4 Ways to Know Your Hospital is Ready for The Joint Commission’s New Hand Hygiene Standards

By Chris Hermann

. Will your hospital be ready the next time a Joint Commission surveyor pays a visit? Here are four ways to know 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 to understand how hospitals are performing when it comes to hand hygiene, but there’s a hidden danger. Direct Observation is susceptible to the Hawthorne Effect, and this artificially inflates hand hygiene rates. Sure, it may have been acceptable to report to your executives that your hospital’s rate is 99.2%, but that won’t fly when the Joint Commission shows up. If your hand hygiene numbers come back above 90%, you probably have a lot of work to do.
  2. If you’re using Secret Shoppers, are they truly secret? In order to avoid the Hawthorne Effect, clinicians must not know they’re being observed. This effect alone can triple hand hygiene, but only when the observer is present.[1] The observer cannot be the Infection Preventionist standing in a corner with a clipboard. They can’t be the same people who are seen over and over again on a hospital floor. They truly must be anonymous folks who are switched out quite frequently to avoid detection.
  3. The number of hand hygiene opportunities captured and reported on 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 being captured is based on a small sample size, it’s unreliable. Most hospital systems would struggle to get 40 good observations for this same month…that’s a sample size of 1%. It’s unlikely that this will provide enough relevant data to lead to behavior change.
  4. Finally, you have seen HAIs fall by at least 45%. The whole reason we spend so much time talking about hand hygiene is that it’s the single biggest factor related to the spread of HAIs. If you take a look at the data related to hand hygiene and HAIs, there have been over 40 peer-reviewed publications linking hand hygiene to a reduction in HAIs. The median decrease is 45%. 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 just about 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 to fail to sanitize one time.

If you’d like to explore how our system typically doubles hand hygiene performance rates, here’s a brief video about how it works, and here’s a white paper on our process of continual, positive behavior change.

[1] a. 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.

b. 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.


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