The Joint Commission’s mission is to “improve healthcare for the public…by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.”1
In an effort to ensure that the public receives safe care in hospitals and other organizations, The Joint Commission aims to reduce healthcare-associated infections (HAIs), which infect around one million patients in the United States each year and lead to approximately 100,000 preventable deaths.2
The Joint Commission, like all major, credible organizations, recognizes that hand hygiene is the most important way to prevent the transmission of HAIs. Unfortunately, hospital hand hygiene performance rates tend to be low – one multicenter study found non-ICU performance averaged 36 percent (and ICUs were only at 26 percent)3. Most people will agree that actual “real world” hand hygiene rates are well below 50 percent, a problem that The Joint Commission’s new change to its hand hygiene standard appropriately addresses in a bold, new way.
A Good Start
Back in 2004, The Joint Commission first tackled hand hygiene with a policy centered around establishing a program4. Healthcare organizations were instructed to implement a program following either the CDC (Centers for Disease Control and Prevention) or WHO (World Health Organization) hand hygiene guidelines. Organizations were required to set goals for increasing hand hygiene performance and then show improvement.
This was a good start, but it didn’t have much teeth. In theory, a hospital could report a hand hygiene performance rate of 20 percent, improve it by 1 percent a year, and maintain compliance. For 14 years, this standard limped along. Yes, healthcare organizations established hand hygiene programs, but it’s uncertain whether hand hygiene performance rates improved. It’s even less clear if HAIs declined or patient safety improved. The intent of this policy was to improve patient safety, but as we’ve seen in nearly every hospital, simply having a program in place doesn’t necessarily translate to real world behavior change.
The Problem with Direct Observation
The central part of the problem is that nearly all hospitals rely on direct observation to monitor hand hygiene and report results back to The Joint Commission. At least a dozen human factors have the ability to taint direct observation findings, from confirmation bias and observer drift to uniform application errors and the inability to see into patient rooms. But direct observation’s truly fatal flaw is the Hawthorne Effect. We’ve seen that the Hawthorne Effect triples hand hygiene rates when clinicians know they’re being watched 5,6 and that their behavior quickly reverts back to their baseline when the observer leaves. So, when a hospital reports hand hygiene performance of 90 percent, its actual baseline is really closer to 30 percent.
As problematic as this is, it’s more concerning that hospitals would try to use direct observation to both monitor and improve hand hygiene in an effort to meet the old Joint Commission standards. Direct observation faces an impossible duality. It can’t be used to both improve hand hygiene and give any semblance of accurate data due to the Hawthorne Effect. If you want to minimize bias in the data collection, you need to ensure observers are secret. However, if your observers are secret, they can’t intervene and provide in-the-moment feedback that’s critical for lasting behavior change.
An Update to Hand Hygiene Standards
Recently, The Joint Commission dramatically changed its hand hygiene standards. As of January 1, 2018, if a Joint Commission surveyor sees one clinician fail to clean his or her hands one time, the organization will be cited as a deficiency resulting in a Requirement for Improvement.7 This means that one missed hand hygiene opportunity will jeopardize a hospital’s accreditation and likely trigger a second survey.
With this new standard, The Joint Commission has made a subtle but incredibly powerful statement. Simply having a process to improve hand hygiene is no longer enough. Hospitals now must ensure that staff actually performs hand hygiene. The days of simply monitoring a problem are over…you now have to fix it.
Why now? The Joint Commission, in an unusually pithy statement, explains, “because organizations have had since 2004 to implement successful hand hygiene programs, The Joint Commission has determined that there has been sufficient time for all organizations to train personnel who engage in direct patient care. While there are various causes for HAI, The Joint Commission has determined that failure to perform hand hygiene associated with direct care of patients should no longer be one of them.”
Five Steps to Compliance
While this new standard is an obvious win for patients, it adds another layer of stress for many healthcare organizations. We recommend responding by following these five steps.
1. Gather accurate, actionable data. Relying on direct observation’s inaccurate, aggregate data that shows up in a report a month later doesn’t change behavior. The modern generation of electronic hand hygiene systems track virtually all hand hygiene opportunities and provide data on individuals. This provides visibility into which clinicians are high performers and which are struggling. Not only does it provide 1,000 times more data to most hospitals, these systems also eliminate the many forms of human bias.
2. Provide reminders. It’s widely acknowledged that the best way to change an individual’s behavior is to provide real-time feedback. Clinicians are hardworking and highly empathetic people who are extremely busy and the top reason they don’t clean their hands is that they‘re busy and forget. The most effective electronic hand hygiene systems provide a real-time reminder to perform hand hygiene. We’ve seen that effective reminders in-the-moment can double – or even triple – hand hygiene performance.
3. Educate. You’d be surprised how much confusion there can be around a hospital’s hand hygiene protocols, even among the most experienced clinicians. Many providers have knowledge gaps and it’s impossible for the Infection Prevention (IP) team to know who understands what. We’ve seen a remarkable thing happen when a nurse or physician hears a reminder to sanitize when they don’t think they should. They’ll ask an IP about it, which is a perfect opportunity to educate and fill those knowledge gaps. Rather than the IP chasing clinicians to ensure they understand hand hygiene protocol, suddenly clinicians come to them with questions.
4. Solve workflow issues. Many electronic hand hygiene systems can track hand hygiene performance by the individual, room, day and time, etc. This gives hospitals visibility into problem areas. For example, there may be patient rooms where the hand sanitizer dispenser is inconveniently located. Or hand hygiene may drop on certain days or during particular times due to hospital demands that may be adjustable. Shedding light on bottlenecks not only improves hand hygiene, it also increases staff efficiency.
5. Don’t forget process. If you add a new technology to improve hand hygiene, you can’t install it and walk away. An established process should be used to address the human factor and get everyone on board and comfortable with the new system. There is a way to use the data in an efficient and systematic way to get the fastest improvement in hand hygiene without overwhelming or disrupting the organization.
The Joint Commission’s new hand hygiene standards will ultimately help protect patients and save lives. Healthcare organizations will need to adapt, but it shouldn’t be stressful, cumbersome or expensive. Technology exists that can help improve hand hygiene and reduce HAIs.
Chris Hermann, PhD, is the Founder and CEO of Clean Hands – Safe Hands. Dr. Hermann started and led the multi-institution research collaboration that developed the core technology utilized in the CHSH system. Over the last 11 years, he led investigators from Children’s Healthcare, Georgia Tech, Emory School of Medicine, the GA Tech Research Institute and the Centers for Disease Control and Prevention. Dr. Hermann earned a PhD in Bioengineering, a MS in Mechanical Engineering, a BS in Biomedical Engineering with High Honors from the Georgia Institute of Technology and is an MD candidate at Emory School of Medicine.
1 https://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx
2 D. Pittet, Emerging infectious diseases 7, 234 (May – Apr, 2001).
3 McGuckin, M, et al. “Hand Hygiene Compliance Rates in the United States--a One-Year Multicenter Collaboration Using Product/Volume Usage Measurement and Feedback.” American Journal of Medical Quality : the Official Journal of the American College of Medical Quality., U.S. National Library of Medicine, 1 May 2009, www.ncbi.nlm.nih.gov/pubmed/19332864.
4 https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2017.pdf (bottom of page 7)
5 Srigley, J.A., et al., Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf, 2014. 23(12): p. 974-80.
6 Hagel, S., et al., Quantifying the Hawthorne Effect in Hand Hygiene Compliance Through Comparing Direct Observation With Automated Hand Hygiene Monitoring.Infect Control Hosp Epidemiol, 2015. 36(8): p. 957-62.
7 https://www.jointcommission.org/issues/article.aspx?Article=IlZJaLJCiRBZC2IRvnKkJTqEEU2n1Rxv3fqmsKqKPb0%3D&j=3545832&e
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