To Do No Harm, Rethink How to Measure Hand Hygiene

By Paul Alper, BA

Primum non nocere is a Latin phrase that means, “First, do no harm.” It is a precept taught to healthcare students around the world and paraphrased in the Hippocratic Oath. Unfortunately, a vast amount of avoidable harm still takes place in healthcare settings worldwide. The good news is that a new technology can provide a solution to a decades-old challenge to patient safety professionals: how to accurately and reliably monitor hand hygiene—the simplest and most effective way to prevent healthcare-associated infections (HAI).

 

Personal and financial effects of HAIs

Ellen Hargett, RN, is the director of quality and process improvement at DeKalb Regional Health System in DeKalb, Georgia. She is trained in Lean and Six Sigma for controlling and improving quality and staff performance in the healthcare environment, and is a skilled and passionate patient safety proponent dedicated to helping her system find ways to avoid harm.

When Hargett became a cancer patient and had surgery at her own hospital, she knew the risks associated with her surgery, but infection was the last thing on her mind. She didn’t imagine that she would join the 700,000 people in the United States who, according to the latest data available from the Centers for Disease Control (CDC), contract an HAI each year, though she was thankfully not one of the 75,000 people who die from the infection (CDC, 2016). After undergoing further surgery to address complications from the cancer surgery, Hargett contracted a severe surgical site infection caused by methicillin-resistant Staphylococcus aureus (MRSA), bacteria that are easily transmitted, often as a result of improper hand hygiene. Hargett had to fight sepsis and deal with an abdominal abscess for months after the second surgery. She was informed that the best option was a third surgery, which would leave an opening in her abdomen for a week. She consented, and it likely saved her life.

Eight months following the initial surgery, Hargett returned to work, though her experience had left her with chronic complications. Hargett’s insurance company was billed $79,000 for the cancer surgery and $239,000 for treatments related to the MRSA infection.

 

Using direct observation to measure compliance

Having had time to observe healthcare worker behavior during her ordeal, Hargett came to realize that true hand hygiene compliance at DeKalb Regional was less than 50%, which is typical for healthcare settings worldwide (McGuckin, Waterman, & Govednik, 2009). Many hospitals, however, boast compliance in the 90% range (Coyne, 2014). That discrepancy often results from hand hygiene compliance being measured by “secret shoppers,” human observers equipped with clipboards and pens—surprising in an age of highly sophisticated automation and technology. This approach to monitoring is also known as direct observation. Observers capture only a tiny fraction of all hand hygiene behavior, typically well below a sample size that would be statistically significant. Also surprising is the lack of mandated standards or guidelines for measuring hand hygiene compliance, leaving hospitals free to design their own measurement and feedback programs. Further compounding the problem, healthcare workers—no matter how discreet the secret shopper is—know when they are being observed and behave differently. This phenomenon is known as the Hawthorne effect: People behave differently when they know they are being watched.

A recent study in Canada found that direct observation resulted in 300% overstatement of hand hygiene behavior (Srigley, Furness, Baker, & Gardam, 2014). Reporting on the study, the Toronto Star said, “Healthcare workers wash their hands three times more often when under the watch of an observer than not” (Coyne, 2014). Collected weekly and published monthly, most Ontario hospitals boast hand-washing rates above 90%. That means for every opportunity hospital staff had to wash their hands, they did at least nine times out of 10.

But in reality, those numbers are less than 30%, according to Michael Gardam, Toronto University Health Network’s director of infection prevention and control and co-author of the study. This can have real consequences for patient health. Gardam was quoted in the Star:

If our numbers are above 90% but we’re still having infections, one obvious explanation for that is because you’re not washing your hands nearly as much as you think you are. We’re fooling ourselves. The numbers that we are getting and we are posting publicly are not real, they’re artificial. (Coyne, 2014)

This is not the only study to reveal a huge overstatement of compliance when using direct observation. A German study demonstrated a 275% Hawthorne effect in 2009 (Scheithauer et al., 2009). To sum up the problem, direct observation—the way that most hospitals around the world measure hand hygiene—gives hospitals a false sense of security, which leads to complacency and inaction. As a result, infections occur, causing pain and suffering and costing lives. Perhaps if hospitals knew their real rates, they would have a sense of urgency about improving them.

 

New technology offers a different solution

Over the past few years, Hargett has become aware of electronic monitoring systems, an emerging technology that can measure 100% of hand hygiene events accurately and reliably. As a result, she calls for a change to the standards and guidelines:

It is now time to recognize that direct observation is no longer the “gold standard” for measuring hand hygiene. With the availability of accurate and reliable electronic systems, it is essential that organizations that accredit hospitals, along with the government and private payors of healthcare, mandate that hospitals adopt technology that will lead to better outcomes and help eliminate the risk of avoidable HAIs.

 

Leaders in healthcare face daily pressure to drive quality improvement and economic efficiencies. This trend has become more prominent as the Centers for Medicare & Medicaid Services (CMS) levies penalties that demand hospitals improve quality or lose revenue. With the new penalty for hospital-associated conditions, including HAIs, imposed under the Affordable Care Act (ACA), hospitals can lose 1% of their total CMS revenue if they fall into the lowest-performing quartile of U.S. hospitals, so there are serious dollars at stake. In 2015, 724 hospitals were penalized, and 758 are being penalized in 2016, 54% of which are in the penalty zone for the second time (Evans, 2015). Today’s quality leaders and patient safety professionals must find new evidence-based ways to improve practices and standards of care, choosing methods that are both effective and relatively easy to implement in their organization’s culture.

Just as other areas of healthcare are adopting advanced technologies for improved efficiencies and care, electronic monitoring can measure compliance accurately and reliably. It has been shown to help drive true improvement in hand hygiene compliance and reduce avoidable infections and their associated costs. Thankfully, awareness of the connection between accurately measuring hand hygiene compliance and improving patient care while reducing cost is beginning to grow among senior hospital leaders.

 

EHCO alliance

To put the significance of hand hygiene compliance in the spotlight, eight companies that offer electronic monitoring technologies formed an alliance in September 2015 and announced their purpose and vision with the launch of their website in February 2016: the Electronic Hand Hygiene Compliance Organization (EHCO). EHCO’s purpose is to increase safety, reduce avoidable harm, and eliminate unnecessary costs at hospitals nationwide. It promotes changes in hand hygiene measurement policy and guidelines at accreditation organizations, government agencies, health insurers, and hospitals. The companies engaged in EHCO include Airista, BioVigil, CenTrak, Clean Hands-Safe Hands, DebMed, Hill-Rom, SwipeSense, and Versus Technology. All produce technology that can capture 100% of hand hygiene events and report compliance accurately and reliably.

EHCO’s goals align with those of hospital leadership: to reduce the risk of HAIs along with associated costs and potential penalties. EHCO invites patient safety and quality leaders to consider the real cost of using antiquated methods of measuring hand hygiene compliance and suggests that now is the time for hospitals to change how they measure this key performance indicator of patient safety and quality.