Implementation of a quality improvement project using the patient as the observer to improve hand hygiene compliance in ambulatory care practices
Background
Monitoring hand hygiene compliance in the ambulatory setting remains a challenge because a healthcare trained observer loses line of sight once the examination room door closes. This quality improvement project focused on the implementation of a hand hygiene compliance improvement programme that is amenable to the routines and work flows of the ambulatory setting.
Methods
After a review of the literature, nursing leadership and infection prevention implemented the ‘patient as the observer’ hand hygiene programme across 32 ambulatory practices.
Results
Patients completed 281,000 observations with an overall compliance rate of ≥90%. The average overall compliance rate by role was 91% for providers, 89% for nurses, and 91% for medical assistants/technicians/others. A 92% compliance average was noted ‘before caring for you’ and 89% ‘after caring for you’ for providers, 90% and 87% for nurses, and 92% and 89% for medical assistants/technicians/others.
Discussion
This study demonstrated that the implementation of a hand hygiene compliance improvement programme using the patient as the observer can be adopted successfully in the ambulatory setting.
Conclusion
Hand hygiene compliance can be monitored effectively in the ambulatory setting with the involvement of the patient as the observer.
Introduction
An estimated one in 31 hospitalized patients contract a healthcare-acquired infection [1], which results in a complicated recovery process, sepsis, increased healthcare costs and, sometimes, death [2]. Proper hand hygiene by healthcare workers (HCWs) is of critical importance to reduce this risk [[2], [3], [4]]. In the last 3 years, there has been renewed interest in hand hygiene due to the coronavirus disease 2019 (COVID-19) pandemic. Despite this increase in interest, hand hygiene compliance still requires ongoing work.
Recent studies have shown that healthcare-associated infection rates decrease when compliance with recommended hand hygiene practices increases [2,5,6]. As hands are the main pathway for the transmission of germs during the provision of care [2], proper hand hygiene, using soap and water or alcohol-based hand sanitizer, remains the single most important factor in preventing the spread of pathogens in healthcare settings [2,3,7]. To this day, it remains a challenge to get HCWs to perform hand hygiene consistently [[8], [9], [10]]. According to the Centers for Disease Control and Prevention, HCWs clean their hands only about 50% of the time when recommended hand hygiene opportunities present themselves [11].
In 2009, the World Health Organization (WHO) introduced ‘My 5 Moments of Hand Hygiene’. This approach defines the key moments when HCWs should perform hand hygiene: before touching a patient; before clean/aseptic procedures; after body fluid exposure/risk; after touching a patient; and after touching patients’ surroundings. This user-friendly, evidence-based approach was designed by WHO to be used in various healthcare settings [12]. In 2006, WHO noted that direct observation of hand hygiene was the ‘gold standard’ and most reliable method for measuring HCW hand hygiene compliance rates [13,14]. In 2015, the Joint Commission Center for Transforming Healthcare developed the Targeted Solutions Tool (TST) for Hand Hygiene [3,15]. This tool uses two of the five WHO moments [12,15] that can be observed easily in an inpatient hospital setting: ‘wash-in’ before touching a patient and ‘wash-out’ after touching a patient or their surroundings [3].
In 2015, Mount Sinai Health System adopted the TST for Hand Hygiene programme in all inpatient areas. Although the ‘HCW as hand hygiene observer’ model of the TST programme works well in the inpatient setting [3,15], it is not feasible in an ambulatory setting. This is because the patient work flow in ambulatory care has unique challenges that make it difficult for workers to observe hand hygiene without interrupting patient care or disrupting the anonymity of the observer [8]. For this reason, ambulatory leadership decided to implement a unique quality improvement hand hygiene compliance programme that is more suited to the ambulatory setting with the aim of improving hand hygiene compliance.
As part of a best-practice initiative to achieve zero harm, nursing leadership at a large, urban multi-site academic healthcare institution in New York City implemented strategies for ongoing assessment and improvement of hand hygiene compliance in the ambulatory setting. In preliminary evaluations, nursing leadership reviewed policies and procedures, training and education, and opportunities for hand hygiene in select outpatient practices. Before project initiation, a 3-month pilot (August–October 2018) was conducted in which staff members were trained to be ‘secret shoppers’ to monitor hand hygiene compliance before and after patient care. A total of 404 direct observations were completed across five ambulatory practices, which yielded a 32% compliance rate. Pilot data provided information on hand hygiene compliance, and revealed challenges with using ‘secret shoppers’ in the ambulatory setting.
It was noted that ‘secret shoppers’ could not observe staff hand hygiene once the examination room door closed. The observation of HCW hand hygiene practices is sometimes hampered because the observer may need to wait outside the patient’s room [8]. This is especially true in ambulatory care as the examination room door often closes after the HCW enters the room, making direct observation impossible. Also, in certain instances, a HCW may enter a room to have a conversation and not necessarily provide care, therefore not creating a hand hygiene moment.
The John Hopkins Hospital conducted a pilot from July 2008 to July 2009 using the ‘patient as the observer’ methodology to evaluate hand hygiene compliance in the ambulatory setting [16]. The pilot results demonstrated patients’ willingness to serve as observers [16]. Studies such as Bittle and LaMarche [16] and Le-Abuyen et al. [17] showed that using the patient as the observer is a valid method for evaluating hand hygiene compliance in the ambulatory setting. They conducted simultaneous validation of patient results using a HCW observer to evaluate the same hand hygiene opportunities evaluated by patients, and found the results to be consistent [16,17].
Empowering patients to actively participate in hand hygiene compliance by the front-line HCWs who provide their care is an integral element of WHO’s multi-modal hand hygiene improvement strategy [12,18]. This also reduces the need for additional healthcare resources for observations [19]. Also, fostering a healthcare environment that encourages patients and HCWs to participate together in a hand hygiene compliance programme can have a positive impact on hand hygiene awareness among both HCWs and their patients [20,21]. Based on the results of the previously mentioned studies, a quality improvement project was implemented to monitor hand hygiene compliance using the ‘patient as the observer’ methodology in this ambulatory setting.
Section snippets
Methods
Mount Sinai Health System, located in New York, USA, is comprised of multiple ambulatory practices and urgent care centres. After a careful review of the literature and discussions with the infection prevention team, the ‘patient as the observer’ methodology was selected, and the project was rolled out across 32 multi-specialty ambulatory practices. This method was selected to mitigate the concern of trained observers not having a true line of sight once the examination room door closed. The
Results
The ambulatory practices see over 800,000 patients annually. For the project review period of January 2019–December 2021, a total of 329,640 observations were made by role (provider = 129,065, nurse = 67,496, medical assistant/technician/other = 133,079) across 32 practices. There were, however, 603,771 (Table I) unique observations as each role required a ‘before caring for you’ and an ‘after caring for you’ observation, although not every patient responded to both questions (Appendix A, see
Discussion/future implications
The results showed that medical assistants/technicians/others and providers consistently outperformed nurses. However, it is challenging to confirm the validity of this performance gap because, sometimes, patients need help to differentiate between a nurse, a provider and a medical assistant/technician/other. According to Savage [23], a study by Becker’s Hospital Review in 2014 showed that 83% of US adults find it difficult to identify employees and differentiate HCW roles within the hospital.
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