By Elizabeth Srejic
Remote video auditing (RVA) with feedback is a promising new technology shown to dramatically improve compliance among healthcare workers (HCWs).1 Emerging research suggests that the proven efficacy of these systems is associated with the real-time performance evaluation and reminders they provide to HCW, which encourages staff to improve or modify aspects of their behavior.
RVA systems began to appear in healthcare settings following concerns over HCWs’ poor hand hygiene – one of the most challenging com-pliance issues in healthcare today.2 Hand hygiene, a fundamental tenet of good healthcare practices and a basic competency widely taught throughout healthcare disciplines, is the most effective way to prevent healthcare-associated infections (HAI) and the spread of antimicrobial-resistant pathogens.3 However, numerous studies report worryingly inadequate hand hygiene compliance in a variety of settings 4-5 in spite of widespread education and awareness, for reasons as diverse as skin irritation from handwashing agents to high intensity of patient care.6-7
At NS-LIJ’s North Shore University Hospital (NSUH) in Manhasset, N.Y., concerns over poor hand hygiene led to the development of a successful employee RVA monitoring program that began with hand hygiene in the hospital’s medical intensive care unit (MICU) and expanded to include other compliance metrics such as effective donning and doffing of personal protective equipment (PPE) in isolation rooms and terminal cleaning of operating rooms (ORs). The RVA technology used in the program, a patented platform developed by Arrowsight, Inc., produced significant and sustained improvements in HCW compliance.
According to Donna Armellino, vice president of infection prevention at Great Neck, N.Y.-based North Shore-Long Island Jewish Health System (NS-LIJ), developing the RVA technology was new territory for Arrowsight, which had previously created video monitoring systems only for compliance monitoring in the meat industry. “This was their first time using their technology within a healthcare setting,” she says. “However, the concept was the same: capturing and auditing images and providing feedback to the practice areas to reinforce what they’re doing in a positive way and allow management to implement interventions that remove barriers to compliance. For example, lotion can be strategically placed for HCWs not complying with hand hygiene due to skin irritation from soap.”
The results of implementing RVA technology at NSUH were first reported in a study published in the peer-reviewed journal Clinical Infectious Diseases.8 In the study, the researchers evaluated HCW hand hygiene compliance in the hospital’s MICU from 2008 through 2010 using RVA. Cameras were placed with views of every sink and hand sanitizer dispenser and sensors in doorways identified when individuals entered or exited. Third-party video auditors observed HCWs performing hand hygiene and assigned a pass or fail using a strict definition of hand hygiene regardless of whether gloves were used. Over an initial 16-week period, the RVA system was used to establish a baseline snapshot of hand hy-giene compliance, which was measured at a very low rate of approximately 10 percent, without providing any feedback to employees. Over the next 16-week period, HCWs were monitored with the RVA system and received real-time feedback on their performance via LED screens mounted on the walls of the MICU and from team leaders. An electronic scoreboard showed the current shift's compliance rate, which was reported in aggregate as opposed to individually to avoid an association of punishment with the compliance effort and motivated staff to im-prove. Within weeks of adding feedback to RVA during the second period, the hand hygiene rate increased to more than 80 percent and reached a sustained rate of 90 percent during a subsequent maintenance period of 17 months. The more than 430,000 hand hygiene data points collected throughout the 25-month study made it most comprehensive study ever conducted on hand hygiene compliance among HCWs.
In a second study headed by the same researchers, RVA and real-time feedback were used in the same manner to monitor HCW hand hy-giene compliance in a second intensive care unit.9 During the first four weeks using RVA without feedback, the compliance rate was only approximately 30 percent. However, the rate increased to more than 80 percent on average by using RVA combined with feedback during a 64-week period.
Following the success of the initial hand hygiene monitoring program at NSUH, the RVA program has been expanded into other pilot projects designed to monitor HCW adherence to other healthcare protocols. One such project conducted in an OR setting involved HCW compliance with protocols including those pertaining to infection control: room turnover times, sterilization practices and "time outs” – or discussions among members of the OR team immediately preceding surgery to ensure safety. The OR study, developed in conjunction with NSUH-LIJ’s anesthesiology provider, North American Partners (NAPA), and Arrowsight, was a larger-scale follow-up to the success of the initial intensive care unit studies conducted at NSUH, according to lead author John DiCapua, MD, chair of anesthesiology at North Shore-LIJ.
“The MICU project showed how powerful that the RVA combined with feedback platform could be in changing culture,” DiCapua says. “Effectively, that project showed that you could change handwashing behavior by monitoring and feeding the compliance information back to the staff so that they know whether they’re doing the job or not – and lo and behold they change their behavior. I took that information and sought to find whether we could do something similar in the OR. We conducted the study at NSUH-LIJ, a large tertiary-care center with 24 ORs and a separate pediatric institution – a much different animal – and we included about 10,000 different data sampling points so it’s a very high-powered study.”
DiCapua says that the results of the larger study were encouraging and paralleled the significant improvements seen in the earlier MICU and follow-up pilot studies. "As with the other studies, after the baseline period feeding the information back to the HCW – in this case the OR staff – with LED boards that showed the day’s compliance rates – produced significant improvement. And to give you a sense of how quickly we fed the information back, we monitored every room 24/7, looking into every room every two minutes, and it took no more than two minutes to get the information up to the LED board. Let’s say that someone does not do a 'time out' correctly – within four minutes it’s displayed on the board. And the appropriate leaders are also notified within minutes. Leaders are then able to work with HCWs to correct any deficits. And with that kind of feedback, people learned. And fast. We submitted the study to a major journal for publication recently and look forward to getting it out.”
Also like the previous two pilot studies, DiCapua says, the impressive results of the OR study unquestionably establish the efficacy of RVA plus feedback as a compliance monitoring tactic. “Researchers have been collecting data on compliance forever, and until now we didn’t have a methodology that worked,” he says. “We started out at about a 26 percent compliance rate for surgical safety checklist and got that up to a rate of above 95 percent – it’s at 100 percent now – and that happened in a matter of weeks. Nothing I’ve ever tried before – lectures, educational materials, screen savers, emails, nothing – ever created that kind of change. People often say they don’t believe the data. But with our system we remove any questions about the validity of the data. It’s unbiased, collected by an uninterested third party from thousands of sam-pling points. So nobody can say it’s not what really happens.”
Armellino agrees that the RVA technology with feedback produced significant advantages over other monitoring methods such as the hospital’s traditional technique of using "secret shoppers" or individuals who pose as patients or colleagues in order to secretly observe HCW behaviors. “Secret shoppers are used to determine staff's true compliance rate, not a rate that is artificially increased due to an awareness of being watched,” she says. “But the staff eventually identifies the observer and consequently the compliance rate that is recorded while staff is being watched does not reflect the true compliance rate when staff is not being observed.” This is where RVA combined with feedback trumps secret shopping, she says.
Like the secret shopper method, direct observation is also a flawed methodology, according to DiCapua. “What typically happens is that a quality assurance department sends someone into a room with a clipboard. With this kind of open observation people alter their behavior because they’re being watched. But when they’re not being watched it’s a different story – you want to know what happens when you’re not there. And you’re only checking a few cases out of a thousand to get an idea of where compliance stands among everyone. So sampling is flawed from the beginning."
Beyond its non-punitive approach to correction and applicability to any type of compliance protocol, DiCapua says what specifically distinguishes the RVA plus feedback method as superior to other compliance monitoring methods is the feedback aspect of the system, DiCapua, says. “Throughout the medical literature, other methods to drive compliance have been used and have gotten nowhere. But using this system we found we can drive compliance within three weeks. We saw the feedback rooms improve and the non-feedback rooms lag behind – and that was our study’s control. But when we provided feedback to all rooms, they all rose to the same level. So the key element here is the feed-back. The feedback is what caused people to change. The feedback is what gave them insight into what their behaviors were when they were working.”
One concern that healthcare facilities might have over implementing an RVA system might be cost. Armellino also says that the cost of these systems varies but should not be prohibitive, especially when taking into account the potentially higher number of HAIs caused by poor HCW compliance. “The costs are associated with the installation of the cameras, LED boards, and the technological components that transmit images from the facility to the third-party auditor. The costs depend upon the size of the area being monitored and there are monthly charges for the third-party auditor. In general, the human cost and unnecessary healthcare expenses caused by poor HCW compliance could justify the cost of the system.”
Accurate infection control surveillance is critical for improving quality of care and patient safety and hospital leaders should consider the im-portance of effectual monitoring methods to ensure HCWs are performing to standard and safeguarding the safety of their patient. According to a 2014 study, a sample of 13 senior managers interviewed for their views on current and innovative strategies to improve HCW compliance yielded seven main themes: culture change starts with leaders, refresh and renew the message, connect the compliance to the whole patient journey, audit results, empower patients, re-conceptualize non-compliance and start using the hammer.10 This and other studies on HCW com-pliance suggest that in many cases, changes in training and behavior are needed among HCW, and policies and interventions that emphasize and enforce specific infection prevention practices may contribute to a strong, advantageous institutional culture of safety.
Elizabeth Srejic is a freelance writer for ICT.
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