Improve Your Hand Hygiene Compliance Rates: Three Insights From the University of Tennessee Medical Center

By Jenn Radtke

Hand hygiene plays a critical role in preventing the spread of pathogens that can lead to healthcare-associated infections (HAI), yet many U.S. health systems are falling short on their hand hygiene compliance rates. The Centers for Disease Control & Prevention (CDC) estimates that healthcare providers clean their hands about half the times they should. Missing these hand hygiene opportunities puts patients at risk for HAIs.

Why are hand hygiene rates so low? It’s because direct observation by secret shoppers, the most common way to evaluate hand hygiene compliance, creates a false sense of security. Secret shopper programs often report a high compliance rate when in actuality, they are only capturing a snapshot in time. Self-reporting or direct observation can be even less accurate because of the Hawthorne effect: Individuals who know they are being watched will change their behavior.

Without reliable data, it’s impossible to determine the best path toward improving compliance. To reach compliance goals of 90% or higher, systems need to measure 100% of all hand hygiene events. Why aim so high? Proper hand hygiene has been proven to reduce HAIs.

As the manager of infection prevention at the University of Tennessee Medical Center (UTMC), I have spent a great deal of time determining ways to increase our hand hygiene compliance. We’ve used secret shoppers and audits to collect hand hygiene compliance information. Using these methods, our compliance rate has hovered around 80% for more than five years—no matter how many new efforts and campaigns we tried to get it above 90%. While researching ways to improve, we learned about electronic compliance monitoring systems. It turned out the data we, and many other healthcare organizations, were collecting was painting a false picture.

Earlier this year, UTMC piloted Ecolab’s Hand Hygiene Compliance Monitoring System for a twomonth trial on the acute care hospitalist unit and the neurocritical care unit. Personnel involved in the program included physicians, pharmacists, case managers, nurses, nursing assistants, physical therapists, respiratory therapists, and environmental services personnel.

With 24/7 electronic monitoring, we found that our actual compliance rate was much lower than our audits were capturing. Our baseline compliance rate was similar to what is published in the literature by other organizations that have implemented electronic hand hygiene compliance monitoring. Having reviewed the literature prior to our pilot, we were not shocked by the results, but we were disappointed—after all, you always hope that your organization is different. It was now clear to us why we were struggling to reach 90%. After the trial of the Ecolab system, our compliance rate increased to 89.4%.

Access to accurate, actionable data will allow us to optimize performance; therefore, we will be implementing this new electronic monitoring system in September. We are excited that we will be able to track results in real time on digital dashboards and generate reports on individuals, staff groups, specific divisions, and the hospital overall to see where we commonly miss hand hygiene opportunities. Access to this information will allow us to take corrective actions needed to effect change and improve patient outcomes.

Implementing change can be difficult. Here are three steps we are taking to make the switch to electronic compliance monitoring easier:

1. Educate staff on what monitoring really means

Electronically monitoring compliance and providing real-time reminders is key to reinforcing best practices and supporting positive long-term change. However, the word “monitoring” may bring up feelings of defensiveness and distrust among staff. They may worry that the system will take on a “Big Brother” role and that leadership will use it for purposes other than that for which it was designed, like tracking time spent with patients and pushing caregivers to be more efficient. Staff should feel reassured that this will not be the case.

It is important to properly explain the program to staff. It isn’t about monitoring; it is about reminding. For example, when you forget to put your seatbelt on in the car, you hear a beep as a reminder to do so. An electronic compliance monitoring system is the same—a simple reminder to do something necessary for safety.

When UTMC staff heard this explanation, they were more open to using the system. Once the pilot started, staff members realized the system was not interrupting their general workflow. They were open to seeing the reports and learning about where they could improve.

2. Establish internal champions

It is natural for people to resist or hesitate when adapting to a new process. For this reason, establishing an internal champion who is passionate about the change—someone who listens and can effectively engage staff members—is crucial. Achieving change in an organization requires a commitment to bringing people along on the journey and creating an inclusive environment. Involving staff from the beginning, providing them feedback along the journey, and sharing outcomes helps them understand their role in solving a problem.

UTMC’s former chief medical officer, Dr. Jerry Epps, was our initial champion. One example of how he supported the initiative was by sending an email to the physicians involved in the pilot, reminding them why we were conducting this test. It is about quality and patient safety, not about scolding staff who aren’t at 90%.

Once we complete our full implementation, we plan to celebrate staff members and departments who are top performers. We will recognize them for improving patient safety, thereby showing that achieving high rates of hand hygiene compliance is possible in our everyday workflow. Patient safety is the top priority, and this recognition may generate a little friendly competition among departments—another reason to strive for high compliance.

3. Make a strong case to the C-suite, focused on ROI

As with any sizable initiative, executives need to understand the potential return on investment (ROI). Start by calculating the cost implications of different HAIs—we focused on Clostridium difficile, central line–associated bloodstream infections, methicillin-resistant Staphylococcus aureus, and catheter-associated urinary tract infections. We evaluated how HAIs can increase patients’ length of stay, mortality rates, cost of care, and need for isolation precautions. We also considered that an added bonus to implementation might be a decrease in staff absenteeism, with fewer sick days among staff as a result of their decreased exposure to pathogens.

A CDC study found that when one U.S. hospital increased its hand hygiene compliance rate above 90%, it significantly decreased its HAI rate, with 197 fewer infections and an estimated 22 fewer deaths. These reductions resulted in an overall savings of around $5 million. Savings like that deliver a strong ROI in comparison to how much it costs to implement the system.

Another factor to consider, while difficult to quantify, is your hospital’s reputation as a safe and cutting-edge facility. That can be a huge draw to potential patients. UTMC initially considered a compliance monitoring system after learning another hospital in Tennessee was using one and reporting major success. Positioning the system to the C-suite as a way to not fall behind the competition was an important argument.

Pushing the industry forward

After seeing such success with the pilot program, UTMC is moving forward with implementing Ecolab’s Hand Hygiene Compliance Monitoring System in all its inpatient areas, with the backing of both the staff and the C-suite. We hope to see HAI rates decrease 30%–40% by keeping our hand hygiene compliance rate above 90% (while also realizing that reaching 100% is unrealistic due to emergencies or other unique circumstances).
Hand hygiene is a simple and effective infection prevention strategy, but manual monitoring is depicting a false narrative of hospitals’ true compliance rates—potentially leaving a big gap in infection prevention measures. Challenge your hospital executives to question the accuracy of current monitoring methods and explore alternatives. You can’t fix poor compliance rates and reduce HAIs with incorrect data. To learn more about electronic hand hygiene compliance monitoring, check out this recent Hand Hygiene Monitoring Technology webinar from PSQH, featuring Payal K. Patel, MD, MPH, from the University of Michigan’s Institute for Healthcare Policy and Innovation.

Jenn Radtke is manager of infection prevention at The University of Tennessee Medical Center.