313. Just Culture (JC) - Does Accountability Change Health Care Professionals (HCPs) Hand Hygiene (HH) Compliance (C)
Session: Poster Abstract Session: Hand Hygiene in Healthcare Settings
Thursday, October 3, 2013
Room: The Moscone Center: Poster Hall C

Background: HH is considered the most important way to prevent infections. Previous studies found deplorable HCPs HHC rates. Ongoing HH education caused increased C from 40% to 60% but peaked at 70%. University of Pittsburgh Medical Center (UPMC) was planning a HH campaign using World Health Organization's (WHOs) 5 Moments of Care. However, a UPMC- Presbyterian (P) Joint Commission visit noted unsatisfactory HHC propelling improvement measures to include a JC. JC does not hold HCP accountable for system failures but conscious disregard for safety is not tolerated. Our objective is to improve HCP HHC using JC methodology at UPMC-P.

Methods: ~950 standardized HH observations (Os) were collected monthly by 4 trained covert (Co) monitors (M). Rates were compared for 2, 7-month periods (P1 and P2) pre /post intervention (8/12 - crossover month).  JC methodology included:

1.      System Change to reliably support HH practices, remove barriers and ensure adequate supplies.

2.      Education/Training of the WHO 5 Moments and JC principles. 21 live sessions educated 2805 HCPs; others used a web-based tool.

3.      Evaluation and Feedback of non C events to determine human or system error.  If human, standard progressive disciplinary process is utilized; verbal, final written warnings, termination. Only nonC by the CoMs could trigger the JC evaluation. Other non COs were teaching moments (TMs). A parallel process was designed for medical staff that included warnings and fines to $500.

4.      Senior level support and participation offering appreciation/coaching (TM) for HH Os.

5.      HH reminder word (Happy Birthday) was utilized. 100 Happy Birthday sheet cakes were distributed.


HH C increased from 72% to 97% OR =0.08 (CI0.07-0.09), p<10-7 and has been 100% for 2 months. 8 HCP received progressive disciplinary action; 7 verbal warnings and 1 terminated.


1)      Education, though vital, is not enough to improve HHC.

2)      Incorporating a JC of patient safety with accountability and potential disciplinary action helped to drive HHC to 100%.

3)      These observations represent a snapshot of HCP HHC. However, the acknowledgment of HH importance has become incorporated into the way work is done and system change has been achieved.

Ashley Querry, BS, Infection Prevention & Hospital Epidemiology, University of Pittsburgh Medical Center - Presbyterian Hospital, Pittsburgh, PA, Carlene Muto, MD, MS, FSHEA, Infection Prevention & Hospital Epidemiology, University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, PA and Emily Magee, BA, MPH, Infection Prevention and Hospital Epitemiology, University of Pittsburgh Medical Center - Presbyterian Hospital, Pittsburgh, PA


A. Querry, None

C. Muto, None

E. Magee, None

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