hospitals during a statewide hand hygiene campaign. Concord (NH): Foundation for Healthy Communities; 2011 Available from: http://www.healthynh.com/. Accessed January 26, 2016. 5. Sringly J, Furness C, Baker G, Gardam M. Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf 2014;23:974-80. 6. Wheeler ME, Petersen SE, Buckner RL. Memory’s echo: vivid remembering reactivates sensory-specific cortex. Proc Natl Acad Sci U S A 2000;97:11125-9. 7. Bittle M, LaMarche S. Engaging the patient as observer to promote hand hygiene compliance in ambulatory care. Jt Comm J Qual Patient Saf 2009;35:519-25. 8. Le-Abuyen S, Ng J, Kim S, De La Franier A, Khan B, Mosley J, et al. Patient-asobserver approach: an alternative method for hand hygiene auditing in an ambulatory care setting. Am J Infect Control 2014;42:439-42.