Improving hand hygiene compliance rates with marketing, accountability, and incentives

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Hand hygiene

Improving hand hygiene compliance rates with marketing, accountability, and incentives

After reading this article, you will be able to:

  • Identify proven methods to improve hand hygiene compliance
  • Explain how monetary incentives improved rates at Texas Children’s Hospital

The perennial problem in healthcare facilities around the country usually comes back to a very simple 30-second procedure. 

Ask any infection preventionist (IP) about his or her major focus on hand hygiene compliance and you’ll likely hear a number of strategies, obstacles, or frustrations with getting staff members to comply with hand hygiene best practices. Hand hygiene compliance rates vary from facility to facility, and even from unit to unit. 

There are three main methods for measuring hand hygiene compliance, according to The Joint Commission’s (formerly JCAHO) monograph Measuring Hand Hygiene Adherence: Overcoming the Challenges:

  • Direct observation
  • Measuring product use
  • Conducting surveys

However, measuring compliance is just half the battle for IPs. Improving compliance is another challenge. Part of the Joint Commission’s National Patient Safety Goal NPSG.07.01.01 requires facilities to set goals for improving hand hygiene rates, and it’s a continued focus of Joint Commission surveyors (see the December 2009 Briefings on Infection Control for more info).

Texas Children’s Hospital in Houston and Abington (PA) Memorial Hospital have both improved their compliance rates through a variety of successful strategies, from marketing to monetary compensation.

Using hand hygiene spies

A common method to track hand hygiene compliance and improve rates is the use of hand hygiene “spies” or “secret shoppers.” Both Texas Children’s and Abington Memorial have used spies to kick-start their programs.

When she first started, Collette Hendler, MS, RN, CIC, infection preventionist at Abington Memorial, said she used hospital volunteers and physicians waiting for residency as hand hygiene spies, but soon found she needed more observations than they could provide.

Roughly two years ago, Hendler formed a team of hospital employees whose “regular work flow allows them to be in all areas of the hospital so they are not noticed.” 

These spies remain anonymous so employees aren’t aware of when they are being watched or who is watching them.

At first, employees were not happy with the thought of colleagues spying on them, and even refuted the collected information when it came back unfavorable. Initially, compliance rates were around 34%.

“But if a nurse manager would say to me he didn’t believe my data, I would tell him to do it himself and see how his data compared to ours,” Hendler says. 

“In the one particular case, he came down halfway through the day and said he couldn’t take it anymore and believed our numbers were what they were,” says Hendler. 

Jeffrey Starke, MD, director of infection control at Texas Children’s, took a similar approach four years ago, but with one exception: He hired outside infection control professionals to come in as hospital employees and anonymously observe hand hygiene. These spies found that Texas Children’s hand hygiene rate was around 50%.

“These are folks that are totally unknown to the people in the institution,” Starke says. “This is also completely unknown to hospital administration. People think administration messes with this, but it’s entirely controlled by IC.”

Creating a buzz

Obviously, these rates were not good enough for each respective facility. Now that the spies had been dispersed to collect data, the message needed to be clear and consistent. 

Both facilities turned to their marketing teams to create more buzz around hand hygiene compliance and offer daily reminders to staff members.

“I actually probably have something that a lot of other hospitals don’t have, and that’s that I have my own PR person who is assigned to the hand hygiene project and I work very closely with him and he comes up with a lot of creative ideas,” Hendler says.

One of those ideas included screen savers with humorous or provoking messages. One included a picture of a young patient that read, “You could kill him with your bare hands.” Another was a spoof of the “Sham-wow” infomercial that read “Hand-wow.” These approaches raised compliance rates to 88%.

“We try and do things that are funny, things that are serious, just try to shake it up so people look at the screen savers and there is some message going on,” Hendler says.

Texas Children’s took a similar approach two years ago, focusing on marketing its hand hygiene campaign rather than just educating employees. 

The marketing team brought in an outside consultant who helped develop a campaign called “Hy-Five” aimed at patients and families as well as physicians and employees.

The campaign increased compliance to approximately 80%, and as a result, Texas Children’s won the Child Health Corporation of America’s National Quality Award.

“Executives love marketing, and so they know that these data are looked at by outside agencies that are looking at us and are doing rankings, and so they know that they can look people in the eye and say, ‘We really believe in quality; here is the data and the awards to back it up,’ ” Starke says.

Relying on incentives and accountability

Starke says even though Texas Children’s reached 80%, getting over that last hurdle to the 90th percentile took additional facilitywide motivation.

“We said we needed to do a little better, and I’m a big believer in incentives,” Starke says. “I think we are all influenced by the same things as other people.” 

Texas Children’s has an employee bonus program called P3. Previously, all incentives were based on financial numbers and volume, but Starke went to his administration and talked it into making hand hygiene part of the bonus program for employees. Then he took it one step further and made it part of the administrators’ bonus program as well.

“I know this sounds trite, but we convinced them that it was the right thing to do,” Starke says. 

“We said, ‘What’s good for the goose is good for the gander,’ and once you agree to do this for the employees, how can you possibly exempt yourselves? [We were] sort of trying to create a ‘just culture,’ and I think this is a very important part of ‘just culture,’ that administrators be just as responsible for these things as the frontline employees are.”

The incentive was not an all-or-nothing approach; the facility had to meet a 95% compliance rate for employees and administrators to get that portion of their bonus, while other factors contributed to other portions of their bonus.

“I mean, what does CMS do?” says Starke, referring to the CMS never events. “CMS is setting a financial incentive, so I don’t see how this is any different than that, except we are controlling it.”

Since implementing this incentive, compliance rates at Texas Children’s have stayed between 95% and 99%, Starke says. Simultaneously, bloodstream infection rates have plummeted. 

Although Starke admits there are other factors to account for this reduction, it has helped set the culture and emphasize infection prevention.

“It’s not like there are administrators browbeating people,” Starke says. “It’s not like people are up there going, ‘If you don’t do this, we can’t vacation this year.’ It’s creating the same culture and expectations at every level of the organization, and I think that’s sometimes where [infection prevention] falls down, is not making executives responsible.” 

Abington Memorial is also in the process of implementing an additional accountability program because compliance rates have begun to plateau at 80%.

Although it isn’t fully implemented, this new program will continue tracking compliance with spies, but managers will hand out index cards. 

If an employee has practiced good hand hygiene, the index card will enter that person in a prize raffle. 

Employees who are observed not washing their hands will receive an infraction. After three infractions, those employees will receive a letter warning them about their noncompliance.

Hendler made it clear that contrary to an article in Philadelphia Inquirer, employees would not lose their jobs for noncompliance, but they would be held accountable.

Abington Memorial also took an approach that has been used in many other healthcare facilities in an attempt to personalize the infections that result from improper hand hygiene. 

In one staff meeting, the hospital’s chief of staff, John J. Kelly, told a story about Catherine “Pat” Zakrzewski, a patient that underwent an amputation and ultimately died from a MRSA infection that could have been prevented through hand washing.

“[She] was one of our physicians’ mothers, and it really got personal and hit home with a lot of people,” says Hendler.


Adapted from Briefings on Infection Control, April 2010, HCPro, Inc.


Establishing healthy competition

Focusing on the culture of hand hygiene at Texas Children’s Hospital in Houston has resulted in some tangible results, says Jeffrey Starke, MD, the facility’s director of infection control.

The hospital now tracks days without bloodstream infections on every floor to give employees a goal to work toward. In this case, the goal is to continue the number of days without a bloodstream infection. Hand hygiene is part of the central line bundle to prevent bloodstream infections.

The facility’s pediatric ICU just went 291 days without a bloodstream infection before recently recording one. Even the neonatal ICU, which is notoriously difficult to keep infection-free, has gone 40 days without a bloodstream infection. “It’s a question of engaging people, making it part of their professional pride, and rewarding them for a good job,” Starke says.