It takes more than one method to bring a hospital's hand-hygiene compliance rate up over 90%. At Barnes-Jewish St. Peters Hospital (BJSPH) in St. Peters, MO, it was a matter of trial and error to reach its compliance goal.
"We started collecting hand-hygiene observations back in 2004," says Kathleen Dougherty, RN, MSN, manager of professional practice and leadership development at BJSPH. "We wanted to see where we were with compliance for guidelines from the Centers for Disease Control and Prevention."
The organization took several leaps forward over the next few years, but it was in 2007 they found several tactics that truly brought them closer to the level of compliance they were looking for.
You've been spotted
"In 2007, we knew we had to do more, and we wanted to do more," says Dougherty. "We wanted to be at 90% hand-hygiene compliance by the end of that year."
BJSPH increased frequency of the audits to at least 100 a month.
"In February 2007, after a brief discussion with a Joint Commission surveyor, we learned of the idea to use cards as a method of feedback during audits. We tool this idea and developed it further, into a very simple, but highly effective, concept: ‘You've been Spotted' cards."
These cards—adorned with a Dalmatian to go along with the "spotted" theme—came in two varieties. At a distance, they appeared indistinguishable, but up close the two varieties were distinctly different.
For positive reinforcement, some of the cards were flagged for incidents where the receiver has been spotted using good hand-hygiene practices. These cards includes a $2 coupon good in the hospital cafeteria or gift shop—enough for a cup of coffee or candy bar, or they can be saved up to buy lunch. Funding for these coupons came from the infection prevention budget.
On the spot
And then there are the other cards, which read, "We are putting you on the spot for not using hand hygiene."
The reason the cards look nearly identical is to prevent any sort of embarrassing scene for the people involved. It's impossible to tell from a few feet away whether you've received a positive card or negative.
"We needed something non-confrontational," says Dougherty. "We wanted something with positive reinforcement, but also something to notify you if you got caught. We didn't want this to be a public display."
The dynamic is an interesting one—especially because the auditors can be from any area of the hospital hierarchy. Secretaries have had to give cards to physicians, lab techs to nurses.
Again, the introduction of the cards showed an increase in compliance—but again, not enough of a jump to be completely satisfied.
"We saw an increase that year. We made it to 90% one month, but for year to date we were at 86%," said Dougherty.
The next step toward improvement: posting names.
"We continued the positive rewards program, but … we started reporting both those who did well, and those who needed to improve," says Dougherty.
The good with the bad
There was a great deal of deliberation within the leadership team on this concept. 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 employees to higher hand-hygiene compliance.
So, to temper the negative reinforcement of posting names—which helped improve compliance as well—BJSPH added an additional, and very public, way of rewarding those who were spotted using proper hand-hygiene processes. /p>
"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 and guests alike, so the congratulatory ceremony—including Bonnie Tyler's 1980s hit "Holding Out for a Hero" playing loud and clear—can be witnessed not only by staff, but also the people using the hospital and their visitors. There's a gift involved for the winner of the drawing as well (a $25 gift certificate) and, in months where the goal is exceeded, multiple names are drawn.
Winners' pictures are taken and posted throughout the building—even built into screen savers on hospital computers. The tactic has been well-received by the staff, and when a winner is present in the cafeteria during the drawing, cheers have been known to break out.