Infection Control Today: Responding to the Joint Commission’s New Hand Hygiene Standards

By Clean Hands - Safe Hands PhD

As of Jan. 1, if a Joint Commission surveyor sees one clinician fail to clean their hands one time, your hospital will be cited. Just one time – let that sink in.

With this new standard, the Joint Commission takes a giant step toward recognizing that hand hygiene plays a critically important part in reducing healthcare-associated infections (HAIs) and increasing patient safety. Yet, most hospitals still struggle with hand hygiene. There are roughly 1.7 million HAIs in the U.S. annually, causing nearly 100,000 preventable deaths and an estimated $20 billion in healthcare costs.

Given the Joint Commission’s new mandate, will your hospital be ready the next time a surveyor pays a visit? Here are four indicators that you’re prepared to meet the new standards.

1. Hand hygiene performance rates among all clinician groups and all shifts are consistently high, but not too high. Direct observation is by far the most common method used by hospitals to gauge hand hygiene performance, but there’s a hidden danger. Direct observation is susceptible to the Hawthorne Effect, where clinicians are typically three times more likely to sanitize when they know they’re being watched. Obviously, this artificially inflates hand hygiene rates. Sure, reporting that your hospital’s hand hygiene compliance rate is 99.2 percent works for executives, but it won’t fly when the Joint Commission shows up. If your hand hygiene numbers come back above 90 percent, you probably have a lot of work to do.

2. If you’re using secret shoppers, they’re truly secret. To avoid the Hawthorne Effect, clinicians can’t know they’re being observed. The observer can’t be the infection preventionist standing in a corner with a clipboard. They can’t be the same people who are seen over and over on a hospital floor. They must truly be anonymous folks who are switched out quite frequently to avoid detection.

3. The number of hand hygiene opportunities captured and reported is consistently high. On average, we see over 4,000 hand hygiene opportunities per bed per month, with some units significantly higher. If the data captured is based on a small sample size, it’s unreliable. Most hospital systems would struggle to get 40 good observations per bed for this same month…that’s a sample size of 1 percent. It’s unlikely that this will provide enough relevant data to lead to behavior change.

4. Finally, you’ve seen HAIs decrease by at least 45 percent. The whole reason we spend so much time talking about hand hygiene is that it’s the single biggest factor in the spread of HAIs. If you look at the data related to hand hygiene and HAIs, over 40 peer-reviewed publications have linked hand hygiene to a reduction in HAIs. The median decrease is 45 percent. If you haven’t seen a major reduction in HAIs, it would be prudent to re-examine your hand hygiene improvement system.

If you have a reporting system that accurately captures nearly every hand hygiene opportunity and your team’s performance is truly high, then you’ll be better prepared when a Joint Commission surveyor comes looking for a single individual failing to sanitize one time.
What if, according to the above criteria, you aren’t prepared for a Joint Commission survey? While there are many ways to increase hand hygiene performance rates as high as possible, one of the most effective is to use an electronic hand hygiene reminder system. These systems have three significant advantages over traditional secret shopper, direct observation methods.

1. Electronic hand hygiene reminder systems capture nearly all hand hygiene opportunities, as opposed to just some. How many opportunities does your secret shopper capture in a month? 75, 150 or 250? Just one unit of a typical hospital might have 75,000 hand hygiene opportunities in a month. When you’re capturing just 0.1 percent to 0.3 percent of the actual data set, it’s impossible for those figures to be statistically significant or meaningful in any real way.

2. They’re much more accurate. Secret shoppers are limited by a number of factors. They typically can’t see into patient rooms, so while they know when a clinician sanitizes in the hallway, they don’t know if she sanitizes in the room. They’re also subject to a whole host of prejudices such as observation bias. Most of the time, these preconceptions are subconscious, but can still result in collecting inaccurate data. People typically observe what they expect to see. For example, someone who has a personal belief that physicians are less likely to sanitize than nurses may end up unintentionally recognizing that pattern. Technology has no such bias.

3. Secret shoppers don’t stay secret for long. As soon as clinicians realize they’re being watched, they change their behavior as the Hawthorne Effect kicks in. That means that direct observation could record a hand hygiene performance rate of 90 percent when it’s actually 30 percent. The data collected is virtually worthless. Data collected by an electronic system isn’t subject to the Hawthorne Effect, making it much more reliable.

While electronic hand hygiene reminder systems collect more accurate and usable data, they’re just the first step in solving the hand hygiene problem. It’s important to understand your hospital’s baseline, but even more important to improve hand hygiene at a rate that’s less likely to generate a Joint Commission citation. That’s where a reminder comes in handy. Some electronic hand hygiene technologies simply collect data, while others remind clinicians to sanitize when they forget. Reminders can come in the form of a light, a beep or a human voice, and are critical. In-the-moment feedback changes behavior much more effectively than receiving a report at the end of the month that provides aggregate hand hygiene figures from the month prior. The latter is not likely to be remembered, much less acted upon.

It’s also important to consider which type of reminder may work best in your facility. Lights and beeps can get lost among the many flashing indicators and noises in a busy hospital. Alarm fatigue is real and for many, a human voice tends to more effectively cut through the clutter.

Clinicians want to do the right thing. They’re highly educated, hardworking, compassionate people, but they’re also extremely busy. Lectures and posters will only go so far as they move through daily patient care routines. On the other hand, real-time feedback every time a hand hygiene opportunity is missed ensures that they sanitize at that moment and each time they’re supposed to sanitize. It truly does change behavior.

Hospitals are increasingly turning to electronic hand hygiene reminder systems to collect accurate data and remind clinicians to sanitize. Not only does this help them avoid Joint Commission citations, but more importantly, it assists in reducing HAIs and increasing patient safety.

(To read this article on Infection Control Today, click here.)


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