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OBM Success Stories
Krista Hinz
Student
The Application of Organizational Behavioral Improvement Methods to a Hospital Hand Hygiene Program as an Undergraduate Psychology Practicum Krista Hinz and Katie Willerick Abstract The goal of the hand hygiene initiative at Bronson Methodist Hospital was to improve staff and physician compliance of hand hygiene. In 2004, the baseline for compliance was 47 percent. Hand hygiene became a strategic organizational objective in 2005. By the end of the year, performance improved to 67 percent. The hospital partnered with Western Michigan University in 2006 to obtain independent auditors for the hand hygiene initiative. A hand hygiene race started off the year and the units ended with 75 percent compliance. Mid-2007 a number of behavioral interventions were implemented and the organization witnessed a statistically significant improvement after July. Year-end average was 88 percent in 2007 and 85% in 2008. From 2004 to 2008, the percentage increase in staff and physician hand hygiene compliance nearly doubled. The organization has celebrated that success and will now raise the bar. The Joint Commission recommends compliance be greater than 90 percent and this hospital intends to exceed that expectation. Background Methods The Bronson Hand Hygiene program is supervised by a graduate student in Western Michigan University’s Behavior Analysis program, as well as the Infection Control department at Bronson. Each semester, three to five undergraduate students from Western Michigan University’s Psychology Department are chosen to collect data on the hand hygiene behaviors at Bronson. The students receive undergraduate practicum credit towards their degree in psychology. Using the students as auditors, as opposed to employees, decreases bias, as the auditors are volunteers at the hospital. The auditors directly observe patient care units at Bronson, documenting compliance and non-compliance of the employees using an audit tool. The auditing process takes place across all days and all shifts, accumulating to approximately 40-60 hours of observation time a week depending on the number of students. An opportunity to audit occurs when a HCW enters a patient, examination, or procedure room. This is referred to as a patient encounter. The worker does not need to necessarily touch the patient directly because objects and equipment in the room represent an infection risk to both the patient and the HCW. A patient encounter is not counted if a HCW walks into a patient’s room and does not come into contact with the patient or environment. The hospital’s hand hygiene policy clearly specifies each time a HCW should use hand hygiene during a patient encounter. At a minimum, hand hygiene should be done as the HCW enters the room before he/she touches the patient and after he/she finishes the encounter as they leave the room, or twice per encounter. Hand hygiene auditors count single events of compliance. For example, if a HCW walks into the room and performs hand hygiene prior to touching the patient or the patient’s environment, that would be counted as one positive compliance. Hand hygiene should occur again if gloves are changed and during the encounter when the HCW touches a more contaminated site followed by a less contaminated site on the patient’s body. Performing hand hygiene prior to entering the patient room (restroom, break room, etc.) or after the HCW leaves the room does not count as the first or last opportunity for that encounter; it must be done in the room where the encounter takes place. Audit data is reported as percent compliance with the total number of opportunities for hand hygiene as the denominator and the number of hand hygiene occurrences as the numerator. Interobserver agreement is also calculated to ensure the measurement is reliable and valid by putting the number of agreements as the numerator and the number of agreements and disagreements as the denominator. Various interventions have been used to improve the behavior of hand hygiene. Graphical feedback is given to all department leaders, who post the results in their department and are encouraged to talk about the results with their staff. The graphical feedback is given monthly to improve hand hygiene awareness. The data can also be broken down into individual departments. This data includes what was touched when non-compliance occurred so departments can focus on educating their staff. Other interventions have included immediate and future reinforcement opportunities. Staff were given a card thanking them, or reminding them to use hand hygiene, depending on if proper hand hygiene was observed or not. These cards could be turned in for a department, or hospital-wide, lottery with the chance to win multiple prizes. Another intervention utilized prompts that were put at the doors of the Emergency Department to remind staff to wash their hands. These stickers were placed on the inside and outside of the doors. Many other interventions took place as well. Results The unique auditing program, support from leaders, and multi-faceted approach all serve an instrumental function. Since 2004, the organization has improved hand hygiene by 87 percent. Baseline was 47 percent. Goals were initially set at 80 percent for 2004 and then modified in 2006 after The Joint Commission recommended 90 percent minimum compliance. Throughout the past four years, the organization has steadily improved from 47 percent in 2004 to 88 percent in 2007 by holding employees and leaders personally accountable. A significant period of improvement occurred during fall 2007. January through July 2007 hand hygiene compliance was 80 percent. After several process improvement changes were implemented, the August through December 2007 rates climbed to a little more than 94 percent. This is a statistically significant increase (p<0.05). Lessons Learned/Next Steps Bronson Methodist Hospital has a vision of excellence. This vision includes exceeding the recommended goal of 90 percent hand hygiene compliance set by The Joint Commission. Next steps include a barrage of behavioral interventions including more immediate feedback and specific goal setting that will accompany the current graphing system. Beginning in May 2009, graphs posted on Bronson’s Intranet will automatically update as soon as the students enter data. This will give all employees at Bronson an active and constantly updated view of hand hygiene compliance. One of the lessons learned from the process is that the auditors need to blend in with their environment. Staff questioned the auditors less when they wore scrubs versus business attire. In addition, some interventions (the feedback cards) lost their reinforcing value over time, so new interventions needed to take place. Audits were originally performed during the day shift only, but since the auditor program through WMU began, all shifts are audited. This is important because there is a different culture at the hospital on days versus nights and weekday versus weekend staff. Overall, this has been a very positive and influential program throughout the hospital. Contact Krista Hinz -------------------------------------------------------------------------------- Footnotes: 1Institute for Healthcare Improvement. 2006. How-to Guide: Improving Hand Hygiene, a Guide for Improving Practices among Health Care Workers. www.ihi.org. 2Centers for Disease Control and Prevention: Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 51:RR–16, 2002. |