3 Reasons Direct Observation Costs More Than You Think

By Clean Hands - Safe Hands

Direct observation of hand hygiene seems like it should be the most cost-effective strategy to monitor, report, and improve staff adherence to hand hygiene protocols. After all, pen and paper (or WiFi-connected tablets and smartphones) are cheap and plentiful – especially compared to sophisticated electronic hand hygiene monitoring and reminder systems.

Dig deeper, though, and the hidden costs of direct observation may surprise you.

Leapfrog’s Direct Observation Requirements for Hand Hygiene

According to the reporting standards established by The Leapfrog Group for the Leapfrog Hospital Survey and Leapfrog Ambulatory Surgery Center Survey, healthcare systems that use direct observation to assess hand hygiene must report 200 observations, or 1.7% of all possible hand hygiene opportunities per unit per month, and those observations must be conducted across all days of the week and all shifts proportional to individuals who interact with patients.

In other words, a hospital that has 250 beds spread across 8 units will need to observe and report 1600 hand hygiene observations per month (200 observations X 8 units = 1600 observations). 

Hidden Cost #1: Staff Time & Compensation

Hitting 1600 observations will require a large investment of staff time – significantly more than most healthcare facilities have currently allocated to direct observation. A 2018 JAMA Network Open article that examined direct observation practices at 10 acute care hospitals found that most sites aimed to complete 10-30 direct observations per unit per month. That’s only 5-15% of the number of observations required by Leapfrog, yet the hospitals had difficulty finding staff to serve as direct observers.

To control costs, many healthcare facilities ask staff members to volunteer as direct observers in addition to their patient care responsibilities. But according to the JAMA Network Open article, that approach doesn’t work particularly well. At least one hospital “struggled with high turnover rate among voluntary staff, which necessitated an ongoing need to train new staff volunteers,” while “other hospitals saw diminishing returns with volunteer recruitment efforts.” A site that eliminated financial incentives for staff who served as direct observers noted a “detrimental effect on staff members’ willingness to volunteer as auditors.”

Direct observation programs create friction between frontline staff and infection prevention teams. This is further exacerbated by the requirement from Leapfrog where the staff have to immediately intervene every time they see someone not perform hand hygiene. Frontline staff do not feel supported, and they believe that observers don’t always see completed incidences of hand hygiene. An adversarial climate is not conducive to staff retention. Instead, staff members who feel their value to the organization is based upon (possibly inaccurately recorded) metrics are likely to pursue employment elsewhere.  

In theory you might be able to stretch existing staff to cover the increased burden, but now is a particularly dangerous time to do so. According to the International Council of Nurses and Medscape’s 2020 Nurse Career Satisfaction Survey, nurses’ stress levels rose significantly during the COVID-19 pandemic, and nurses and other healthcare workers are reporting high levels of burnout. In addition, many organizations have experienced major reductions in the workforce and furloughs. Most health systems are already stretching their front line staff too thin as it is. Adding more responsibilities to their plate will likely exacerbate dissatisfaction and fuel staff turnover.

Hidden Cost #2: Hiring Costs

Realistically, most organizations won’t be able to effectively meet the standards with current staff, and will have to hire additional staff to perform direct observation that is needed to meet the new standards. Let’s take a look at the financial investment needed for an average 250-bed hospital with 8 different clinical units. Let’s assume the same 1,600 observations per month above as a starting point and calculate the time needed to perform these observations. 

According to “Hand Hygiene: A Handbook for Medical Professionals,” it takes an average of 10 minutes to record a hand hygiene operation. This may seem like a long time, but it’s both the published average and what we’ve seen historically based on our system validation. 

 Let’s look at the math:

10 minutes X 1600 observations per month = 16,000 minutes, or 267 hours per month to collect necessary hand hygiene data for a 250-bed hospital. 

This equates to 1.7 FTEs that will do nothing but perform hand hygiene observations. Another thing to keep in mind is that these individuals must perform observations on all days of the week and all shifts. This requirement is surprisingly the greatest challenge for most organizations to hit. 

Now let’s take a look at the costs associated with meeting these standards. The most cost effective way to meet these standards would be to employ technicians to perform the observations. 

267 hours X $40/hour (the median RN wage, according to the Bureau of Labor Statistics) = $10,680 per month or over $128,000 per year for direct observation only

This correlates to over $80,000 for just the time it takes to record hand hygiene. Additional time is needed to intervene when hand hygiene practice falls short of expectations, to train and validate the observers, and to report and share collected data. This estimate also doesn’t include staff benefits.

Hidden Cost #3: Loss of Revenue

Whether you hire additional staff to conduct hand hygiene monitoring or end up having to replace staff who left, you’ll likely incur hiring costs related to direct observation — but these are not the only costs associated with poor hand hygiene. Healthcare facilities that don’t meet the hand hygiene standards outlined by The Leapfrog Group will be rated more poorly than facilities that do – which could result in a loss of revenue. Consumers are less likely to choose a hospital or ambulatory surgery center with poor hand hygiene and patient safety scores.

Additionally, hand hygiene is linked to healthcare associated infections (HAIs). As part of the move toward value-based care, healthcare facilities that rank in the bottom 25% with respect to hospital-acquired conditions (HACs, including HAIs) are subject to CMS payment reduction

A Smarter Alternative to Direct Observation

A January 2021 BMC Infectious Diseases article reported that an electronic hand hygiene system that includes real-time reminders and feedback, like the SwipeSense system, “has a more noticeable effect on promoting hand hygiene” than direct observation, or electronic systems that do not include real-time feedback and reminders.

The bottom line: an electronic hand hygiene reminder system is an investment in the financial well-being of your healthcare organization. It’s also an easier and less expensive way to meet Leapfrog’s hand-hygiene standards, and is much more effective than direct observation. The leading systems combine real-time feedback and predictive analytics to do far more than simply monitor hand hygiene. These systems consistently improve hand hygiene, which leads to a reduction in HAIs. This is the primary reason why Leapfrog has expressed a strong desire to use electronic systems. 


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