Hand Hygiene

Direct Observation: A Robust Approach for the WHO 5 Moments

By Paul Alper

Editor's note: This column originally appeared in the March 2020 issue of Healthcare Hygiene magazine.

I was recently asked by the head of infection prevention at a community hospital how to design a robust hand hygiene direct observation program. Their objective was to get the most accurate compliance data possible, as they got ready for an upcoming Joint Commission visit.

I thought there might be others who would like to know how to accomplish this given that direct observation is still the most widespread method used for hand hygiene performance measurement. This is in spite of the fact that direct observation has been shown to have many shortcomings, including lack of accuracy due to the Hawthorne Effect,1 lack of inter-rate reliability and bias on the part of the observers.

An Evidence-Based Approach
Drawing on the methodology of a landmark study2 by Steed, et al. that, for the first time, scientifically determined the number of hand hygiene opportunities (HHOs) in various settings using a disciplined approach to direct observation-based on the WHO 5 Moments, I have created a “best practices for direct observation” checklist.

Here is a summary and checklist for how facilities could implement the approach used in the study and acquire compliance data that is as accurate and reliable as we likely can expect data from direct observation to be.

Checklist for a Robust Direct Observation Program
Note that apps to capture and compile direct observation data for smart phones and tablets are available from your App Store or provider. We will address the manual process in Steps 3, 4 and 5 below but simply follow app instructions if you are using one of them instead.

1. Train observers. This should consist of the following three steps:
a. Total familiarization with The WHO 5 Moments Poster.
b. Complete familiarization with the WHO Hand Hygiene Training Films and Slides Accompanying the Training Films.
c. Practice doing observations with feedback from a lead observer or infection prevention manager.

2. Assess inter-rater reliability. Conduct this routinely to ensure consistency of data collection.
a. In its simplest form, observers could conduct direct observations together and compare results. A lead observer could also accompany observers to reinforce consistent results.

3. Conduct Direct Observation. Observation of hand hygiene behavior is accomplished using the WHO Data Collection Tool or a modified version as such was the case in the HOW2 Study. Johns Hopkins Medicine also has created a Hopkins Medicine Monitoring Tool.
a. Complete the top part of the header before commencing observation (except end time and duration)
b. A session should last no more than 20 minutes.
c. Record HHOs in the appropriate column and fill in the square corresponding to the indications for hand hygiene detected.
d. Record hand hygiene events or HHEs (or hand hygiene actions) observed or missed for each indication.
e. Glove use may be recorded only when a hand hygiene event is missed while the healthcare worker is wearing gloves.
f. At the end of the session, record end time and duration.

4. Compile the data. Data from each Observation Form should be entered into a master data base such as Excel. Total hand hygiene events for a period are aggregated and divided by the total number of HHOs to determine the Compliance Rate for specific periods of time (week, month, quarter, year) for specific units as well as aggregated for the entire organization.

5. Create graphs and reports. Performance graphs and appropriate reports should be created and then shared with unit and organization leadership.

6. Give front-line staff feedback. Front line workers should be provided with performance feedback as immediate as possible after report creation.

7. Create performance improvement action plans. Units and departments should be responsible and accountable for action plans to remove unit specific barriers and obstacles to proper hand hygiene behavior.
While data from direct observation may be overstated, if collected consistently, it should provide a sound tool for measuring real improvement and the impact of initiatives designed to drive sustainable growth in hand hygiene behavior.
Thanks to the HOW2 authors for the creative research that inspired this column.

References:
1. Srigley JA, Furness CD, Baker GR and Gardam M. (2014). Quantification of the Hawthorne Effect in Hand Hygiene Compliance Monitoring Using an Electronic Monitoring System: A Retrospective Cohort Study. BMJ Qual Saf. 23, 974–80.
2. Steed C, Kelly JW, Blackhurst D, Boeker S, Diller T, Alper P and Larson E. (2011). Hospital hand hygiene opportunities: Where and when (HOW2)?
The HOW2 Benchmark Study. Am J Infect Control. 39(1), 19–26. doi:10.1016/j.ajic.2010.10.007

Paul Alper, BA, led the launch of PURELL®, invented the first electronic hand hygiene monitoring system proven to reduce infections while improving behavior and eliminating costs and is now the VP Patient Safety Innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC. He can be reached for questions or comments at paul@next-levelstrategies.com.

Gloves: An Essential Component of Proper Hand Hygiene

By Paul Alper

This column originally appeared in the February 2020 issue of Healthcare Hygiene magazine.

Just as important as proper cleaning and sanitizing of hands, is proper glove use. While there are a variety of gloves used in healthcare, we will address the proper use of non-sterile, single use (disposable) exam gloves and their role in protection of the patient as well as the healthcare provider.

Complete Hand Hygiene Education
Hand hygiene education must include instruction on proper glove use, not just when and how to perform hand washing or sanitizing. Wearing gloves does not replace proper hand hygiene practices but should be used as indicated according to accepted guidelines.
Using an alcohol based hand sanitizer before donning gloves is essential to ensure no contamination of other gloves in the box as they are removed from the original box or storage container.

Guidelines and Recommendations – When to Wear/When to Remove or Change
The WHO (World Health Organization), CDC (Centers for Disease Control) and OSHA (Occupational Safety & Health Administration) all recommend glove use during a procedure or task when contact is likely:
• With blood or bodily fluids
• With mucous membranes
• With non-intact skin
• With other potentially infectious materials
• When handling or touching contaminated equipment or surfaces

Knowing when to remove or change gloves is just as important as when to wear them. Gloves protect the healthcare worker as well as the patient but they also pose a risk if not removed when contaminated. Timing of and technique for donning and doffing of gloves is essential to eliminating the risk of HAI transmission.

he CDC, WHO and OSHA all have recommendations regarding removing and changing of gloves:

The CDC recommendations include:
• Remove gloves after caring for a patient
• Do not wear the same pair of gloves for the care of more than one patient (this also means never washing them between patients)
• Change gloves when moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs
• Carefully remove gloves to prevent hand contamination

The WHO recommends that gloves should be removed:
• As soon as gloves are damaged or suspected of being damaged
• When contact with blood, other body fluids, non-intact skin and mucous membranes has occurred and ended
• When there is an indication for handwashing or sanitizing

OSHA’s recommendations for when to change gloves include:
• As soon as practical when contaminated, torn or punctured
• Changing gloves between patients regardless of condition

Common Usage Errors
Common errors with proper glove use include prolonged use, using when not indicated and the presence of jewelry.
Prolonged use and over use of gloves also poses a risk. Using gloves for an extended period of time can result in the transmission of disease causing microorganisms due to a possible failure to identify an indication for hand hygiene and then performing it.
When there is no potential for exposure to blood or body fluids, mucous membranes, non-intact skin or contaminated environmental surfaces, gloves should not be worn.

Jewelry should never be worn during patient care, even if wearing gloves. Nor should it be worn during proper hand hygiene.

Skin Health and Gloving
Occupational dermatitis is a common issue among healthcare workers. High frequency hand hygiene can potentially remove protective lipids from the skin, making it more prone to drying and irritation. This increases the risk of colonization with bacteria and can potentially result in the spread of disease causing microorganisms.

Proper and frequent use of a latex and nitrile compatible lotion, especially at the start and end of the shift, along with the use of gloves manufactured with therapeutic additives such as oatmeal and aloe are two ways to reduce the risk as well as help soothe and recover hands that have become dry, chapped and irritated.

Importance of Glove Size
Selecting proper sized gloves is essential to achieving proper protection. In general, gloves should cover the entire hand and wrist and feel snug without being too tight and allow full movement of the hand and fingers.

Like most things in life, one size does not fit all. Common disposable gloves range in size from extra small to extra-large. Be sure to follow the manufacturer’s guidance on how to properly fit each healthcare worker on your staff.

Steps to Take Now
• Review your facility’s hand hygiene training and education and be sure that proper use of gloves is adequately covered including demonstrations for proper donning and doffing technique
• Use direct observation not only for measuring hand hygiene compliance but proper glove use adherence, taking the time for interventional feedback when errors occur.
o Make the unit leadership responsible for proper glove use by all front line workers
• Foster a psychologically safe patient safety culture so that healthcare workers feel safe talking to anyone at any level about their proper use of gloves as well as hand hygiene

Proper glove use is often taken for granted, but attention to all of the details surrounding proper use – when, why and how to use them is essential for the prevention of HAIs and the overall safety of everyone one in your facility’s community.

Paul Alper, BA, led the launch of PURELL®, invented the first electronic hand hygiene monitoring system proven to reduce infections while improving behavior and eliminating costs and is now the VP Patient Safety Innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC.

Electronic Monitoring Systems: Essential Considerations

By Paul Alper

This column originally appeared in the January 2020 issue of Healthcare Hygiene magazine.

In my October column I said the following about electronic monitoring: “While a nascent category that is still in the early adopter phase, the migration from human direct observation or secret shoppers, to validated, automated, systems that constantly measure healthcare worker performance is here to stay. The scientific evidence is becoming clear that the future “gold standard” will be the combination of direct observation (DO) as a “coaching and obstacle identification tool” with electronic monitoring as the “measurement tool.”

I thought it might make sense to follow that column up with a checklist of essential consideration” should you and your organization decide to consider potential adoption in the near future and need a framework to create an RFP.

While there are systems with many more features to consider, these are the ones that are most important to think about.

For some, you will have to choose between options based on what would best suit your organization’s culture and your budget. Of course, whatever system you consider, there should be published outcomes evidence in support of adoption:

1. Numerator capture (how many HH events actually occurred). The system must aggregate BOTH soap and sanitizer hand hygiene events into an accurate numerator with a minimum 98 percent validated capture.

2. Denominator calculation (how many HH events should have occurred). You must choose: does the system base its HH rate on a) IN and OUT HH or b) Or the WHO 5 Moments for HH? In either case, you will want to see evidence on how the denominator is calculated and how it has been validated.

3. Reporting level. You will have to choose – does the system base its reporting on a) group/unit/department level hand hygiene rates or b) Individual healthcare worker HH rates?

4. Report/dashboard access. The system should provide intuitive, unambiguous reports and dashboards both via direct system access (such as by logging on to the system) and also via “push” or automatically generated reports via email.

5. C. diff room reporting. The system should provide the ability to see both soap- and sanitizer-event trending so that real time feedback can be given to staff as to whether or not they are complying with the typical C. diff protocol - the switch to soap and water hand hygiene from alcohol-based hand sanitizer which does not kill C. diff spores.

6. Type of Infrastructure. You must choose: a) is the system exclusively dedicated to hand hygiene compliance measurement (aka a stand-alone infrastructure) or b) one that works like an application (APP) with a new or previously installed real-time locating system (RTLS) infrastructure. RTLS systems will typically support multiple APPs such as nurse call, workflow assessment, people and equipment tracking etc. If you do go with option b, you will want to explore the level of hand HH expertise on the part of the RTLS/APP provider to be sure you’re comfortable that they have the requisite capability needed to support your organization’s enterprise wide adoption.

7. Behavior change support. Successful outcomes (for example sustainable compliance improvement, culture change and reduced infections) are going to be very much dependent on how you approach changing your culture from one that relies on Direct Observation for measurement (with its typical overstatement of real compliance rates by up to 300 percent) to one that relies on virtually real time data that will likely reveal a 30 percent to 40 percent compliance range when you first implement it.

You will want to verify that the system under consideration a) provides an evidence based behavior change framework, b) supports “psychological safety” – the ability for anyone to speak up in a professional and appropriate manner to colleagues (peers, superiors and subordinates) when hand hygiene does not occur when it should have and c) uses a positive and pro-active approach to dealing with data denial – this is the attitude by some on staff who will take the position that “my behavior is fine, it’s the data/system that’s inaccurate.”

8. Reminders to do HH at the point of care. You will have to decide if this a “must have,” “nice to have,” or “doesn’t matter to us” feature. This is accomplished, for example and depending on the system, by lights on the badge or dispenser, badge vibrations or by a voice reminder at the dispenser.

While I think there will be some exciting next-generation technologies introduced over the next couple of years that will leapfrog the current generation in terms of new and important features, accuracy, reliability, evidence in support of adoption and lower cost, I hope this proves helpful. Happy New Year!

Let me know what you think and please send me your specific hand hygiene challenges, frustrations and nagging problems – I’ll share ideas that might be of interest in this monthly column paul@next-levelstrategies.com. Connect with me on LinkedIn.

Paul Alper, BA, led the launch of PURELL®, invented the first electronic hand hygiene monitoring system proven to reduce infections while improving behavior and eliminating costs and is now the vice president of patient safety Innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC.

A Self-Assessment Tool: How Do Your Units Compare?

By Paul Alper

This column originally appeared in the December 2019 issue of Healthcare Hygiene magazine.

In last month’s column, (see page 34 in the November 2019 issue), I presented an evidence-based checklist for how to drive improvement with what you have; that is, regardless of how you are training, educating, measuring and giving feedback, the checklist provides a framework for driving improvement that has been shown to work when implemented with solid discipline.

This month, we will take that a step forward and provide a self-assessment tool for unit managers to use for the purpose of getting a solid baseline of where they stand today and then conducting routine self-assessment updates to measure improvement. Also included is a scoring guide so that infection preventionists (IPs) can compare their units and use the scoring to identify those units that need the most immediate coaching and feedback.

A Hand Hygiene Self-Assessment Tool

Note that point values for each response are included as part of the questions, but these should be removed when using as the tool with the units. Select the response that best describes your unit and its routine practices. Be honest and frank:

  1. Our unit is responsible for hand hygiene improvement and we are held accountable for meeting monthly/quarterly compliance growth targets.
  2. Strongly agree (10)
  3. Agree (7)
  4. Neither agree nor disagree (0)
  5. Disagree (0)
  6. Strongly disagree (0)

 

  1. Our unit leadership’s annual performance appraisal/bonus is tied in some way to meeting our hand hygiene improvement goals.
  2. Strongly A\agree (10)
  3. Agree (7)
  4. Neither agree nor disagree (0)
  5. Disagree (0)
  6. Strongly disagree (0)

 

  1. Our unit routinely identifies obstacles and barriers to hand hygiene performance and then puts in place action plans with the goal of eliminating them.
  2. Strongly agree (10)
  3. Agree (7)
  4. Neither agree nor disagree (0)
  5. Disagree (0)
  6. Strongly disagree (0)

 

  1. Our unit identifies the obstacles and barriers to hand hygiene compliance using:
  2. Direct observation (10)
  3. Group discussion (7)
  4. Other (1)

 

  1. We measure hand hygiene compliance and give feedback on performance:
  2. Daily or weekly (10)
  3. Monthly (7)
  4. Quarterly (5)
  5. Twice a year (1)
  6. Once a year (0)

 

  1. We celebrate when goals are achieved and identify what we will do differently when they are not.
  2. Strongly agree (10)
  3. Agree (7)
  4. Neither agree nor disagree (0)
  5. Disagree (0)
  6. Strongly disagree (0)

 

  1. When our goals are met, we then set new, higher goal.
  2. Strongly agree (10)
  3. Agree (7)
  4. Neither agree nor disagree (0)
  5. Disagree (0)
  6. Strongly disagree (0)

 

  1. Psychological safety is the way we work; anyone can speak up when there is risk of doing harm (such as not doing proper hand hygiene when it is indicated) without fear of retribution or other negative consequences.
  2. Strongly agree (10)
  3. Agree (7)
  4. Neither agree nor disagree (0)
  5. Disagree (0)
  6. Strongly disagree (0)

 

  1. Our organization’s senior leaders are responsible for modeling proper hand hygiene behavior and they are authentically engaged in our hand hygiene improvement efforts.
  2. Strongly agree (10)
  3. Agree (7)
  4. Neither agree nor disagree (0)
  5. Disagree (0)
  6. Strongly disagree (0)

Add 10 points if you stop a healthcare worker as a matter of standard practice when doing Direct Observation and they fail to perform hand hygiene, reminding them that they need to do so before providing care.

Scoring:

  • 100: Outstanding. Stay diligent and focused!
  • 80-99: Excellent, but still room for improvement.
  • 60-79: Good, but should make getting more than 80 a high priority for the next period.
  • Below 60: Poor. An opportunity to take your safety culture and hand hygiene practices up a notch. In need of coaching and feedback.

We are a long way from “getting hand hygiene right,” and this is just one framework that requires no investment other than time and that might make sense to consider in some adapted form. Feel free to modify and adapt in any way that aligns well with your culture and organization. A three- to four-unit pilot will help you see if it works for you.

Let me know what you think and please send me your specific hand hygiene challenges, frustrations and nagging problems – I’ll share any ideas that might be of interest and help in this monthly column paul@next-levelstrategies.com. Connect with me on LinkedIn.

Paul Alper, BA, led the launch of PURELL®, invented the first electronic hand hygiene monitoring system proven to reduce infections while improving behavior and eliminating costs and is now the vice president of patient safety innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC.

A Checklist to Drive Higher Compliance: Using Actionable Feedback to Drive Meaningful Change

By Paul Alper

This column originally appeared in the November 2019 issue of Healthcare Hygiene magazine.

I’m often asked a simple question by healthcare organizations: “We are not ready to change products or put in an electronic monitoring system yet – but we do want to use evidence-based practices to drive improvement with what we have in place today.”

Giving that some thought, I’ve put together a checklist based on an actionable feedback model that should help you make some changes in the way your organization thinks about hand hygiene compliance, its safety culture and the social fabric of your community. The checklist is based on insights and inspiration gained from some interesting studies1-3 basic PDSA cycles thinking and my 35-plus years of working in many aspects of hand hygiene and patient safety innovation.  Here’s the list:

  1. Make hand hygiene compliance a unit/ward/department responsibility. Hand hygiene compliance improvement should be a defined responsibility at the Unit level with the manager responsible and accountable for meeting growth targets.1 A great way to help ensure results is to tie this directly to the performance appraisal process.
  2. Identify the unit-specific barriers and obstacles to hand hygiene behavior plus action plans to remove Them. Each unit becomes responsible for identifying its unique barriers and obstacles to hand hygiene compliance and putting in place specific action plans to remove them.1 This might be best accomplished using Direct Observation to capture those unit specific behaviors that need to be modified.2
  3. Establish unit-specific improvement goals. Each unit is responsible for establishing its own realistic improvement goals monthly, which should be achievable assuming the action plans are carried out as assigned.1 The end game is that the barriers and obstacles identified can be continuously reduced or eliminated.
  4. Measure performance and give routine feedback consistently. Use the most robust approach to measurement available to your organization within the resource constraints (time, people, money) and provide performance feedback on a consistent basis (weekly to start, migrating to monthly, for example). Be sure to measure the behavior standard that you train staff on – in/out, WHO 5 Moments, CDC or a variant you’ve chosen for your organization. If the approach is electronic monitoring, ensure its accuracy has been validated. If you’re using direct observation, be sure you control for inter-rater reliability.

Note: A quick thought about the Secret Shopper concept: it seems difficult to comprehend why an organization would allow the practice of seeing potential risk (not cleaning hands) and then only marking down the missed hand hygiene event without intervening to ensure care is delivered with cleaned hands. It’s a troubling concept.

  1. Celebrate successes and then set a new, higher goal. When goals are not met, have the same barrier/obstacle/action plan conversation.

 

  1. Make psychological safety a cultural norm. Anyone at any level within the organization can remind anyone else regardless of their level or status when hand hygiene is missed in a professional, “out of patient view” way, without the fear of reprisal.
  2. Make leaders responsible for modeling and authentic engagement. C-suite leaders must know about, support and model the behaviors expected across the entire staff community.

In one of the studies on which the checklist is based on, Childers, et al. used this basic framework at Memorial Sloan-Kettering Cancer Center, and a baseline rate of hand hygiene of 60-70 percent increased to 97 percent as measured with direct observation.1

Kelly, et al. also used a similar approach with electronic monitoring for measurement at the Greenville Memorial Hospital and achieved a 25 percent increase in hand hygiene compliance with a 43 percent reduction in MRSA infections.3

Steed, et al. also used a variant at the same organization combining modified use of the Joint Commission’s Targeted Solutions Tool with electronic monitoring for measurement and achieved aggregate performance increase on four test units of 23.5 percent within six months that was statistically significant.2

To be clear, we are a long way from “getting hand hygiene right” – this is just one framework that requires no investment other than time that might make sense to consider in some adapted embodiment that aligns well with your culture and organization. A three- to four-unit pilot will help you see if it works for you.

Let me know what you think and please send me your specific hand hygiene challenges, frustrations and nagging problems – I’ll share any ideas that might be of interest and help in this monthly column paul@next-levelstrategies.com.

Paul Alper, BA, led the launch of PURELL®, invented the first electronic hand hygiene monitoring system proven to reduce infections while improving behavior and eliminating costs, and is now the vice president of patient safety innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC.

References:

  1. Son C, Chuck T, et al. Practically speaking: Rethinking hand hygiene improvement programs in health care settings. Am J Infect Control. 39(9), 716–724. 2011.
  2. Kelly W, Blackhurst D, et al. Use of the Targeted Solutions Tool and Electronic Monitoring to Improve Hand Hygiene Compliance. Paper Presented at the 2016 SHEA Conference.
  3. Kelly W, Blackhurst D, McAtee W and Steed C. Electronic Hand Hygiene Monitoring as a Tool for Reducing Healthcare-Associated Methicillin-Resistant Staphylococcus aureus Infection. Am J Infect Control. 44(8), 956-957. 2016.

Hand Hygiene: The Problem We Only Think We Solved

By Paul Alper, BA

Editor's note: This column originally appeared in the October 2019 issue of Healthcare Hygiene magazine.

All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as self-evident. – Arthur Schopenhauer, philosopher

What would Ignaz Semmelweis think if he were able to observe the state of healthcare hand hygiene today? The Austrian physician who, while working at Vienna General Hospital’s first obstetrical clinic, first proved the link between hand hygiene (disinfection with a chlorinated lime solution) and the reduction of infections (child bed fever) in 1847, might wonder why so much, yet so little, progress has taken place in the 172 years since his discovery. In spite of the innovations highlighted below, global hand hygiene compliance rates remain no greater than 50 percent, and patients are still getting infections from pathogens such as methicillin-resistant Staphylococcus aureus (MRSA), methicillin-susceptible Staphylococcus aureus (MSSA), vancomycin-resistant Enterococcus (VRE), associated with transmission by unclean hands.

Semmelweis certainly experienced the first two stages of truth as Schopenhauer observed them. Many contemporary doctors were offended at the notion they should wash their hands, and not only ridiculed him, but also shunned him. Acceptance of the benefits of hand hygiene as “self-evident” took the work of Louis Pasteur and Joseph Lister and occurred years after Semmelweis’s death.

Since that seminal work more than 100 years ago, there have been only three major, disruptive changes in healthcare hand hygiene.

1. “Bag in a Box” (BIB) soap technology in the 1970s:This invention introduced sealed, sanitary soap cartridge refills with a proprietary valve that only fit compatible, proprietary dispensers. The inner workings of the dispenser were engineered to accept the BIB refill. Think “razor” (the dispenser) and “disposable razor blade” (bag in a box refill) business model. Pushing or pulling the dispensing bar activated a valve that allowed the soap to flow from the dispenser. This sanitary approach eliminated the use of gallons that could fill any bulk reservoir soap dispenser by simply pouring in the liquid.

Sani Fresh® invented the original BIB with a “pull” style dispenser, and eventually Kimberly-Clark purchased that company. GOJO accelerated this trend by entering into the market with its “push” style dispenser. Of note is that the bulk soap sold in the range of $3 to $5 per gallon, but with BIB refills costing about $2 to $3 per 800 ml refill, the price of soap went up to more than $10 to $12 per gallon. Mocked as ridiculously expensive by purchasing departments, the Sani Fresh team pushed its sanitary benefits with clinical decision makers and today, sealed soap and sanitizer refills are the standard of care in healthcare, with the use of bulk, pour and fill style dispensers virtually non-existent.

2. Alcohol Hand Sanitizer: “We’ll never use that stuff; we wash with soap and water,” was the typical response from infection preventionists in the late 1980s and 1990s when introduced to alcohol-based hand sanitizers (or hand disinfectants and handrubs, as they were also known largely in Europe). The idea of no longer using soap and water was ridiculed by infection preventionists! It was a violation of everything they took to be self-evident when it came to soap and water handwashing.

The widespread use of alcohol for hand disinfecting began in the 1970s in Europe but didn’t come into serious use in U.S. hospitals and healthcare facilities until the late 1980s when PURELL® and other brands were first introduced into institutional use. Once healthcare workers realized how much faster and efficient it was to clean hands with an alcohol hand sanitizer, objections went away, and institutional use accelerated. Use of alcohol hand sanitizer further increased with the retail launch of PURELL and the first TV ads that ran in 1997, which led to its use becoming a societal norm and part of the popular culture. The CDC’s updated Healthcare Hand Hygiene Guideline in 2002 cemented alcohol based hand sanitizers as the absolute standard of care and the primary way healthcare workers sanitized their hands, the exception being when hands are visibly soiled or recently exposed to bodily fluids or spores at which point they need to be washed with soap and water.

3. Electronic monitoring for hand hygiene compliance. Hand hygiene compliance, whether a worker properly performs hand hygiene when indicated, has typically been measured by direct observers attempting to watch healthcare workers. This practice mimics that of “secret shoppers,” whereby the observers try to remain unknown to the workers and attempt to discreetly record whether they do hand hygiene when indicated. This system is inherently flawed however, because if a secret shopper observes the lack of hand hygiene and does not intervene, they are enabling risk of harm to the patient.

The problem is that healthcare workers—no matter how discreet the secret shopper is—know when they are being observed and behave differently. This phenomenon is known as the Hawthorne Effect: people behave differently when they know they are being watched. Further compounding the problem is that direct observation typically only captures less than 1 percent of all hand hygiene opportunities, which is not a statistically valid sample. The result is that compliance rates are dramatically overstated – typically by up to 300 percent based on studies,1 and this means that compliance measured as 90 percent with direct observation may in reality be only 30 percent.

A number of electronic systems to measure compliance were launched during the 2010s. These systems eliminated many of the shortcomings of direct observation, such as the Hawthorne Effect and small sample size, since electronics can capture nearly 100 percent of hand hygiene events at all times. Die-hard defenders of direct observation certainly ridicule and oppose the technology’s adoption, citing direct observation as the “gold standard” (which it was until this more accurate, reliable and effective technology category came along). While a nascent category that is still in the early adopter phase, the migration from human direct observation or secret shoppers to validated, automated, systems that constantly measure healthcare worker performance is here to stay. The scientific evidence is becoming clear that the future “gold standard” will be the combination of direct observation as a “coaching and obstacle identification tool” with electronic monitoring as the measurement tool. 2-3 Further, overstated rates, such as those proven by Srigley et al, enable a false sense of complacency that unacceptably puts patients at risk. Given the ability to mitigate the risk of patient harm with this new technology, it is likely that it will overcome the ridicule and opposition phases and move towards widespread acceptance.

And, the market is moving, too. For instance, a growing number of progressive health systems have gone with full commercial implementation (the Greenville Health System, now Prisma Health, in South Carolina and the Atlantic Health System in New Jersey among them). Further, most of the group purchasing organizations that have added the category of e-monitoring and studies have demonstrated its clinical and economic benefits.4

Whether e-monitoring will become the standard of care will depend on whether a system that is simple, affordable and overcomes some of the inherent implementation and cultural barriers in currently available systems is developed – and there is no reason why that shouldn’t happen.

The Future of Hand Hygiene
Despite these innovations, healthcare hand hygiene still has a lot of room for improvement, given that compliance is only about half of what it should be. For instance, healthcare workers who must clean their hands 40 to 50 times a shift should be confident that the products they use actually improve skin health, but products they find drying remain a barrier.

Additionally, healthcare hand hygiene should be multidisciplinary, drawing from fields such as human factors engineering, behavioral science, and data science to propel the next innovations.

An inventory of the prospective attributes of that best in class, next generation hand hygiene approach might look like this:
• Hand hygiene products (soaps, sanitizers and lotions) that are “skin friendly,” with the lowest possible risk of healthcare worker intolerance
• Dispensers that are not only able to measure compliance, but indicate product levels and any performance issues, ensuring product is always available and empty dispensers are a thing of the past
• Training and educational tools based on sound behavioral science that drive high levels of sustainable performance improvement with requisite culture change
• Affordable, validated methodology for measuring compliance accurately and reliably, with feedback approaches that foster psychological safety (everyone feels safe reminding anyone to do hand hygiene when an opportunity is missed) and the development of a just safety culture
• Predictive analytics that forecast hot spots (risk of low compliance and/or hospital acquired infection transmission) before they occur
• And what roles will artificial intelligence, learning systems and the Internet of Things play? Probably significant ones.

One would hope that we are about to put all the learning and capabilities to work and that by the 200th anniversary of Semmelweis’s seminal research, proper hand hygiene will be a habit for every healthcare worker around the world.

Whatever the next disruptive innovation brings, it is time to get hand hygiene right. We live in an age of value-based healthcare, and variability of performance should not and cannot be tolerated. It will take early adopter pioneers, willing to accept the ridicule, knowing that what they are doing represents the truth for themselves and those for which they care.

Paul Alper led the launch of GOJO’s PROVON® and PURELL® brands in the late 1980s and 1990s. He invented and was highly involved in the clinical research behind the first hand-hygiene electronic monitoring system. He is now the vice president of patient safety Innovation for Medline Industries, Inc. through an exclusive engagement with his consulting practice, Next Level Strategies, LLC.

References:
1. Srigley JA, Furness CD, Baker GR and Gardam M. Quantification of the Hawthorne
Effect in Hand Hygiene Compliance Monitoring Using an Electronic Monitoring System: a
Retrospective Cohort Study. BMJ Qual Saf. 23, 974-80. 2014.
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