Empowering Patients to Speak Up About Hand Hygiene

By Chris Hermann

Patients are an important part of the hand hygiene equation.

The CDC website reminds patients that they “can play a role in asking and reminding healthcare providers to clean their hands,” and the latest Leapfrog hand hygiene standards include assessment of institutional culture and patient involvement in hand hygiene promotion.

There’s just one problem: patients are hesitant to speak up.

In the 13 years I worked as a medical student, not one patient ever asked about or commented on my hand hygiene – and it’s absolutely not because I’m good at hand hygiene. I’m sure I failed to wash or sanitize my hands on numerous occasions, yet despite an institutional policy that explicitly encourages all patients and staff to speak up if they see an instance of missed hand hygiene. The only person who ever called me out was one of my attending physicians who knew I was working on Clean Hands-Safe Hands and noticed that I didn’t wash my hands when re-entering a patient’s room after the patient’s chest x-ray. She likely only spoke up because she knew I was working to improve hand hygiene performance and made a good natured joke about it.

Her knowledge of my work gave her the “excuse” she needed to mention my missed hand hygiene opportunity. I’ve since realized that patients need excuses to speak up as well. 

Power Dynamics Inhibit Patient Involvement

Dozens of research studies have now revealed that patients are hesitant to discuss healthcare providers’ hand hygiene practices. Studies conducted in the United States and United Kingdom have found that patients can easily understand the link between hand hygiene and infection prevention, and that many patients say they’re willing to ask their providers about hand hygiene after being told that patient involvement is welcome. 

In some studies, 80-90% of patients agreed to ask their healthcare providers if they washed or sanitized their hands, but only 60-70% of patients actually did so. Other studies report even more dismal rates of patient involvement. Only 40% of patients who read a brochure that stressed the importance of asking healthcare workers about hand hygiene talked to their providers about hand hygiene during their hospitalization. Other studies have found that only 3-5% of patients ask healthcare providers to cleanse their hands. 

Why don’t patients speak up? They don’t want to be considered “troublemakers” and they’re afraid of unconscious reprisals. A 2018 study published in BMJ Quality & Safety found that 50-70% of surveyed intensive care patients were hesitant to voice concerns about possible mistakes or inadequate clinician hand hygiene. Just 31% of patients and family members said they were “very comfortable” discussing hand hygiene. (The study didn’t reveal how many actually talked to their providers about hygiene.)

Real-Time Voice Reminder is an Audible Nudge

My family experienced this dynamic first-hand. As a complete coincidence, my mother was hospitalized at a healthcare facility that had recently installed the Clean Hands-Safe Hands system and was in the hospital the day they turned on the Natural Language Voice Reminder. I knew their hand hygiene rates were suboptimal, so when she was admitted, I told my mom, “They have a hand hygiene problem, and you have to say something if your providers don’t wash their hands.” 

She didn’t. Despite my urgent reminders. There even was one instance where I was in the room with her and I prompted her, and she still didn’t feel comfortable saying something. 

At the time, the Clean Hands-Safe Hands natural voice reminder was switched off because the hospital was still gathering baseline data (phase one our hand hygiene pathway). The system was silent and so was my mom. The next day happened to be the day that the facility turned on the Real-Time Voice Reminder. My mom found her voice that day as well. Inspired in part by her pride in me and my work, she commented every time the system reminded a staff member to sanitize their hands.

It was an instant flip. Before the voice reminder, she was completely uncomfortable speaking up, even when I was in the room, encouraging her. When the voice came on, she used it as a conversation piece. It was her “excuse” to talk to her providers about hand hygiene. 

The hand hygiene rate for her room that day was 100%. 

Set the Stage for Patient Engagement

My mom’s experience taught me that patients need invitations and opportunities to offer input.

When the Clean Hands Safe Hands system audibly reminds care providers to sanitize their hands, patients like my mother feel more comfortable speaking up because they don’t have to independently broach the subject. The presence of the system also signals a system-wide willingness to address hand hygiene, so patients know that their providers are striving for excellence. 

Healthcare environments that provide multiple opportunities for patient engagement empower patients.In essence, the voice reminder creates an environment that makes patients comfortable using their voice. Just ask my mom. 

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