Wash Your Hands and Get Your Flu Shot, or Get Out

Safety experts are fed up with healthcare workers who do not comply with hand washing and influenza vaccination mandates. It's time to take a new approach to ensuring compliance, they say.

It's time for individual healthcare workers to be held accountable for following certain safety practices proven to reduce patient harm, safety experts from the National Patient Safety Foundation's Lucian Leape Institute say.

The Institute feels so strongly about the need for personal responsibility on the part of healthcare workers that it recommends employees be fired if they repeatedly and deliberately flout basic and easily met patient safety requirements.

Hand washing and mandatory flu vaccinations are the first two safety practices the Leape Institute wants hospitals to enforce, according to Robert Wachter, MD, an NPSF board member. He wrote about the matter in the HealthAffairs Blog last month.

"The right of "individual veto" cannot be considered more important than safety practices that are backed by "sufficiently compelling supportive evidence," Wachter argues in the Health Affairs piece. "They (hospitals) must be willing to terminate clinicians for deliberate and repetitive non-compliance."

Wachter, a member of the Institute and a professor and interim chairman of the Department of Medicine at the University of California, San Francisco, explained his position further when I reached him by phone recently.

"Up until now," he told me, "hospitals approached these safety practices with the outlook that healthcare workers knew they should follow them, but there were no consequences if they didn't. We exhorted people to follow them and we created systems to make it easier for them. But compliance is still not where it should be."

Flu Vaccination Pressure Ratchets Up at Hospitals

The Institute calls for near-100 % compliance for hand washing and flu vaccinations, the first two safety measures on its list of criteria to help hospitals determine when a practice should be placed on a "Must Do" list. Wachter writes:

"Of course, there will be exceptions, such as emergency procedures in which there isn't time for hand hygiene, or legitimate medical reasons to forego influenza vaccination, but such circumstances are rare and should not weaken the general expectation for compliance. Central to this argument is that clinicians cannot choose, as individuals, to forego "must do" practices."

Universal compliance is feasible; indeed, compliance rates close to 100% have already been achieved in some institutions, though such rates are far from typical. Both practices have been endorsed by the National Quality Forum, relevant specialty societies, and broad professional consensus."

Put Processes in Place
Frank Federico, RPh, executive director, strategic partners, for the Institute for Healthcare Improvement, agrees with the Institute's call for accountability and consequences, but with a caveat: "Before a hospital requires 100% accountability, we must make sure that we have the appropriate processes in place and that we have made it as easy as possible for employees to comply with these safety practices."

Writes Wachter:

"Just as we believe that individual clinicians will be driven to universal compliance out of professionalism, we believe that healthcare leaders will create systems to facilitate and measure compliance out of their desire to do the right thing."

Erin S. DuPree, MD, chief medical officer and vice president for The Joint Commission Center for Transforming Healthcare, says The Joint Commission has historically required healthcare facilities to reach a high level of hand hygiene compliance.

"We learned through our work in the Center that many hospitals do not have unbiased, accurate measurement systems to determine actual hand hygiene performance which is necessary for improvement efforts. The Center's work with leading hospitals uncovered the root causes of this chronic patient safety problem and developed solutions to facilitate organizations capacity to improve hand washing and ultimately get to the aim of 100," she says.

Hospitals claiming they cannot meet these standards are in the wrong business, Wachter writes:

"We are even less sympathetic to the frequently heard argument that these standards will put hospitals (or clinicians) out of business. Hospitals or clinicians unable to achieve uniform adherence with "must do" practices should not be in the business of delivering health care."

No-blame Philosophy
The University of California San Francisco Medical Center hires people to secretly observe employees' hand washing practices, Wachter says. Individuals are not cited. Instead, the reports are unit-based and have helped push hand washing compliance to almost 100%.

The Institute doesn't specifically prescribe how hospitals should go about ensuring that employees adhere to these practices. But individual facilities may be creative in coming up with solutions, Wachter suggests.