Best practices for elevating hand hygiene compliance above 90
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This document outlines a patient safety program called Clean Saves that aims to increase hand hygiene compliance and reduce healthcare-associated infections in hospitals. It discusses establishing a baseline, gaining commitment through motivational interviews and champions, modeling behaviors, and modifying behavior through education, observations, feedback and celebrating successes. The goal is to implement evidence-based practices to establish a culture of hand hygiene and infection prevention.
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Best practices for elevating hand hygiene compliance above 90
- 1. Clean Saves A Patient Safety Program for Washington Hospitals Joyce Winter, RN
- 2. Clean Saves Best practices for elevating hand hygiene compliance above 90% for longer than 12 month periods
- 3. Hand Hygiene Compliance Health Care Associated Infections Worried? Hand Hygiene Compliance fades with time
- 5. What to do? Evidence Based Practice ↑ Hand Hygiene Compliance ↓ Health Care Associated Infections
- 6. Join in! Illinois Masonic Medical Center The Heart Hospital Baylor Plano Vanderbilt University Medical Center Memorial Sloan- Kettering Cancer Center St. Christopher's Hospital for Children Cincinnati Children’s Hospital
- 7. Culture Change Baseline Data Motivational Interviews Inter- disciplinary Champions Education External Connections Observations Feedback ↑ HHC ↓ Fewer HCAIs ↑Lives & Money Saved
- 9. Compelling Story Role Modeling Capability Building Reinforcing Culture Change Gain Commitment Model Behaviors Modify Behavior Improve Skills Keller, S., & Aiken, C. (2009). The inconvenient truth about change management. McKinsey Quarterly.
- 10. Cornerstone #1Keller, S., & Aiken, C. (2009). The inconvenient truth about change management. McKinsey Quarterly. Spin a Compelling Story Motivational interviewing + / - Behavioral motivators Gain Commitment
- 11. Cornerstone #2Keller, S., & Aiken, C. (2009). The inconvenient truth about change management. McKinsey Quarterly. • Compliance not Commitment • False Reflections “Yes, sir.” Model the Behavior Model Behaviors
- 12. Reinforce Change ↑Surprise ↓Money Cornerstone #3Keller, S., & Aiken, C. (2009). The inconvenient truth about change management. McKinsey Quarterly. Modify Behaviors
- 13. Cornerstone #4Keller, S., & Aiken, C. (2009). The inconvenient truth about change management. McKinsey Quarterly. Mindsets – build BELIEF Field & Forum – overcome BARRIERS Capability Building Build Skills
- 14. Changing cultureGreenhalgh, T., Rober, G., MacFarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: Systematic review. The Milbank Quarterly,82(4), 581-629. Retrieved May 2013.
- 15. Culture Change Baseline Data Motivational Interviews Inter- disciplinary Champions Education External Connections Observations Feedback ↑ HHC ↓ Fewer HCAIs ↑Lives & Money Saved
- 16. WHO’s Hand Hygiene Self Assessment Framework Baseline Hand Hygiene Compliance Rates Baseline Data Modify Behavior
- 17. Gain Commitment MotivationalInterviews create system tension, a compelling story, complexity, innovation-system fit, negotiation amongst adopters, and perceived relative advantage anticipate implications (i.e. task issues) build capabilities and confidence
- 18. Interdisciplinary Engagement • Vertical integration • Hand Hygiene Council • Covert observers Gain Commitment
- 19. Champions • Opinion leaders • Multidisciplinary • Model hand hygiene AND receiving feedback Gain Commitment
- 21. Personnel 5 Moments Less than you think Peer feedback Less recontamination Fewer gloves Patients Why it’s important How to get clean Asking health care workers Education (cont.) Improve Skills
- 22. External Connections •Local school contests •Media interaction Gain Commitment
- 23. Modify Behavior • Varies with unit performance levels Overt • Gold Standard Covert Observations
- 24. Hand Held Device Data Collection •iScrub •Germ Patrol Modify Behavior
- 25. Behavioral Feedback Compliance • Timely • Individualized • Competitive • Customizable Continual • Screensaver • Posters Correcting • Professional peer feedback • Violation letters Modify Behavior
- 26. Remember If they can do it, we can too. Harness change theory. It’s a team effort.
Editor's Notes
- There is much supporting evidence linking HHC and HCAI. However there are two studies that question it.
- As we know HCAIs affect many people and have numerous ramifications.
- The purpose of this PowerPoint is to discuss EBP program elements that will increase HHC and consequently decrease HCAI.
- These six hospitals elevated HHC above 90% for 12 months. This presentation is derived from identifying common and/or outstanding features.
- 8 Program elements revolving around culture change were identified. However, they all relate to four key areas of impact, which will be examined first.
- These are gaining commitment, modeling behaviors, improving skills and modifying behavior. And these four areas closely correspond with the four cornerstones of change management identified by the internationally renowned and imminently successful consulting company McKinsey & Co.
- McKinsey & Co. wrote an article called The Inconvenient Truth of Change Management in which they explained that typical change management programs only succeed approximately 30% of the time. They use these four cornerstones to obtain much more consistent results. They gain commitment with a compelling story. When I say story, I’m talking about the self talk people use to understand why they do what they do. In other words, the story people tell themselves about the change. Modeling behaviors and role modeling are synonymous… it is about setting a good example Reinforcing is how we modify behaviors so as to sustain the change Improving skills or capability building is about empowering those changing.
- The stakeholders need to know why they should change their behaviors and for that they need a compelling story. Remember these three fundamentals when spinning that story. Motivational interviewing - Utilize interviewing to discover what they think is the story because when employees help form the story, it typically garners approximately 5 times greater commitment to change. + / - Constantly harping on employees to fix the problem can lead to unproductive fatigue and resistance. Capturing opportunities is great for generating excitement and enthusiasm, but lead to risky practices. Behavioral motivators And not all people are motivated the same way. We know of five behavioral motivators. Ideally, the compelling story will appeal to each. Some people really want to have a positive societal impact Others want to feel they benefit the customer Shareholder primacy refers to the concept that a company’ first duty is to be profitable and benefit the company and shareholder Other people want to feel valued by their work peers Some are the what’s in it for the me type
- The tendency for subordinates to say Yes, sir leads to compliance and not commitment. Compliance tends to dwindle over time while commitment can be culture changing. It’s ironic that we call it HHC when instead we should be seeking HH Commitment.
- Surprise is better than money. Some companies make the mistake of throwing money at a problem because they are under the misconception that money and results have a linear relationship. Methods that use more surprise and less money gain benefits disproportionate to spending. For example, some companies have chosen incentive packages that affect pay scale. It’s more effective to identify a most improved unit and then surprise them with a pizza party. Example triggers: most improved unit most nominated by peers as vocal champion most nominated by peers as having given professional feedback most often identified in post care patient surveys as having explained and modeled HH Example rewards: pizza party for most improved unit designated parking spot foot massage gift certificate for online nursing store show up to work and it’s a pamper day
- Build Skills & BELIEF It is important to meld mindsets because they drive behaviors. Research shows that people need believe to in their ability to make the change as much as to believe in the importance of that change. People can believe a change is necessary to their survival, but if they don’t believe in their capability then they won’t try. Imagine cigarette smokers who know they are shortening their life but aren’t willing to try cessation programs because they don’t believe they can do it. Motivational interviewing is a technique that allows interviewees to convince themselves they are capable. Further, it is important to overcome barriers to implementation. Using the “field and forum” approach can help. McKinsey & Co. describe field and forum as where “classroom training is spread over a series of learning forums, and fieldwork is assigned in between”. Fieldwork assignments link directly to the day jobs of participants, requiring them to put into practice new mindsets and skills in ways that are “hardwired” into the things for which they are accountable.
- This is a model of organizational diffusion of change that is health service specific. Key concepts: Associated environmental factors include relative advantage, negotiation amongst adopters, compatibility, complexity, trialability, observability, reinvention, soft peripheries, risk, task issues, required knowledge for execution, and augmentation/support. Affecting aspects of the adopters included personality traits, motivation, meaning, and decision type (related to adoption), and adoption concerns. Additional diffusion influences included social network structure (i.e. informal/formal, vertical/horizontal), group homophily, opinion leaders/champions, links to outside world, and a formal dissemination program. Examining this model in depth would be it’s own presentation; please remember it as a reference supporting why proposed interventions are likely to work.
- Now that four foundational areas have been established, let’s examine the eight interventions identified at the start of the
- It’s essential to have baseline data to assess program efficacy, which will be used in the ongoing behavior modification. HHSAF The WHO has created a 30 min self assessment survey for infection control leaders to fill out about their facility. It helps identify fundamental areas that may need improvement. Each section of questions is accompanied by targeted tools that can be used to address those specific areas. I know there is a lot of information out there and the WHO’s Guideline can be overwhelming. It’s so long they have a guide to the guide. But this is only five pages and is designed to be completed in approximately 30 minutes. Baseline HHC rates need to be established.
- Motivational interviews will provide an opportunity to teach, inspire and engage staff. They can increase the probability of diffusion adoption and commitment because they access these elements identified in Greenhalgh, et al.’s model. And adopters are five times more likely to commit to a program they helped to develop (Keller & Aiken, 2009). The commitment gained, as opposed to compliance, will sustain program efficacy (Lencioni as cited by Williams, 2006). Further, a key component of behavioral change is the subject’s belief in their ability to perform as desired (Rollnick, 2005). These interviews offer an opportunity to convince staff of program viability and gain stakeholder buy-in.
- A common theme in successful HHC efforts is involvement from everyone. Interdisciplinary formal leadership must be seen as supportive. Opinion leaders from multiple disciplines need to be vocally supportive. A formal HH Council that is vertically integrated and multidisciplinary is a method of accomplishing these objectives. The council should be augmented by a cadre of covert observers. The first round of covert observers should be pulled from management positions. Observing other units and other disciplines will promote understanding and cooperation. And they may see operations methods they wish to incorporate. When these observers have been mostly outed then the second round should pull from volunteers. Every effort should be made to keep the volunteer pool healthy and happy so as to maintain anonymity. Should this wear out, a 3rd round should be derived from hiring “secret shoppers”.
- Ethics Committee needs to be vertically integrated and interdisciplinary. Further, HH champions should be chosen that are opinion leaders. Typically, they will not be new hires and they may or may not be in managerial positions. Both groups need to model two desired behaviors. In addition to HH Commitment, they need to model receptiveness to peer feedback. Teaching staff how to give and receive professional peer feedback will lead to a culture change with ramifications beyond HHC. Tom Talbot of Vanderbilt found this worked well for them. They call it the cup of coffee technique. And they have found it makes people more likely to speak up about other things than HHC. Leaders often mistake how well they are modeling the desired change. They need concrete 360-degree behavioral feedback (multi-rater appraisals or multi-source feedback) to sensitize organizational principals to needed change and that will make them effective champions.
- Ideally, education should be interactive. Further, recipients will be able to immediately apply what they have learned and then after trialing it talk about it in order to hardwire the new behaviors.
- The 5 Moments need repetition just like we repeat RACE HCWs need to know they clean less often then they realize. This will make them more receptive to feedback. They need to know how to give and receive feedback Australia wrote two sample protocols that minimize recontamination and reduce the number of HH opportunities HCWs use gloves inappropriately and that is not safe for the patient and it spends money on gloves. Patients need to know why it’s important They need to know how to get clean And we need them to be comfortable asking HCWs if they have washed. However, it is dangerous to put all the burden on them as some cultures will never be comfortable with this concept and this will exacerbate the marginalization of the vulnerable.
- External connections increase buy-in. While posters in and of themselves have been shown to be unsuccessful at sustaining HHC, a contest involving local schools, where staff may themselves have students, creates the desired external connections. And local media may be willing to do a series of opinion pieces of the campaign. The hospital’s medial liaison should be able to convey the story in a way that is attention capturing and favorable to the hospital. The pitch might be, although our HHC rates are good, we want to be among the top in the nation and here’s how we’re doing it.
- Observations may be either overt or covert. Overt observations elicit the Hawthorne Effect , which varies with unit performance. So, if a unit’s pride in their performance declines, there’s a good chance their HHC will, too. The best practice recommendation is to use covert teams who observe areas outside their own unit. An additional benefit is cross disciplinary understanding. However, even the best efforts by staff to be clandestine will wear thin. At this time, a transition to secret shoppers is appropriate.
- This type of system saves employee hours, is easy to transport, and can be used to conduct covert observations. Further, it offers the opportunity for near real time feedback. Two operating systems present free applications designed to collect HHC observation data: Apple and Android. They offer iScrub and GermPatrol, respectively. Both generate CSV files that can be emailed and then easily converted to Excel files. From Excel, charts may be created. This allows expedient, visual statistics on HHC categorized by unit or by role. GermPatrol additionally offers a field in which to put the staff member’s name and data on false nail compliance.
- Compliance feedback should be Timely, Individualized, Competitive, and Customizable. Although serving staff monthly compliance feedback has been useful, weekly emails would be better. Additionally, the IT department could set up unit-specific compliance rates that are accessible by employees from secured terminals or that employees can choose to have emailed to them at intervals of their choice. Having unity and discipline specific feedback will access competitive motivation. Posters, as previously mentioned, will serve as constant reminders. These and the screensaver should incorporate images of eyes to promote honorable behavior because images of eyes have been shown to promote ethical behavior. Staff needs to be able to give and receive professional feedback. Staff that is non-compliant should receive violation letters with escalating consequences that are non-punitive with regard to compensation or job security. Each violation should be met with counseling; however, every third tier has a consequences: at 3 they give an in-service, at 6 they write a research paper that is published in the monthly newsletter, and at 9 they meet with the CNO and CEO.