A culture of support: 4 ways to improve hand hygiene compliance

As healthcare embarks onward through the era of value-based care, hospitals are under mounting pressure to reduce the spread of healthcare-associated infections to improve outcomes and avoid fiscal penalties. As antibiotic resistance becomes increasingly difficult for healthcare organizations to mitigate, comprehensive infection prevention programs are necessary for both the financial wellbeing of a hospital and the health of patients.

During a Nov. 17 webinar sponsored by Ecolab — a global provider of water, hygiene and energy technologies — Linda Homan, RN, CIC, senior manager of clinical and professional services with Ecolab's healthcare division, discussed the importance of compliance with hand hygiene and environmental hygiene protocols to the success of comprehensive infection prevention programs. Additionally, Ms. Homan examined human behavior models that influence compliance, as well as unique measures that can provide a broad look at hospital-wide hand and environmental hygiene compliance.

Multiple studies have confirmed the efficacy of hand sanitizers, environmental disinfectants and sporicides in eliminating pathogens like Clostridium difficile and methicillin-resistant Staphylococcus aureus. Still, preventing these pathogens from infecting hospital patients is a major challenge for many infection prevention programs. The success of such programs is predicated almost entirely on one factor — provider compliance.

"We've shown that hand sanitizers and disinfectants are effective, so what is the challenge that we have?" asked Ms. Homan, during the webinar. "Why do we still have a problem? In many cases it's because of compliance, or human factors or human errors."

1. Promote. According to Ms. Homan, to properly promote compliance among providers, it is important to understand some of the human motivations influencing compliance. According to one well-accepted social cognitive model-the Health Belief Model, motivations to act include

• Perceived susceptibility: This is the individual's perception of the likelihood that failing to comply with infection prevention protocols will result in an infection for either him or herself or the patient depending on the situation.
• Perceived seriousness: A caregiver's interpretation of the seriousness of the outcome to the patient or caregiver if they are not compliant.
• Cues to action: This describes how providers react to the strategies employedto encourage compliance, e.g. hand sanitizer located at the point of use
• Perceived benefits: This is the caregivers opinion of the ability of the advised action to reduce the risk or seriousness of impact
• Perceived risks: These are the tangible and psychological costs of taking the advised action
• Self-efficacy: Compliance is influenced by a provider's confidence in their ability to complete the action they are being asked to do.
• Social pressure: This is a provider's perception of pressure generated from the social makeup of an organization. Will they be held accountable for compliance?
• Intention to perform: This is a caregivers readiness or willingness to perform the desired behavior

Regarding the behavioral models, Ms. Homan said, "If you think about it, we're balancing this every day in healthcare. Not only for our own health, but for the health of our patients...we have to be thinking about how we can impact those beliefs, how we can remove the barriers from those perceptions and try to make it easier for people to make the right decision."

2. Improve. Some traditional methods shown to help encourage compliance with infection prevention measures among staff include motivational programs, administrative measures and training initiatives. For a motivational measure, presenting staff with real-life, personal stories regarding the human cost of HAIs can make an emotional appeal to providers to improve compliance. Administrators can also play a key role in improving compliance by being vocal advocates themselves. If employees understand directives are coming from the top down, they may feel more compelled to comply with them. Consistently retraining employees regarding hygiene best practices and system-wide benefits of compliance helps maintain and improve compliance levels among staff, as well.

Currently, an increasing body of evidence points to behavior modification techniques, like posting signage designed to address health beliefs in strategic locations throughout the hospital, as an underutilized and viable method of boosting infection prevention adherence.

For instance, a recent study published in the journal of Health Psychology, found posting the image of man's eyes over the sanitizer dispensers boosted hand hygiene compliance by 33 percent. This image may invoke social pressure to promote compliance.

3. Measure. To properly measure hand hygiene, every hospital is required to implement a program in accordance with the recommendations of either the CDC or the World Health Organization and set goals for compliance improvement.

Hospitals have several different options to consider when monitoring compliance.

• Direct observation: This method involves monitoring the actual hand hygiene actions of staff. It can be done manually — with an actual person doing the monitoring — or it can be done with the assistance of technology such as smartphone apps. The smartphone apps can improve the likelihood of making covert observations and reduce the instances of Hawthorne effect, which is a social occurrence in which individuals alter or improve their behavior in response to their awareness of being observed.
• Measuring product use: This is an indirect way of conducting observations by quantifying the amount of soap and sanitizer used. Mathematical models can be used to determine how many hand hygiene opportunities there were versus how often staff actually took advantage of these opportunities.
• Electronic monitoring: Several different types of sensors are now available to measure handwashing compliance. While they can be expensive, a major benefit of electronic monitoring is it can provide administrators with real-time feedback on compliance prior to a healthcare worker's interaction with patients.

Compliance with environmental hygiene can be measured by direct observation, fluorescent markers, ATP or environmental culture. There are advantages and disadvantages for each of these measures, but according to the CDC Toolkit: Options to Evaluate Environmental Hygiene, the goal is to optimize high touch surface cleaning using an objective monitoring and feedback method.

4. Create. Another crucial aspect of maximizing compliance is a culture of support in which providers feel the organization advocates for them in their endeavors and is not eager to punish them, according to Ms. Homan. It's important to encourage providers to be active participants in a facility's culture of compliance, which requires honest feedback. Staff are less likely to provide administrators with candid information if they believe they work in a punitive environment.

"Punishing really doesn't work," said Ms. Homan. "Whenever there is a near miss or an accident, [everyone must] learn from the mistake. Don't blame or punish people, but use it as a learning opportunity to change the process, to change the workflow. This going to create a culture of support that's going to make it easier for people to want to work to improve the process."

To view the webinar, click here

To download the webinar slides, click here

To download past webinars, click here

More articles on infection control: 
Mumps outbreak in Arkansas tops 1,800 cases 
'Nightmare bacteria' detected on US pig farm 
CDC: Mumps outbreak hits 10-year high

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