ISSUE: Compliance with hand hygiene guidelines among healthcare workers is the single most important intervention in the reduction of facility acquired infections and the one most frequently omitted. Alcohol-based products were made readily available in each patient room in 1999 and interviews with staff members identified knowledge deficit of the importance of hand hygiene was not an issue yet compliance remained low.

PROJECT: Infection Control proposed that monitoring of compliance be conducted in individual care/service departments by the Managers or Designee to foster buy-in. The approach of promoting a culture of safety related to hand hygiene was used for anyone providing care or a service on the particular unit.

Initially, a data collection tool with 15 indicators measuring all components of hand hygiene was utilized. This proved to be labor intensive and yielded poor return rates. After much discussion with patient care managers and multiple other disciplines, a simple to use data collection tool with two indicators was developed. This tool was easy to use and data submission greatly improved, yielding 440-450 total observations per month.

Leadership support of the project was instrumental in the program success. Conducting discussion of the project at Management Meetings and proposing hand hygiene compliance as a “Red Rule”, which required Hospital Board approval, validated the importance. A “Red Rule” is determined by the organization to be of such importance that failure to comply could result in disciplinary action, but through verbal prompts and peer coaching, failure should not occur.

Involvement of Medical Staff was solicited through inclusion in random observations, prompts, and discussion at physician attended meetings. The hand hygiene project outline and monthly results were added to the online Medical Staff Annual Infection Control Update, required for re-credentialing. Physician results are posted monthly in the physician lounge.

Hand hygiene posters, storyboards and verbal prompts were implemented. Monthly data collection was and continues to be conducted and submitted to Infection Control with rapid feedback provided by department and discipline via intranet allowing departments to benchmark with one another.

RESULTS: Hand hygiene performed upon entering the room: at or above 90% for the past 5 months, 3 of which were above 95%

Hand hygiene performed prior to exiting the room: at or above 90% for the past 8 months, 5 of which were above 95%.

Increased alcohol-based product utilization per 1000 patient days per quarter correlated with the increase in compliance.

LESSONS LEARNED: While competition and peer pressure are great motivators, a successful hand hygiene program also requires continuous feedback, verbal prompts, interdisciplinary collaboration and a non-punitive culture supported by leadership.