996. Healthcare Workers and Hand Hygiene:  Accountability Improves Compliance
Session: Poster Abstract Session: Hand Hygiene 2012
Friday, October 19, 2012
Room: SDCC Poster Hall F-H

Despite the importance of hand hygiene (HH)in prevention of hospital acquired infections (HAI), and the Centers for Disease Control and Prevention guidelines, compliance rates among healthcare workers (HCWs) remain low in most hospitals. After education and marketing campaigns yielded HH compliance rates of 69%, our 900 bed academic tertiary care hospital instituted an accountability model to improve HH compliance among employees.


HH observations were conducted by Hospital Epidemiology (HE) nurses across all shifts and all units (an estimated 20 observations obtained per unit monthly, withan average of 1800 observations monthly). Monthly feedback of unit and department specific data was provided to all staff. The accountability model involved recording and reporting names of individual HCWs to the department manager for education and coaching after each occurrence. Repeat noncompliance resulted in a stepwise counseling process up to and including termination. The program was tested as a pilot with the Respiratory therapy (RT) staff, and subsequently expanded hospital wide.  Staff members were informed and educated prior to the program as to its intended use as a patient safety initiative. Unit/department specific HH data as well as names of staff were provided by HE to managers every two weeks. Unit performance was reported to executive management monthly.


Baseline HH complianceof RT staffwas 56% and increased to 88% with the program (p<0.001).  Success of the program led to other unit managers adopting the program over subsequent 6 months until the program was expanded hospital widein Feb 2011. Hospital wide compliance increased after full implementation from 60% to 92% (p <0.001) and has been sustained at over 94% since June 2011.


Increased and sustained high levels of HH compliance among HCW were achieved after implementation of an accountability model and ongoing observation and feedback of performance. While ideal measurement methods for HH compliance have not been established, the use of an accountability structure to the HH education, measurement and marketing campaigns in our institution has contributed to sustained improvement in compliance as well as in improved culture of patient safety.

Rehka Murthy, MD, Hospital Epidemiology, Cedars-Sinai Medical Center, Los Angeles, CA


R. Murthy, None

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