By Karin Lillis
There is “universal recognition” that hand hygiene practices reduce the spread of healthcare-associated infections (HAIs), notes nursing researcher Elizabeth McInnes, yet “healthcare workers’ compliance with best practice has been suboptimal. Senior hospital managers have responsibilities for implementing patient safety initiatives and are therefore ideally placed to provide suggestions for improving strategies to increase hand hygiene compliance.”
In response, McInnes, who is with the School of Nursing, Midwifery and Paramedicine at Australian Catholic University in North Sydney, Australia, and colleagues recently published a paper in BMC Infectious Diseases, “A qualitative study of senior hospital managers’ views on current and innovative strategies to improve hand hygiene.”
McInnes, the lead researcher on the project, explains that there is currently a debate in the infection prevention and control arena about whether there should be a shift in focus from a systematic failure to personal accountability, in order to strengthen hand hygiene compliance programs. She adds that obtaining the perspective of senior hospital managers on whether such an approach would be feasible and also their views on innovative strategies to improve hand hygiene compliance is an under-researched area. “Senior hospital managers have a pivotal role in relation to patient safety strategies, including hand hygiene compliance, so they are well-placed to give an informed perspective on these issues,” she notes.
One of the main areas the survey covered was WHO’s Five Moments for Hand Hygiene. As part of its May 2014 Save Lives: Clean Your Hands campaign, WHO advocates that healthcare workers should clean their hands:
1. Before touching a patient
2. Before clean/aseptic procedures
3. After body fluid exposure/risk
4. After touching a patient
5. After touching patient surroundings
Hand hygiene protocol typically focus on the bedside clinician and those who have physical contact with the patient, but they appear to cause confusion for non-clinical staff who may enter a patient “zone,” but have no actual contact with that patient.
“One of the most important findings were that strategies and programs that are based on the Five Moments for Hand Hygiene need to be tailored to specific clinical settings and take into account the whole patient journey,” McInnes says, “including patient interactions with clinical and non-clinical staff such as environmental services and food services staff.”
Nonclinical staff may enter patient rooms but have no physical contact with the patient. Managers in that setting felt that the Five Moments did not apply to their staff, the study reports. “Frankly, when we saw the Five Moments posters, it didn’t mean much to us,” one non-clinical manager notes in the study. “We don’t touch patients but we do enter the zone …It just clouded the message.”
Allied health professionals say they also were challenged to meet the requirements of the Five Moments, McInnes and colleagues report.
Participants also note that when hand hygiene educational and promotional materials weren’t updated regularly, they were less likely to pay attention to them. They suggested that hospitals take their cues from the advertising industry — regularly refreshing the “mode and content” of the messages. Says one senior manager from non-clinical services, “Posters that support hand hygiene and best practice need to be revamped and changed in the same way that advertising posters get changed at my local bus stop.”
“Another important finding was to keep refreshing and renewing the messages and educational content of hand hygiene programs,” McInnes says. “Participants notes the importance of learning from social marketing in terms of keeping messages fresh and current, particularly in an environment where there are multiple patient safety messages that staff must be constantly aware of.”
Other study participants questioned whether these kinds of educational/marketing strategies — like signs on the wall — were able to influence practice changes over the long term, McInnes and colleagues write.
Virtually all agreed that culture change has to start with the leaders. “It is everybody’s business. If you don’t have the culture, you can have the best education program in the world, but it won’t be taken up at all if it isn’t supported by the leaders,” one senior manager of non-clinical support services tells the researchers.
Participants stressed the importance of including infection control staff in developing and adapting hand hygiene policies — specifically as they relate to the WHO’s Five Moments.
“(Infection control staff) could observe how different groups of staff interact with patients in various settings across the organization to help identify how to introduce or modify the Five Moments in hand hygiene to accommodate the different settings and interactions” the researchers write.
The most unexpected finding, McInnes notes, came from several respondents who says that failure to comply with a hand hygiene policy equals a patient safety error.
“A number of participants considered that hand hygiene non-compliance could be viewed as a patient safety lapse,” McInnes says, “and this could serve to increase the impact and importance of hand hygiene compliance programs. Survey participants emphasized that details of such an approach — for example how to formally record hand hygiene lapses as a patient safety error — would have to be ironed out.”
“Several participants viewed non-compliance to hand hygiene in the same light as a staff member ‘causing an injury’ to a patient and that non-compliance placed patients in danger as it could potentially cause a critical illness as well as breached local and (national health) policy,” McInnes and colleagues write.
The challenge lies in how to document such breaches, the researchers note. “The problem is that it could be so common but nobody is going to fill out an incident form for breaching hand hygiene,” one clinical services senior manager tells the researchers. Moreover, existing hospital incident reporting systems, the researchers write, aren’t typically designed to account for patient safety breaches like failing to adhere to hand hygiene policy. Hospitals would have to design special reporting systems.
There was no consensus on whether healthcare facilities should impose financial penalties, focus on performance management or link pro-fessional accreditation or reaccreditation to “successful completion of a hand hygiene education program,” the researchers write.
Some suggested that approaches like performance management could help healthcare facilities transition from “system responsibility to indi-vidual accountability.” However, such transitions may be difficult, the participants note, because the prevailing atmosphere at many healthcare institutions is one of “no blame.” Rather than focusing on the person who made the error, the facilities consider where in the system a break-down occurred.
Nearly all of the participants says they favored a graded approach to “managing noncompliant staff” — penalties increasing with each breach of hand hygiene policy. They notes that more research was necessary to determine what kinds of disciplinary actions or penalties would be most effective. Participants, however, agree that disciplinary actions should be part of multipronged approach to encouraging and monitor-ing hand hygiene compliance.
“Future studies could examine the views of other groups of hospital staff and investigate the acceptability by different disciplines of some of the suggested strategies,” notes one survey participant.
“There was also enthusiasm across the sample for introducing the notion of individual responsibility for ensuring best practice hand hygiene alongside system-wide approaches and also a strong sentiment was expressed that generally patient safety initiatives are best served by ap-proaches in which both system and individual roles and responsibilities are given equal footing,” McInnes says.
Survey participants agreed that any culture change — whether implanting or revamping polices, or taking disciplinary measures for failure to comply — has to start from the top down. They note that senior leaders — like nursing unit directors or managers — should “directly engage” with frontline managers, supervisors and staff “and secure their commitment to embed the message that best practice hand hygiene is part of the organizational mantra and the way we do things around here.”
“Obtaining optimal hand hygiene compliance rates across all clinical settings is an ongoing challenge for all health services throughout the world,” McInnes concludes. “Because it is often difficult to prove that an instance of hand hygiene non-compliance directly relates to patient harm, it is challenging to achieve 100 percent compliance. This points to the need to reinvigorate campaigns with a focus on both system and individual responsibilities.”
She also notes that, “Future research is needed on frontline hospital staff’s views of the hand hygiene strategies nominated in this qualitative study, including further investigation of whether there is value in conceptualizing hand hygiene non-compliance as a patient safety error and with implementing penalty-based approaches. We need to disseminate our findings widely — and also design an intervention based on these findings that could be piloted — and, if results are promising, evaluated in an adequately powered trial.”
Karin Lillis is managing editor of EndoNurse magazine, a publication of Informa Exhibitions.
McInnes E, et al. A qualitative study of senior hospital managers’ views on current and innovative strategies to improve hand hygiene. BMC Infectious Diseases. 2014. 14:611. Available at: http://www.biomedcentral.com/1471-2334/14/611.
World Health Organization. (2014). Save lives, clean your hands. Available at: http://www.who.int/gpsc/5may/en/.