Behavior Modification is Key to Boosting Hand Hygiene Compliance, Avoiding Survey Deficiencies

By Kelly M. Pyrek

Behavior modification is shaping up to be one of the most important ways to address suboptimal hand hygiene compliance in hospitals. A personal and institutional accountability paired with the attitude that everyone is responsible for good patient outcomes is how high-performing facilities are achieving this organizational priority and performance expectation.

As Dunne, et al. (2018) observe, "Echoing the lessons of Semmelweis in the 1800s, hand hygiene is frequently described as the most effective preventive measure for healthcare workers, especially when complementing effective hospital hygiene practices that ensure proper cleaning and appropriate use of disinfectants and antimicrobials. The recognized issue with poor hand hygiene compliance among healthcare workers, and reports of recontamination of previously chemically disinfected clinical surfaces through hand contact, place hand hygiene education and monitoring at the core of HAI prevention and control." However, they acknowledge the barriers to practice: "Workload, location of hand rubs and soaps, perceived quality, effectiveness and potential dermatological effects of hygiene materials affect compliance behavior."

Dunne, et al. (2018) observe that while education, behavioral modification and hygiene product development are "important enablers of hand hygiene," they emphasize that "desired behavior compliant with good hygiene practice is arguably the most pivotal factor influencing success in prevention of HAI, whether it be surface cleaning or hand hygiene. Innovative technology-enabled tactics have been well described … More simply, and perhaps more accurately, direct observation of actual practice has remained a core tenet of compliance measurement, albeit that such assessment is labor-intensive and requires staff trained in its performance. We, like many others, face the challenges of implementing and evaluating interventions to overcome ever more frequent and clinically difficult outbreaks. Hand hygiene is a relatively simple activity, evaluated relatively simply. It is, therefore, not surprising that hand hygiene-mediated interventions have been frequently reported. It is reasonable to state that, irrespective of variability in study design quality, and acknowledging Hawthorne effects, these interventions typically result in beneficial changes in hand hygiene compliance even if not necessarily sustained. Considering the credible evidence supporting use of multi-modal education and behavior interventions (including ‘nudging’) to successfully encourage desirable hand-hygiene-compliant behavior, we suggest that prudence dictates that such interventions should become a required component of any future protocols assessing more elaborate or sophisticated approaches… Failure to adopt this proposed requirement, given the potential diversion of constrained resources, may represent lost opportunities to build on prior interventions and loss of potentially sustainable benefits."

Understanding and addressing the compliance behavior of healthcare personnel has never been more important, especially for healthcare institutions seeking and maintaining Joint Commission accreditation. It has been nearly nine months since the organization announced on Jan. 1, 2018 that any observation by Joint Commission surveyors of individual failure to perform hand hygiene in the process of direct patient care will be cited as a deficiency resulting in a Requirement for Improvement (RFI) under the Infection Prevention and Control (IC) chapter for all accreditation programs. Surveyors also have been surveying an institution’s hand hygiene program to National Patient Safety Goal (NPSG) 07.01.01. This NPSG, introduced by the Joint Commission in 2004, requires healthcare organizations to:
- Implement a hand hygiene program
- Set goals for improving compliance with the program
- Monitor the success of those plans
- Improve the results through appropriate actions

Sylvia Garcia-Houchins, MBA, RN, CIC, director of infection prevention and control in the Division of Healthcare Improvement at the Joint Commission, emphasizes that hand hygiene compliance "should have been on the radar for many, many years." Garcia-Houchins, a former infection preventionist with more than 30 years of experience in infection prevention and control in both hospital and long-term care settings, adds that it has always been expected that hospitals have a goal to improve hand hygiene. "Many healthcare personnel and facilities have taken that standard to heart, have actionable goals, and have improved over time, while others have stagnated," she says. "During the survey process you may hear that a facility's hand hygiene compliance rate is 99 percent, but still see personnel not washing their hands and there is evidence of the transmission of organisms that are transmitted by contact, we are thinking that there is a disconnect somewhere -- at an apparent 99 percent compliance rate, maybe you should start looking at it more closely."  

Garcia-Houchins continues, "There are many more studies coming to the forefront about the importance of hand hygiene and how to protect patients. We know it is the No. 1 way not just to protect our patients, but to protect our staff, visitors and everyone else who walks through the door. A lot of facilities say they are conducting hand hygiene observation and that they are at 99 percent compliance, but when you run a secret-shopper program, your organization's actual rate may be about one-third of what you are observing. I advise facilities to do a reality check to see if your organization is actually performing well or not."

As a statement from the Joint Commission points out, "Because organizations have had since 2004 to implement successful hand hygiene programs, The Joint Commission has determined that there has been sufficient time for all organizations to train personnel who engage in direct patient care. While there are various causes for HAI, the Joint Commission has determined that failure to perform hand hygiene associated with direct care of patients should no longer be one of them." 

Garcia-Houchins says that the Joint Commission is not on a mission to destroy staff and facility morale by issuing RFIs during surveys, but rather seeks to help institutions' patient safety goals.

"I attended a hand hygiene symposium at this year's APIC annual meeting where the ballroom was full by 6 a.m.," she recalls. "A ballroom full of people who would think enough about hand hygiene to get up at 5 or 5:30 in the morning and attend a symposium on how to improve hand hygiene indicates that people are focused on this issue. I heard a lot of concern on the part of infection preventionists; someone got up and said, 'If you have one instance of not washing your hands, you are going to be found out of conditions for participation. The Joint Commission takes it seriously, and you can't do electronic HH monitoring because it's going to show that your hand hygiene rate isn't as good as your observation rate.' The participant who commented started a conversation about the Five Moments and the challenge that electronic systems cannot monitor the Five Moments, and actually, no one presently known can monitor the Five Moments correctly. I had to get up and I said, 'I have been in this line of work for 35 years and the Joint Commission is not out to get anybody, we are doing this to improve the safety of  patients, staff and visitors, and part of the survey process is to look at best practices -- and hand hygiene is definitely a best practice -- and that the Joint Commission is working to ensure that people are moving toward that ultimate goal of 100 percent." 

Garcia-Houchins continues, "Now, if you are at 25 percent, and the surveyor walks around and sees that no one is washing their hands, there's going to be a real problem -- that could be a condition-level finding. But if the surveyor is walking around and people are washing their hands and the data shows that the healthcare organization was at 50 percent and now it is at 60 percent, you are making progress. Surveyors are going to look at it from a what-are-they-seeing, what-is-the-data-showing perspective, looking at the infection risk. For example,  if someone is doing something invasive, such as putting in a central line, and the surveyor is watching that procedure and he/she says, 'Gee, no one washed his/her hands before they put on their gloves,' then for sure, it is going to be a much more serious situation than if the healthcare worker walked out of the room and forgot to wash his/her hands -- until hopefully someone stopped him/her and said, 'Hey, you forgot to wash your hands.' Surveyors are looking for that cultural part of hand hygiene. They observe if one clinician    advised, 'Excuse me, you forgot to wash your hands' and the other clinician says, 'Oh thanks, I forgot,' or 'I was thinking about something else.' Those are the kinds of situations that the Joint Commission is investigating; surveyors are looking not just for whether staff wash their hands, but are they monitoring it, are they trying to improve their hand hygiene rate, are they culturally aware and reminding each other?"

In general, surveyors issue an RFI to organizations for failure to implement and make progress in their hand hygiene improvement programs, according to NPSG.07.01.01. With the exception of the Home Care and Ambulatory Care Accreditation programs, observations of individual failure to perform hand hygiene were not cited as deficiencies if there was otherwise a progressive program of increased compliance.

A surveyor has the latitude to determine how best to handle an observed breach of hand hygiene, Garcia-Houchins explains, noting that the process has evolved over the years to give surveyors flexibility. "Even if the surveyor is mid-sentence when addressing another issue, he or she still may be observing a healthcare worker walking in or out of a room without washing their hands," she says. "The surveyor may be looking around to see if anyone else noticed and stopped the healthcare worker to remind him/her to wash his/her hands. If appropriate, the surveyor may also say to a staff member, 'Hey, I just observed that person come out of the room and not wash his/her hands, can you go follow up with him/her? If the surveyor is in a critical location of the healthcare organization, for example, observing in the operating room, he/she might lean over to the accompanying staff member and say something quietly so he or she does not alarm anyone, but the surveyor also wants to make sure the correct procedure is performed for the patient."

As we have seen, the Joint Commission requires healthcare organizations to have a hand hygiene program and to show steady improvement in compliance with the guidelines. A healthcare organization can implement hand hygiene guidelines established by either the Centers for Disease Control and Prevention (CDC) or the World Health Organization (WHO). In 2016, Jacqui Reilly, PhD, professor of infection prevention and control at Glasgow Caledonian University in Scotland, published research indicating that the WHO's six-step hand hygiene technique is superior to a three-step method suggested by the CDC in reducing bacteria on healthcare workers’ hands. 

During the randomized controlled trial in an urban, acute-care teaching hospital, Reilly and colleagues observed 42 physicians and 78 nurses completing handwashing using an alcohol-based handrub after delivering patient care. The six-step technique was determined to be microbiologically more effective for reducing the median bacterial count (3.28 to 2.58) compared to the three-step method (3.08 to 2.88). However, using the six-step method required 25 percent more time to complete (42.50 seconds vs. 35 seconds).

“One of the interesting incidental findings was that compliance with the six-step technique was lacking," Reilly says. "Only 65 percent of providers completed the entire hand hygiene process despite participants having instructions on the technique in front of them and having their technique observed. This warrants further investigation for this particular technique and how compliance rates can be improved."

Sometimes, scenarios are not as cut-and-dried, and so Garcia-Houchins says that surveyors will ask about the facility's official hand hygiene policy and what they have adopted as the evidence-based guideline that dictates practice. "Facilities have the option of adopting the CDC guideline or they can adopt the WHO guideline," she confirms. "More and more facilities adopt a policy that requires staff perform hand hygiene when entering a patient's room and when exiting a patient's room. For example, if a nonpatient-care worker such as an environmental services worker walks into a patient room, he/she should have performed hand hygiene prior. If the patient says to that individual, 'Do you mind handing me that water pitcher,' his/her hands would already be clean because he/she just walked in and would have previously performed hand hygiene, so organisms don't move from room to room." 

When it comes to electronic hand hygiene compliance monitoring, Garcia-Houchins says surveyors are witnessing an increase in the number of institutions that use automated systems. "Many facilities that use electronic monitoring have staff that can't wait to tell the surveyor about it, as they are very proud. The staff often boast about the automated system.  For example, upon entering a nursing unit, a facility representative may say, 'We are doing such-and-such for hand hygiene and this is the kind of system we have chosen, this is how it works, and this is the feedback we have provided to staff. Clinicians are incredibly creative and in many facilities, surveyors don't have to ask about what is being done to inform hand hygiene; while looking around the facility, it is often very evident that the institution is committed to hand hygiene. The Joint Commission’s surveyors are very savvy when it comes to noticing the flavor of the hand hygiene efforts. From the moment they enter the healthcare facility, the surveyors are looking at what types of media are being used. Nowadays, when we walk into a facility, often at the door there's a poster that says, 'Cover your cough and wash your hands.' These signs provide the surveyor with a feel for the facility's approach to hand hygiene. Many facilities implement a hand hygiene campaign such as "Pump in, pump out.'  I visited one facility that featured beautiful posters on their elevator doors that illustrated the hospital's commitment to hand hygiene. The message was emphasized every time staff interacted with patients."

The movement around finding creative ways to boost hand hygiene compliance is gaining momentum in many facilities. Garcia-Houchins points to a recent anecdote: "A presenter at the hand hygiene symposium at APIC discussed the importance of staff taking ownership of hand hygiene. Staff need to 'own' their unit, and when there is a visitor they remind them that 'you are visiting my home so you need to wash your hands.' It is similar to the custom of removing their shoes at the door at home -- that is their policy and they are holding people accountable to follow it. Those types of units are ultimately successful. I know the presenter, and what she didn't tell the audience was that her own unit is extremely committed to improving hand hygiene and enthusiastically follow her lead. This manager had her phone set up so that the electronic hand hygiene monitoring system alerted her phone if compliance fell below 60 percent. So, she would get notified in the middle of the night by her phone and would subsequently call her unit each time. When the unit manager was away, her secretary stepped in and sent out a text message to staff alerting them, 'Hey guys, our hand hygiene compliance is dropping.'  That unit has been extremely successful because washing their hands has become an accepted way of practice on their unit."

If a healthcare facility receives an RFI, it must state in its plan of corrections how it will address and correct its shortfall in hand hygiene practice. "Facilities that receive an RFI in hand hygiene usually seek clarification of how to better understand the problem and how to improve," says Garcia-Houchins. "It may be that the organization recognizes the need to step up hand hygiene efforts on a particular unit and will devote additional resources to achieving that. There is a whole spectrum of responses to RFIs being seen currently, and every facility gets to make its own decisions about how it can best monitor and improve practices. I always remind people that 'perfect is the enemy of good,' meaning the first step to successful hand hygiene is getting staff to wash their hands consistently. Once they consistently commit to hand hygiene, then they can work on their technique. A healthcare organization cannot go from bad to perfect; it must get to good first." 

Garcia-Houchins says that despite the current emphasis on education and training around hand hygiene, facilities should instead focus on individual and institutional accountability and human factors engineering. 

"Studies are showing that education and training around hand hygiene is not enough," she says. "In the organizations that are very successful in improving their hand hygiene rates, it's more of a self-awareness among staff members that has been developed. At one facility I visited, the medical director used the Kubler-Ross stages of death and dying to describe the process of improving hand hygiene. He explained the facility's hand hygiene rates and provided the data to staff -- the data showed that staff is only washing their hands 50 percent of the time -- and the first reaction from healthcare personnel is denial: 'No, that wasn't me, that was her.' Or, 'I wash my hands all the time, it's the doctors.' Or 'No, we wash our hands all the time, it's the nurses.' Then they may proceed to the anger stage, then the bargaining stage, where they may ask, 'If I walk into one room and wash my hands after coming out of that room and I walk straight into the next room, does that count for the next room?' They go through all those Kubler-Ross stages until they reach the point of acceptance; it is what it is, you must wash your hands. Personnel are in all those stages at some point, and teaching people to wash their hands is not going to improve their hand hygiene. Everyone pretty much knows how to wash their hands, and most healthcare workers have been taught when to wash their hands -- after all, it's one of the first topics addressed during infection prevention and control orientation on the first day of work. The Five Moments are covered, or at the very least, the importance of pumping in and out with hand sanitizer and washing your hands with soap and water when they are visibly soiled."

Garcia-Houchins continues, "It's not usually a matter of teaching, it's usually a matter of healthcare personnel accepting their role in performing hand hygiene and also recognizing that not only must they hold themselves accountable, but their peers as well. And that's usually when units start to see a difference in behavior. Hand hygiene compliance rates go up when a group of people decides that it needs to make a change. So, success is related to achieving buy-in from staff. As an IP I used to tell people, 'I can't wash your hands for you; only you can decide to wash your hands.' Most facilities these days provide an abundant amount of alcohol-based hand sanitizer, and there are electronic pumps that indicate when it runs out of product, but we cannot make people wash their hands unless they are holding themselves accountable. I have been to facilities that achieved this by listing everyone's names on a chalkboard scoreboard in the breakroom. If personnel saw anyone not washing their hands, they would put a little hash mark next to that person's name. I have visited healthcare organizations where a 'clicker' was sounded every time someone didn't wash his/her hands. There are a variety of tactics that can help raise awareness, but holding each other accountable for hand hygiene is what makes a real and lasting difference." 

Breaking Down Barriers
Countering the known barriers to hand hygiene compliance is critical.  For example, if hand hygiene compliance data are not collected or reported accurately or frequently, the Joint Commission recommends that facilities begin using data as a framework for a systematic approach for improvement. It is essential that facilities utilize a sound measurement system to determine the real score in real time, that they scrutinize and question the data, and that they measure the specific, high-impact causes of hand hygiene failures and target solutions to those causes. 

A lack of accountability can be countered with the institution requiring its leadership to commit to hand hygiene as an organizational priority and demonstrate support by role modeling consistent hand hygiene compliance. Additionally, hospital leaders can be trained as just-in-time coaches to intervene to reinforce compliance. The Joint Commission says that healthcare facilities should consider implementing employee contracts to be signed by all healthcare workers to reinforce their commitment to hand hygiene. An institution may also weigh the application of progressive disciplinary action against repeat offenders. Expectations should be applied equally to all healthcare workers. 

If an institution lacks a safety culture, or if the culture does not emphasize hand hygiene at all levels, the Joint Commission advises that the facility make hand hygiene a habit as automatic as looking both ways when crossing the street or fastening the seat belt in a vehicle. Hospital leadership should consider making a commitment to achieve hand hygiene compliance of 90-plus percent and be prepared to serve as a role model by practicing proper hand hygiene. Finally, everyone in the facility -- doctors, nurses, food service staff, housekeepers, chaplains, technicians, therapists -- must be held accountable and responsible for upholding good infection prevention practices. 

If healthcare workers are distracted and forget to wash their hands, the Joint Commission recommends using a code word among healthcare workers to signal to a peer that they missed an opportunity and need to wash. Also, facilities should identify new technologies to make it easy for healthcare workers to remember to clean their hands, such as RFID, automatic reminders, and warning systems. Visual cues reinforce hand hygiene messages and training. These include stickers, colors, and posters. Visual cues need to be changed periodically so that they continue to be effective.
Systems should be evaluated and revised to help support proper hand hygiene practices. Focus on the system, not just on people, the Joint Commission says, by:

• Making it easy; examine work flow of healthcare workers to ensure ease of washing hands:

• Providing easy access of hand hygiene equipment and dispensers

• Creating a place for everything: for example, a healthcare worker with full hands needs a dedicated space where he or she can place items while washing hands

• Limiting entries and exits from a patient’s room – make supplies available in room 

Dunne CP, Kingston L, Slevin B and O'Connell NH. Editorial: Hand hygiene and compliance behaviors are the under-appreciated human factors pivotal to reducing hospital-acquired infections. Journal of Hospital Infection. Vol. 98, No. 4. Pages 328-330. April 2018.

Joint Commission. Accreditation and Certification. Effective Jan. 1, 2018: Individual hand hygiene failures to be cited under IC, NPSG standards. Dec. 20, 2017.

Joint Commission Center for Transforming Healthcare. Hand hygiene storyboard: Identifying Causes, Targeting Solutions. Jan. 14, 2015.

Reilly J, Price L, Lang S, Robertson C, Cheater F, Skinner K and Chow A. A pragmatic randomized controlled trial of 6 step versus 3 step hand hygiene technique in acute hospital care. Web: Infection Control & Hospital Epidemiology. March 31, 2016.