Today’s leaders of healthcare facilities are faced with difficult challenges. Organizations that want to prosper must respond to these challenges and change strategies to continue creating value. There is undisputed evidence that adherence to hand hygiene reduces cross-transmission of harmful organisms. With so much at stake, there should be no stone left unturned in the pursuit of gaining a better understanding of the current state of hand hygiene behavior.
In the context of our current reality, it would be natural to assume that healthcare workers (HCW) would know how and when they should perform hand hygiene. However, this assumption couldn’t be farther from the truth. HCWs can probably list a few or most of the indications for when to perform hand hygiene. Yet if you observe a HCW performing a complex task such as passing medication while using a med scanner or performing a dressing change, or watch a foodservice worker pass out meal trays, it will become apparent that they are often confused about when to perform hand hygiene within the context of their busy workflow.
Hand hygiene behavior is frequently observed covertly by “secret shoppers.” While this methodology helps determine hand hygiene compliance, it does not allow the observer to take advantage of teachable moments or to better understand hand hygiene barriers. Real-time identification of hand hygiene misses along with direct individual accountability have been shown to improve compliance.1,2 To this end, many hospitals also have their infection preventionists or other hand hygiene team members serve as coaches, or just-in-time (JIT) coaches, who stop HCW when they observe a missed opportunity and have a conversation about contributing factors for noncompliance and provide education on hand hygiene protocols. While extremely valuable, this coaching occurs sporadically and often exclusively during dayshift, not on off-shifts and weekends. Considering the many opportunities for hand hygiene, the current system simply isn’t providing HCW with what they need to make hand hygiene a ritual, automatic behavior-– consistent immediate feedback.
Recognizing that unit leadership and frontline HCW are closest to the patient—who better to speak up and provide the immediate reminders when hand hygiene opportunities are missed? Unit-led just-in-time coaching may very well be the key to providing consistent (24/7), nonpunitive, on-the-spot feedback when hand hygiene noncompliance is observed.
It is well accepted that speaking up for patient safety is an effective way to prevent adverse events--unit staff are familiar with this concept, and JIT coaching follows this model. And while not everyone will be comfortable approaching their noncompliant peers or those in positions of authority, many HCW do possess the essential qualities/traits of an effective coach: Recognized as a leader, role model, highly respected by peers, passion for patient safety, approachable, and willingness to speak up to peers and others across the chain of command.
While we often talk about the safety culture at the organizational level, safety culture is actually a local phenomenon and is best measured at the unit level. And because unit leadership are predominantly responsible for quality and safety outcomes in their units—it only makes sense to share the responsibility for hand hygiene outcomes with those at the unit level. Training unit staff (including unit managers) to become JIT coaches takes time, and deploying this tactic in a unit takes commitment, leadership support and careful planning. But as part of an overall strategy to improve hand hygiene and as a component of a broader effort to improve the culture of safety, it can make a huge difference.
Good metrics drive strategy, direction and performance. Electronic compliance monitoring (ECM) systems have been developed to serve as a better metric for monitoring hand hygiene compliance, although metrics of any kind do not change behavior. However, when ECM systems are combined with performance improvement strategies, hand hygiene rates can be increased and sustained leading to an increased culture of safety.