It's long been considered good clinical practice for hospital staff to wash their hands before and after coming into contact with patients and their surroundings, but now there is a financial incentive as well.
As part of the Patient Protection and Affordable Care Act, the Hospital-Acquired Condition Reduction Program went into effect for fiscal year 2015. Hospitals that rank in the quartile of hospitals with the highest total HAC scores will have their CMS payments reduced by 1%.
Add that to CMS' readmissions penalties, and senior healthcare leaders now have plenty of motivation to find strategies to prevent the spread of infections within their organizations.
A Focus on Hand Washing
Cleveland-based MetroHealth System, a safety-net provider with 731 licensed beds and $905 million in fiscal year 2014 operating revenue, has been focusing intensively on hand hygiene since 2010, says Alfred Connors, MD, the system's executive vice president and chief medical officer.
The need for more vigilance became clear when a bacterial infection spread from one patient room to the next, Connors says. The patient in the second room had been transferred from another hospital where tests had shown he did not have the bacteria.
"Four days later, he was sick with a bloodstream infection that was the same bacteria as the patient in the next room, even though we had supposedly put him in isolation. It was clear that our processes for protecting him didn't protect him," Connors says.
The patient ultimately died, and while it is not clear that the death was caused by the infection, it nonetheless spurred MetroHealth into action.
"I reported it to our CEO and to the board as a possible bad outcome due to a quality issue. They were highly motivated and very clear with me about how much they wanted me to fix this problem and how unhappy they would be with me if I didn't," Connors says.
"We decided to make the hospital safer. If someone comes in and doesn't have an infection and gets one here, then that is because we didn't protect them effectively. We didn't isolate someone else who had an infection or we didn't keep an infection from coming in on the doctor's hands."
Monitoring Staff Behavior
Connors began by auditing MetroHealth's hand washing practices. He hired four part-time hand hygiene monitors to observe anonymously what was happening in every unit in order to take a hospital-wide approach to fixing the problem.
"What I learned was that about 70% of people were washing their hands every time they came into or left a patient room," Connors says. "[The remaining] 30% was mostly people just running into a room for a second to grab something. But if you watch, you see that they might turn on a light switch, or touch a bedrail, or touch the TV. It was clear that this was not working."
MetroHealth then implemented its "Wash-In, Wash-Out" initiative, which consists of mandatory education and frequent monitoring and feedback to drive home the importance of following a more consistent regimen and to increase awareness and accountability, Connors says.
"Everybody believed their hand washing rates were fine, and that it was everybody else who was the problem."
After the first four weeks of the training program, MetroHealth's hand washing rates increased to 85%, which was better, but not good enough for Connors.
"I wanted to get above 90%," he says. "The next week, 12 units were above 90%, and the following week, all but one unit were above 90%."
Being Transparent with the Data
To encourage competition and adherence, the health system posts the numbers for hand washing rates on its Intranet site.
"Nobody wants to be the worst unit. It's kind of fun, and it also works remarkably well. In 2011, for the year, we were at 97%. We've been able to keep it consistently high for four years so that is a big win," Connors says.
Additionally, MetroHealth posts the date of the last infection in each unit. "When I first proposed that, everyone was against it, but the fact is that posting it motivates people because no one wants to see a bad number. It hurts when you haven't had an infection in six months, and then you have to post that you've had an infection. This is constantly reminding people how important this is. It's very visible, and we have a lot of transparency."
Achieving Staff Buy-In
Connors had to make about a dozen phone calls during the initial monitoring period to encourage participation from some hand hygiene offenders, he says, but most people were on board from the start.
"I didn't get a lot of pushback. It was more of a reaction of people being glad we are doing this. The fact is I've gotten really good support. People are really proud of this because they see the positive effects."
Improving Cost, Quality, and Patient Safety
MetroHealth spends about $400,000 per year on infection control measures such as the hand hygiene program. Other efforts include better antibiotic stewardship, better room cleaning, and chlorhexidine baths for ICU patients.
In return, the system is reaping a significant financial benefit. From its HAC prevention efforts between 2011 and 2014, MetroHealth has saved approximately $5.3 million of medical costs.
Additionally, infections are down substantially. From 2010 to 2014, central line-associated bloodstream infections dropped 35% and ventilator-associated pneumonia dropped 71%.
"This is clearly a win for the hospital financially. Better care costs less, saves money and lives, and is better for patients. It's doable. It's not expensive. And it's clearly the right thing to do for patients," Connors says.
Moreover, he adds, this attentive approach to infection prevention is also a key component of quelling patients' fears about being in the hospital.
"[HAC is] one of those metrics that CMS looks at when they are determining penalties, and that is part of this, but the real reason we are doing it is because infections scare people. When you come into the hospital, you are scared you are going to catch something, and the fact is you can. If you are ill and get an infection that is not a trivial thing."
Rene Letourneau is a contributing writer at HealthLeaders Media.