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Hand hygiene rates improved through variety of reinforcement styles

Infection control

After reading this article, you will be able to:

  • Describe changes made by Barnes-Jewish St. Peters Hospital to improve hand hygiene numbers from 2004 to 2005
  • Discuss the results of additional staff training in 2006
  • Identify methods for preventing negative staff reaction to hand hygiene surveys
  • Discuss methods for improving the overall culture for hand hygiene compliance

It takes more than one method to bring a hospital’s hand hygiene compliance rate above 90%. At Barnes-Jewish St. Peters (MO) Hospital (BJSPH), it was a matter of trial and error to reach its compliance goal.

“We started collecting hand hygiene observations back in 2004,” says Kathleen Dougherty, RN, MSN, manager of professional practice and leadership development at BJSPH. “We wanted to see where we were with compliance for guidelines from the Centers for Disease Control and Prevention [CDC].”

Taking 100 observations per quarter, the organization found its hand hygiene compliance rate was 57%. Conversations began on how to reach the CDC goal. The 2004 numbers illustrated the need for increased compliance; the renewed awareness alone caused a significant jump in compliance in 2005.

“We got our rates up to 79% [in 2005],” says Dougherty. “This came about just based on a general heightened awareness of hand hygiene. We didn’t have a pointed focus or implementation plan.”

Although the jump was encouraging, it still did not bring the organization’s compliance numbers to an acceptable level. But the organization was collecting data.

The facility has seen significant rates of improvement each year since this time—remaining over 90% and at times hitting 99% compliance in 2009.

Education and training

BJSPH is a member of BJC HealthCare, a 13-hospital system in Missouri. The hospitals share a center for healthcare quality and effectiveness, which works closely with all facilities to develop standards and practices to be used across the system.

“The center looks at regulations that relate to clinical quality and patient safety and assists with development of protocols and procedures to facilitate positive results,” says Dougherty. The center knew hand hygiene compliance was about to explode on the national level. At the time, The Joint Commission (formerly JCAHO) was increasing its focus on this issue, and BJC wanted to be prepared.

“We also knew we’d be accountable to publish data [on hand hygiene compliance] on a regular basis,” says Dougherty. Thus, in 2006, mandatory training was implemented. “Every employee was provided with training on hand hygiene in 2006,” she says.

However, the increase in compliance was minimal, climbing to 80% that year. Simultaneous to the training, the organization started using hand hygiene auditors—essentially undercover agents looking for hand hygiene compliance—to act as observers.

“These auditors were on all shifts like secret shoppers,” says Dougherty.

They came from all walks of hospital life—not just physicians and nurses, but secretaries, housekeepers, lab techs, and others.

When the numbers did not rise as much as expected, extra training was provided, additional auditors were trained, and compliance rates were reported at departmental meetings.

You’ve been spotted

“In 2007, we knew we had to do more, and we wanted to do more,” says Dougherty. “We wanted to be at 90% hand hygiene compliance by the end of that year.”

BJSPH increased the frequency of the audits to a minimum of 100 per month.

“Our point of view was if you increase your ‘n,’ you have a better chance of being successful,” Dougherty explains.

In February 2007, after a brief discussion with a Joint Commission surveyor, BJSPH learned of the idea to use cards as a method of feedback during audits. The hospital took this idea and developed it further into a very simple but highly effective concept: “You’ve Been Spotted” cards.

These cards—adorned with a Dalmatian to support the “spotted” theme—come in two varieties. At a distance, they appear indistinguishable, but up close, the two varieties are unique.

For positive reinforcement, some of the cards are flagged for incidents in which the receiver has been spotted using good hand hygiene practices. These cards include a $2 coupon that’s good in the hospital cafeteria or gift shop, which is enough for a cup of coffee or candy bar.

Receivers of multiple positive reinforcement cards can use them together to purchase lunch. Funding for these coupons came from the infection prevention budget.

On the spot

The second type of card reads, “We are putting you on the spot for not using hand hygiene.”

The reason the cards look nearly identical is to prevent embarrassment for the people involved. It’s impossible to tell from a few feet away whether you’ve received a positive or negative card.

“We needed something nonconfrontational,” says Dougherty. “We wanted something with positive reinforcement, but also something to notify you if you got caught. We didn’t want this to be a public display.”

The dynamic is an interesting one, especially because the auditors can be from any area of the hospital hierarchy. For example, secretaries have had to give cards to physicians.

The introduction of the cards showed an increase in compliance, but not enough of a jump to be completely satisfactory. “We saw an increase that year. We made it to 90% one month, but for year-to-date we were at 86%,” says Dougherty.

Posting names was the next step toward improvement. “We continued the positive rewards program, but … we started reporting both those who did well and those who needed to improve,” explains Dougherty.

The good with the bad

There was much deliberation within the leadership team on the concept of posting names. Leaders made a conscious decision to hold everyone accountable while continuing to use the carrot instead of the stick, staying with positive reinforcement to motivate their employees to higher hand hygiene compliance.

To temper the negative reinforcement of posting names—which helped improve compliance as well—BJSPH implemented an additional, and very public, way of rewarding those who were spotted using proper hand hygiene processes.

“Any [month] we meet or exceed our goal, we will take the names of everyone who was recognized as doing a good job, put their names into a drawing, and have a ‘hand hygiene hero’ drawn in the cafeteria,” says Dougherty.

The cafeteria is shared by staff members and guests, so the congratulatory ceremony, which includes the loud playing of Bonnie Tyler’s 1980’s hit “Holding Out for a Hero,” can be witnessed not only by staff members, but also patients and their visitors. The winner of the drawing receives a $25 gift certificate, and in months in which the goal is exceeded, multiple names are drawn.

Winners’ pictures are taken and posted throughout the building and even made into screensavers on hospital computers. The tactic has been well received by staff members, and when a winner is present in the cafeteria during the drawing, cheers have been known to break out.

Handling positive recognition is easy. Those spotted to be noncompliant can be more of a challenge.

Non–staff members are not immune to the card system. If a physician or advanced practice nurse is spotted not following hand hygiene protocol, the hospital’s risk manager follows up with the independent practitioner separately.

It’s not all “gotcha,” either. BJSPH uses the “Just Culture” concepts, acknowledging human error, and the follow-up for noncompliance is not without managerial discretion. The factors leading up to an incident are taken into consideration when a noncompliant employee is spotted. “Managers are expected to hold staff accountable,” says Dougherty.

To the program’s benefit, the auditors have remained remarkably consistent over its duration. To keep the secret shopper concept fresh, the auditors don’t continually work the same shifts or areas of the building. A fluid schedule allows the auditors to remain anonymous even as they keep their role year after year.

“We’ve sent the message that these patients belong to all of us,” says Dougherty.


Adapted from Briefings on The Joint Commission, December 2009, HCPro, Inc.