Why Does Low Hand Hygiene Compliance Still Plague Healthcare? 4 Reasons

The Centers for Disease Control and Prevention first released formal written guidelines on handwashing in hospitals in 1975. The idea that washing one's hands reduces the risk of infection has been around long before that, however. In 1822, a French pharmacist discovered liquid chloride solutions could be used as disinfectants and antiseptics, according to CDC.

Why then, is hand hygiene still a problem? According to a 2002 CDC report, healthcare worker compliance to hand hygiene standards averages at 40 percent.


Dr. Felix Aguirre is vice president of medical affairs at IPC The Hospitalist Company.
Dr. Felix Aguirre
Felix Aguirre, MD, vice president of medical affairs at IPC The Hospitalist Company; Allison Aiello, PhD, MS, associate professor of epidemiology at the University of Michigan School of Public Health in Ann Arbor and a member of the Tork Green Hygiene Council; and Mark Graban, chief improvement officer of KaiNexus, provide insight into why hand hygiene rates among healthcare workers remain low despite roughly 190 years of knowledge of its effectiveness in stopping the spread of infections.

1. Problem: "Hand hygiene? It's not a problem here"

One of the biggest roadblocks to improving hand hygiene among healthcare workers is their unawareness of low compliance rates, according to Dr. Aguirre. This lack of awareness can stem from failure to monitor and share hand hygiene compliance rates with staff, or faulty monitoring methods. For example, direct observation in an intensive care unit at North Shore University Hospital in Manhasset, N.Y., showed an adherence rate of 60 percent. When the hospital used an objective monitoring system that provided constant observation and feedback, however, it found the rate to be less than 10 percent.

Even if staff are aware of low hand hygiene compliance rates, they may not feel an urgency to improve adherence because the consequences — infections or death — may not be obvious. "Unless someone dies, [they think] it's not a problem," Dr. Aguirre says.

Solution: Monitor and provide feedback and leadership
To increase awareness of low hand hygiene compliance rates, healthcare leaders should start by measuring current compliance rates and sharing data with staff. Objective measurement tools such as video and other technology can provide more accurate rates than methods like direct observation or indirect monitoring through "secret shoppers," which suffer from subjectivity and inconsistency.

However, measuring compliance rates will not effectively raise staff's awareness if these rates aren't communicated consistently. Providing feedback on hand hygiene adherence rates is critical to keeping everyone engaged and aware of the issue.

In addition to reliable surveillance methods and feedback, raising awareness of hand hygiene deficiencies requires leadership. Unless a leader makes hand hygiene a key focus area for the organization, medical staff will likely not buy in to hand hygiene initiatives, according to Dr. Aguirre. "It takes a champion to step up and make this happen," he says.

Mark Graban is chief improvement officer of KaiNexus.
Mark Graban
2. Problem: "I don't always have time to wash my hands"
Another common reason healthcare workers cite for low hand hygiene adherence is lack of time. "The problem is certainly not a lack of posters reminding staff to wash their hands. These signs (of varying cuteness or scariness) have been hanging in hospitals for decades. It's time for hospitals to give up on that as a way of increasing hand hygiene. Staff know they should practice proper hand hygiene. [The issue is] lack of time. [There's] too much waste in the process," Mr. Graban says.

Solution: Reduce waste, provide incentives
Mr. Graban suggests healthcare organizations use Lean methods to eliminate waste from processes and increase efficiency. For example, hospitals can use the "5S" methodology, a Lean technique for organizing work spaces, to consolidate all IV-related supplies onto one shelf instead of multiple shelves or rooms, Mr. Graban says. Eliminating unnecessary steps frees up time staff can use to wash their hands. "In this approach, we focus on the system, not blaming individuals," he says.

Another strategy to address time constraints is providing incentives for meeting hand hygiene goals, according to Dr. Aguirre. There are many non-monetary incentives and rewards that can stimulate engagement in this patient safety initiative, he says.

3. Problem: "There's never any soap"
Even when healthcare workers are aware of hand hygiene compliance issues and have time to wash their hands, they may face a barrier of limited resources. If dispensers aren't always filled with sanitizer and sinks aren't located in convenient places, the best-intentioned workers will have difficulty complying with hand hygiene practices all the time, Dr. Aguirre says.

Besides limited resources, the type of resources may hinder improved hand hygiene compliance. For example, the type of soap may irritate employees' hands.

Solution: Ensure sufficient resources
To address issues related to hand hygiene products, organizations should establish a process to ensure soap dispensers and sanitizers are always filled and easily accessible. Healthcare leaders should also ask staff members about their satisfaction with the hand hygiene products. If a type of soap irritates or dries employees' skin, leaders should look into alternatives to make hand hygiene compliance easier.

Dr. Allison Aiello is associate professor of epidemiology at the University of Michigan School of Public Health.
Dr. Allison Aiello
4. Problem: "I didn't know we had to wash our hands that way."
While most healthcare workers understand the importance of hand hygiene, they may not be aware of the correct techniques and times for washing hands. "While staff and employees are more cognizant of handwashing, there's still plenty of room for educating residents about the importance of proper hand hygiene," Dr. Aiello says.

Solution: Educate staff
Healthcare leaders need to educate employees on infection control practices, including hand hygiene, beginning at orientation. "Specifically, the proper method to washing and keeping hands clean, gloving before touching patients and sanitizing throughout the day after interacting with other residents or contaminated objects needs to be an ongoing discussion," Dr. Aiello says. "The continuation and enhancement of education among staff, residents and visitors about proper hand hygiene is key to addressing this issue."

Improving hand hygiene compliance is possible
There are various reasons for low hand hygiene compliance rates among healthcare workers beyond those listed here. Healthcare leaders need to determine the root causes in their own organizations to guide improvement strategies. By educating and engaging employees, streamlining processes and championing the issue, leaders can boost hand hygiene compliance to unprecedented levels.

More Articles on Hand Hygiene:

Make Hand Hygiene a Top Patient Safety Goal: Q&A With Premier Safety Institute's Gina Pugliese
Study: Hand Hygiene Poster Increased Likelihood of Washing Hands

Strategies to Achieve Hand Hygiene Compliance: Overcoming Challenges & Emphasizing Engagement

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