By Lori Moore, MPH, BSN, RN, CPPS – GOJO Industries
As hospitals reopen services, patients are seeking assurances that their healthcare facility has made their personal well-being a priority from the moment they are admitted. Studies show patients feel safer knowing that their healthcare providers’ hand hygiene is being monitored.1 Observing hand hygiene behavior and performing Just-in-Time (JIT) coaching has been an effective strategy for infection preventionists (IPs). However, this valuable on-the-spot coaching by IPs occurs only sporadically. As a result, reminders are infrequently provided, behavior change is not sustained, and hand hygiene remains a challenge.
What makes hand hygiene so challenging? First, hand hygiene is a simple task performed in a complex environment. There are scientists who study our healthcare systems within the context of what they refer to as the Complexity Theory.2 This theory proposes that if we are going to improve patient safety, some of our behaviors need to be performed with a high degree of predictability, or as some would say, with a high level of reliability. The circumstances in which variation in behavior or process should be minimal are when: 1) the levels of certainty and clinical agreement are high, and 2) the science base is consistent.3 Hand hygiene falls here. Few would argue that hand hygiene is one of the most important defenses against the transmission of harmful organisms, and hand hygiene guidelines are in alignment on the moments for hand hygiene.4-5 So ideally, this would be a behavior that we would want performed with a high level of reliability.
Second, hand hygiene is challenging because it is the task that is performed the most in any healthcare setting. Automated hand hygiene monitoring systems have shed new light on this.6 No other task comes close. And it involves so many healthcare providers. Each and every person entering or exiting a patient room is an independent decision maker, deciding if and/or when to clean their hands.
Adding to the challenge is the fact that for most healthcare facilities, the responsibility for hand hygiene typically falls on the shoulders of a few, namely IPs. This responsibility is without a doubt disproportionate to the extraordinary number of opportunities for hand hygiene. Furthermore, IPs generally do not have direct authority over healthcare providers who are the targets of hand hygiene behavior change/modification.
Finally, let’s throw culture into the mix. Peter Pronovost and Bryan Sexton studied safety culture and found that while there was variation across 100 individual hospitals, there was even more variation when they looked at 49 individual units within a single hospital.7 As it turns out, safety culture is mostly a local phenomenon occurring at the unit level. To change behaviors and practices that make up a unit culture, you have to understand those behaviors and practices, and for that you must be a part of the unit. Achieving an in-depth understanding of unit culture is nearly impossible for an IP who has a broader facility responsibility.
The above-mentioned challenges signal a long-overdue shifting of the paradigm whereupon IPs begin to work through others to influence hand hygiene behavior, namely nurse managers. This is really about playing our strengths. It is the nurse managers who are responsible for unit-based quality metrics. Nurse managers are also best positioned to impact performance, empower unit staff to solve problems and influence safety culture at the unit level. In contrast, the leadership of IPs is based on influence rather than authority. Their leadership role involves establishing a clear vision, communicating and collaborating with other leaders and the provision of expertise in problem-solving.8
From this perspective, IPs would be well served to focus less on changing hand hygiene behaviors and more on building meaningful partnerships with nurse managers, especially when it comes to just-in-time coaching. Nurse managers have the advantage of residing on the unit with the ability to observe performance on a consistent basis as compared to the sporadic presence of IPs. Recognizing that unit leadership and frontline healthcare providers are closest to the patient, who better to speak up and provide the immediate reminders when hand hygiene opportunities are missed? Unit-led JIT coaching may very well be the key to providing consistent, nonpunitive, on-the-spot feedback when hand hygiene noncompliance is observed.
Training nurse managers and unit staff 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 overall patient safety, unit-led JIT coaching can be the best strategy for creating a culture in which it becomes the expectation to be reminded to clean hands when an opportunity is missed rather than the exception. For more information go here.
- 2018 Houston Methodist follow-up patient survey, GOJO AMS pilot results survey.
- Wachter RM. Understanding patient safety. McGraw-Hill Companies. 2008.
- Plesk P. Redesigning health care with insights from the science of complex adaptive systems. Appendix B in: Crossing the Quality Chasm.
- Boyce JM, Pittet D, and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. MMWR Morb Mortal Wkly Rep 2002;51(RR-16):1-45.
- World Health Organization. WHO Guidelines for hand hygiene in health care. Geneva, Switzerland: World Health Organization; 2009.
- Moore LD, Robbins G, Quinn J, Arbogast JW. The impact of COVID-19 pandemic on hand hygiene performance in hospitals. Am J Infect Control 2021;49:30-33.
- Pronovost PJ, Sexton B. Assessing safety culture: guidelines and recommendations. Qual Saf Health Care 2005;14:231-233.
- Billings C, Bernard H, Caffery L, Dolan SA, Donaldson J, Kalp E, et al. Advancing the profession: an updated future-oriented competency model for professional development in infection and prevention and control. Am J Infect Control 2019;47:602-614.