The dynamic is an interesting one, especially because the auditors can be from any area of the hospital hierarchy. For example, secretaries have had to give cards to physicians.
The introduction of the cards showed an increase in compliance, but not enough of a jump to be completely satisfactory. "We saw an increase that year. We made it to 90% one month, but for year-to-date we were at 86%," says Dougherty.
Posting names was the next step toward improvement. "We continued the positive rewards program, but . . . we started reporting both those who did well and those who needed to improve," explains Dougherty.
The good with the bad
There was much deliberation within the leadership team on the concept of posting names. Leaders made a conscious decision to hold everyone accountable while continuing to use the carrot instead of the stick, staying with positive reinforcement to motivate their employees to higher hand hygiene compliance.
To temper the negative reinforcement of posting names—which helped improve compliance as well—BJSPH implemented an additional, and very public, way of rewarding those who were spotted using proper hand hygiene processes.
"Any [month] we meet or exceed our goal, we will take the names of everyone who was recognized as doing a good job, put their names into a drawing, and have a 'hand hygiene hero' drawn in the cafeteria," says Dougherty.
The cafeteria is shared by staff members and guests, so the congratulatory ceremony, which includes the loud playing of Bonnie Tyler's 1980's hit "Holding Out for a Hero," can be witnessed not only by staff members, but also patients and their visitors. The winner of the drawing receives a $25 gift certificate, and in months in which the goal is exceeded, multiple names are drawn.
Winners' pictures are taken and posted throughout the building and even made into screensavers on hospital computers. The tactic has been well received by staff members, and when a winner is present in the cafeteria during the drawing, cheers have been known to break out.
Handling positive recognition is easy. Those spotted to be noncompliant can be more of a challenge.
Non-staff members are not immune to the card system. If a physician or advanced practice nurse is spotted not following hand hygiene protocol, the hospital's risk manager follows up with the independent practitioner separately.
It's not all "gotcha," either. BJSPH uses the "Just Culture" concepts, acknowledging human error, and the follow-up for noncompliance is not without managerial discretion. The factors leading up to an incident are taken into consideration when a noncompliant employee is spotted. "Managers are expected to hold staff accountable," says Dougherty.
To the program's benefit, the auditors have remained remarkably consistent over its duration. To keep the secret shopper concept fresh, the auditors don't continually work the same shifts or areas of the building. A fluid schedule allows the auditors to remain anonymous even as they keep their role year after year.
"We've sent the message that these patients belong to all of us," says Dougherty.