Healthcare Business Today: The Joint Commission’s New Hand Hygiene Standards Could Hit You Where It Hurts

February 3, 2018, by Dr. Chris Hermann, Founder and CEO, Clean Hands – Safe Hands

In case you missed it, the Joint Commission recently made a drastic change to its hand hygiene standards. Previously, hospitals were simply required to implement a hand hygiene program and improve results over time. However, as of January 1, 2018, if a Joint Commission surveyor sees one clinician fail to clean his or her hands one time, the hospital will be cited with a deficiency resulting in a Requirement for Improvement (RFI).

This policy change could have far-reaching ramifications for hospitals in three areas.

1. Potential Loss of Accreditation. The Joint Commission won’t accredit organizations until the RFI is resolved. This entails submitting an Evidence of Standards Compliance (ESC) within 60 days to show that you’re now meeting the standard. If the ESC is accepted and there are no other compliance issues, your hospital will likely be accredited. Some hospitals may receive an “Accreditation with Follow-up Survey” designation, with the second survey occurring between 30 days and six months after the first survey. If there are additional significant issues, a “Preliminary Denial of Accreditation” or “Denial of Accreditation” may be imposed.
2. Financial Cost. Joint Commission surveys are an expense and paying for a second survey after a citation isn’t how any hospital would choose to spend its budget. More importantly, a loss of accreditation and battered reputation could lead to fewer patients and lower income. Higher expenses and lower revenue combined are a double whammy on the bottom line.
3. Organizational Disruption from a Follow-Up Survey. Let’s face it – a second accreditation visit is a huge disruption to the daily operations of a hospital. When the surveyors show up, all activity is disrupted and key hospital initiatives get sidetracked. Do you really want to risk a follow-up survey when there’s a way to prevent it?

Clearly, it’s in every healthcare organization’s best interest to ensure hand hygiene performance is as high as possible. The best way to do this is with an electronic hand hygiene reminder system. These systems monitor virtually every hand hygiene opportunity. They also remind clinicians to sanitize when they forget. In comparison, direct observation typically captures less than 1 percent of all opportunities and does not serve to remind nor change behavior in the moment.

If you’re using direct observation and you’re receiving hand hygiene data that reports performance rates of 90 percent or more, you shouldn’t trust that data. The Hawthorne Effect (see footnotes 1,2) is a well-documented phenomenon whereby clinicians who know they’re being watched will typically triple their hand cleaning activity. So a documented rate of 90 percent is typically closer to 30 percent in reality. And don’t fool yourself that your staff doesn’t know they’re being watched – they do. It doesn’t take long to figure out that the person with the clipboard hanging out in the hallway is the proverbial “secret shopper.”

Electronic hand hygiene reminder systems can significantly increase hand hygiene performance. And just the fact that you’re using one signals to The Joint Commission that you take hand hygiene and patient safety seriously.

We recently had a hospital partner receive a special commendation from The Joint Commission for being a leader in hand hygiene because they’re using our electronic hand hygiene reminder system. In addition, the surveyor suggested that the hospital submit this information for The Joint Commission to feature on its website as a best practice.

Why has The Joint Commission upgraded its standards? Because it is correctly associating hand hygiene with patient safety. More than 40 peer-reviewed studies have directly linked hand hygiene with a reduction in Hospital Acquired Infections (HAIs). The Joint Commission knows that the one clinician they see failing to clean his or her hands may be the person carrying C. diff or MRSA from one patient room to another. After years of providing hospitals with direction on this, the Joint Commission is expressing zero tolerance for these types of preventable infections.

Patient safety is a priority at all hospitals. By using an electronic hand hygiene reminder system, you can increase hand hygiene, often doubling it or more. You can also reduce HAIs – we’ve seen reductions range from 75 – 80 percent within six months. And by changing clinicians’ hand hygiene behavior, you can avoid a Joint Commission citation, keep your accreditation, reduce organizational disruption and avoid a hit to your bottom line.

(Click here to read this article on Healthcare Business Today.)

[1] Srigley, J.A., et al., Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf, 2014. 23(12): p. 974-80.

[2] Hagel, S., et al., Quantifying the Hawthorne Effect in Hand Hygiene Compliance Through Comparing Direct Observation With Automated Hand Hygiene Monitoring. Infect Control Hosp Epidemiol, 2015. 36(8): p. 957-62.