1006. Physicians and Hand Hygiene Compliance:  Accountability Works
Session: Poster Abstract Session: Hand Hygiene 2012
Friday, October 19, 2012
Room: SDCC Poster Hall F-H
Background: Hand hygiene (HH) compliance among healthcare workers (HCWs) remains low in most hospitals; many reports have shown that physician (MD) HH compliance has consistently been lower than that of other HCWs. After education and marketing campaigns yielded MD HH compliance rates of 66%, our institution developed and instituted an accountability model to improve HH compliance among MDs.

Methods: Approximately 2500 MDs have clinical privileges at our 900 bed private academic tertiary care hospital, with approximately 500 employed by the institution and the rest private MDs.   HH observations were conducted by Hospital Epidemiology (HE) nurses across all shifts and all units hospital wide (an average of 1800 observations monthly, of which 400 per month included MDs). Monthly feedback of department specific data was provided to medical leadership. The Medical Executive Committee (MEC) approved an accountability policy in Sep/2010. HE was charged with reporting names of individual MDs to the respective department chair (DC) for individual education and coaching after each occurrence. Repeat noncompliance resulted in a stepwise counseling process up to and including a mandatory HH education class by HE, and suspension of clinical privileges. Names of noncompliant MDs were posted at the discretion of the DC at committee meetings.  DCs received detailed information from HE about noncompliant MD observations every 2 weeks. Housestaff noncompliance was reported to the program chair for followup. HE monitored the department followup and submitted monthly updates to the MEC of MD HH rates and of department chair actions.

Results: MD HH compliance improved after full implementation of the MEC accountability policy to 92% (p<0.001).  A parallel accountability program for all hospital staff resulted in increased compliance from 60% to 92% (p <0.001).

Conclusion: Increased and sustained high levels of MD HH compliance was achieved following implementation of an accountability model. 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 HH compliance among MDs.

Rekha Murthy, MD, Cedars-Sinai Medical Center, Los Angeles, CA, Rebecca Denny, RN, Cedars Sinai Medical Center, Los Angeles, CA and Angela Jin, MPH, Hospital Epidemiology, Cedars-Sinai Medical Center, Los Angeles, CA


R. Murthy, None

R. Denny, None

A. Jin, None

See more of: Hand Hygiene 2012
See more of: Poster Abstract Session

Findings in the abstracts are embargoed until 12:01 a.m. PST, Oct. 17th with the exception of research findings presented at the IDWeek press conferences.