Today's infection prevention: How to transform Leapfrog Hospital Safety Grades with electronic hand hygiene monitoring

Hand hygiene, as a principle for safety in hospitals, has been around for over a century,” Leah Binder, president and CEO of The Leapfrog Group, said. However, despite the well-understood importance of hand hygiene in healthcare, many hospitals still struggle to achieve high levels of protocol adherence, which can increase the risk of hospital-acquired infections.

To better understand the current state of hand hygiene in hospitals, Becker’s Hospital Review recently spoke with a group of experts about infection prevention during the pandemic and what leading hospitals are doing to achieve and sustain better hand hygiene.

These experts included The Leapfrog Group’s Ms. Binder, Ecolab Healthcare Senior Manager for Clinical Affairs Linda Homan, CIC, RN, BSN, and two leaders from Pittsburgh-based Allegheny Health Network, a 13-hospital academic health system: Amy Cotton, DNP, senior vice president of quality and safety, and Juliet Ferrelli, network director of infection prevention.

While the importance of hand hygiene is well known, gaps still exist

"The CDC has said hand hygiene is one of the most important ways you can reduce the risk of infection in hospitals," Ms. Homan said. "The importance has always been there." But despite recognition of the importance of hand hygiene, many hospitals still fall short.

"Hand hygiene is the cornerstone of infection control, yet compliance remains low, averaging 50 percent across hospitals nationwide," wrote the authors of a JAMA Internal Medicine research letter published in April.

"It's long past time that hospitals and ASCs and all healthcare settings become experts at hand hygiene," Ms. Binder said. "When the pandemic started, we should have felt like hospitals were the safest place in America and should have felt reassured that hospitals really knew about hand hygiene and how to protect people from infectious disease — that should be their expertise. Sadly, this isn’t how we felt."

By focusing on safety, Leapfrog has elevated the focus on hand hygiene

The Leapfrog Group is well known for its Hospital Safety Grade, which uses a consumer-friendly letter grade system to evaluate more than 2,700 hospitals on how well they keep patients safe from harm and errors.

Ms. Binder explained that the Leapfrog Hospital Safety Grade is based equally on measures of a hospital’s processes to prevent errors and outcomes. Leapfrog’s hand hygiene standard, with five components, is part of the Safety Grade’s process measures. However, good hand hygiene also has a positive impact on outcomes. "If you achieve our standard for hand hygiene," Ms. Binder said, "you are going to prevent infections, and infections have a very heavy weight in the Hospital Safety Grade."

One of the real-world challenges hospitals experience is that meeting Leapfrog’s standard, which is based on the World Health Organization’s Hand Hygiene Self-Assessment Framework and vetted by top experts, requires collecting data on 200 hand hygiene observations per hospital unit per month. Dr. Cotton from Allegheny Health Network estimated that the health system's manual audits of hand hygiene took over 10,000 hours of staff time. Further, "audit and feedback can improve compliance, but audits traditionally occur using direct observation, capturing few events and leading to inaccurate measurements," according to the JAMA Internal Medicine research letter.

Many hospitals are looking for a better, easier way to gather data for Leapfrog and comply without doing hundreds of human observations per month, and Ms. Binder noted her organization has seen increased interest among consumers in the grades amid the pandemic and heightened concern about safety in hospitals.

Hand hygiene temporarily improved during the pandemic but has regressed at some hospitals

"When the pandemic hit, hand hygiene went up," Ms. Homan said, "because everyone started washing their hands more in hospitals and outside of hospitals. There was hand sanitizer everywhere and everybody was using it all the time." This assertion was supported by a study about hand hygiene at the University of Chicago Medical Center. The study found that prior to the pandemic, UCMC’s level of hand hygiene compliance was only 54.5 percent, but peaked at almost 93 percent across all units on March 29, 2020, according to the JAMA Internal Medicine research letter.

However, as the pandemic continued and infections started to wane, "hand hygiene in some places started to slip back toward the baseline," Ms. Homan said. She said some of this slippage may have been due to the challenge of the high patient volume and the complex care required by COVID-19 patients.

In terms of infection control and hand hygiene, the pandemic may have been a wakeup call. "The pandemic raised people’s awareness of hand hygiene," Ms. Homan said. Ms. Binder agreed, offering Leapfrog’s perspective. "We feel the pandemic opened everyone’s eyes to the critical importance of infection prevention in hospitals. And the number one way to prevent infection is old-fashioned hand hygiene."

Electronic monitoring program helps hospitals achieve and sustain high levels of hand hygiene

While hand hygiene compliance slipped during the pandemic at some hospitals, others were able to maintain a high level of compliance throughout. Ms. Homan described a data review of four of Ecolab’s customers that had implemented Ecolab’s Hand Hygiene Compliance Monitoring System, part of the Ecolab Hand Hygiene Program, prior to the pandemic. These four hospitals all achieved compliance in excess of 80 percent prior to the pandemic — and sustained that level of compliance during the pandemic.

The reason for these results, in Ms. Homan’s view, is that Ecolab’s electronic monitoring system continuously monitors hand hygiene compliance in the patient zone for every healthcare worker. The system captures robust, actionable data by individual, shift, discipline, unit and patient across the hospital automatically. The program can help hospitals improve in areas like infection rates that significantly impact a hospital’s total Leapfrog Hospital Safety Grade, according to Ms. Homan.

The data captured by the system produces reports and analytics that allow hospital leaders to assess performance at all levels, providing visibility to where improvements are needed.

Importantly, "What drives sustained behavioral change is that Ecolab’s electronic monitoring system provides immediate feedback to the healthcare worker," Ms. Homan said. It does this through lights on the employee’s badge — which can be green, yellow or red — and through a sound if an employee misses a hand hygiene opportunity. "It's a real-time reminder system, which is the best way we’ve seen to raise compliance, sustain compliance and change behavior," Ms. Homan noted. The process is built into the existing workflow, so if a healthcare worker is performing hand hygiene at the appropriate times, no change in behavior is needed. This ensures results that are sustainable whether healthcare workers are in triage mode during the pandemic, or not.

Alleghany Health Network has experienced multiple benefits from the Ecolab Hand Hygiene Program

Dr. Cotton summarized AHN’s perspective: "The pandemic served to shine a spotlight on how we could (and should) be leveraging innovation and technology to support patient safety and free clinicians to spend their time caring for patients."

At AHN, Ecolab’s Hand Hygiene Compliance Monitoring System fits well with the health system's patient-focused approach. "Implementing this system across AHN has supported a culture of patient safety with both leadership and frontline staff," Dr. Cotton said. "The robust reporting capabilities is something that stood out," added Ms. Ferrelli. "Being able to report down to the individual employee helps bring ownership where it is needed most, at the bedside.” Ms. Ferrelli also cited the program's actionable real-time data, which was lacking in previous solutions used at AHN.

In addition, AHN has been able to reduce the number of observation audits required to demonstrate the health system’s safety practices for Leapfrog. Ms. Binder mentioned that hospitals have a variety of ways of meeting Leapfrog’s hand hygiene standard, of which electronic monitoring is one component.

Taking a multi-modal approach goes beyond electronic monitoring

Several years ago, Ms. Homan said, the World Health Organization came out with hand hygiene recommendations and included a multi-modal approach. The idea was that improving hand hygiene requires efforts along multiple dimensions, including education, training, feedback and signage.

As part of a multi-modal approach, Ecolab has expanded its Hand Hygiene Program to include a new hand hygiene continuing education course, to keep nurses and other healthcare professionals up to date on hand hygiene. As part of its program, Ecolab has also created a Hand Hygiene Observation Tool, which is an app for smart devices to monitor hand hygiene compliance and quality. This observation tool provides an opportunity to verify whether individuals are washing their hands correctly and provides an opportunity for guidance and coaching. "It's about technique," Ms. Homan said. "It's about practice and it can augment an electronic compliance monitoring tool already in use."


Hand hygiene is a critical activity in healthcare; it always has been and always will be. Proper hand hygiene decreases infections and improves outcomes. The pandemic raised people’s awareness of the importance of hand hygiene, which provides an opportunity to build momentum for better infection control in the hospital. Momentum can be built through an electronic compliance monitoring system, like Ecolab’s, that provides accurate, actionable data and a variety of detailed reports. Ecolab’s system provides these benefits without disrupting a health system’s workflow. In addition to an electronic monitoring system, a holistic, multi-modal approach helps engrain handwashing in the organization’s culture, creating and sustaining a culture of patient safety and compliance, and helping organizations achieve excellent Safety Grades.

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