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Monetary Incentives, Marketing, Accountability Drive Hand Hygiene

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   April 08, 2010

A perennial problem in healthcare facilities usually comes back to a very simple 30-second procedure. Ask any infection preventionist (IP) about his or her major focus on hand hygiene compliance and you'll likely hear a number of strategies, obstacles, or frustrations with getting staff members to comply with hand hygiene best practices.

Measuring compliance is just half the battle for IPs. Improving compliance is another challenge. Part of the Joint Commission's National Patient Safety Goal NPSG.07.01.01 requires facilities to set goals for improving hand hygiene rates, and it's a continued focus of Joint Commission surveyors.

Roughly two years ago, Collette Hendler, MS, RN, CIC, infection preventionist at Abington (PA) Memorial Hospital formed a team of hospital employees whose "regular workflow allows them to be in all areas of the hospital so they are not noticed." These hand hygiene "spies" remain anonymous so employees aren't aware of when they are being watched or who is watching them.

"If a nurse manager would say to me he didn't believe my data, I would tell him to do it himself and see how his data compared to ours, and in the one particular case he came down halfway through the day and said he couldn't take it anymore and believed our numbers were what they were," Hendler says.

After the spies had been dispersed to collect data, the message needed to be clear and consistent. Both facilities turned to their marketing teams to create more buzz around hand hygiene compliance and offer daily reminders to staff members.

"I actually probably have something that a lot of other hospitals don't have, and that's that I have my own PR person who is assigned to the hand hygiene project and I work very closely with him and he comes up with a lot of creative ideas," Hendler says.

One of those ideas included screensavers with humorous or provoking messages. One included a picture of a young patient that read, "You could kill him with your bare hands." Another was a spoof of the "Sham-wow" infomercial that read "Hand-wow." These approaches raised compliance rates to 88%.

"We try and do things that are funny, things that are serious, just try to shake it up so people look at the screensavers and there is some message going on," Hendler says.

Texas Children's Hospital in Houston took a similar approach two years ago, focusing on marketing its hand hygiene campaign rather than just educating employees, says Jeffrey Starke, MD, director of IC. The marketing team brought in an outside consultant who helped develop a campaign called "Hy-Five" aimed at patients and families as well as physicians and employees.

The campaign increased compliance to around 80%, and as a result, Texas Children's won the Child Health Corporation of America's National Quality Award.

"Executives love marketing, and so they know that these data are looked at by outside agencies that are looking at us and are doing rankings, and so they know that they can look people in the eye and say, ‘We really believe in quality; here is the data and the awards to back it up,' " Starke says.

Starke says that even though Texas Children's reached 80%, getting over that last hurdle to the 90th percentile took additional facility-wide motivation.

"We said we needed to do a little better, and I'm a big believer in incentives," Starke says. "I think we are all influenced by the same things as other people."

Texas Children's has an employee bonus program called P3. Previously, all incentives were based on financial numbers and volume, but Starke went to his administration and talked it into making hand hygiene part of the bonus program for employees. Then he took it one step further and made it part of the administrator's bonus program as well.

"I know this sounds trite, but we convinced them that it was the right thing to do," Starke says. "We said, 'What's good for the goose is good for the gander,' and once you agree to do this for the employees, how can you possibly exempt yourselves? [We were] sort of trying to create a 'just culture,' and I think this is a very important part of 'just culture,' that administrators be just as responsible for these things as the frontline employees are."

The facility had to meet a 95% compliance rate for employees and administrators to get that portion of their bonus, while other factors contributed to other portions of their bonus.

Since implementing this incentive, compliance rates at Texas Children's have stayed between 95% and 99%, Starke says. Simultaneously, bloodstream infection rates have plummeted. Although Starke admits there are other factors to account for this reduction, it has helped set the culture and emphasize infection prevention.

"It's not like there are administrators browbeating people," Starke says. "It's not like people are up there going, 'If you don't do this, we can't vacation this year.' It's creating the same culture and expectations at every level of the organization, and I think that's sometimes where [infection prevention] falls down, is not making executives responsible."

Evan Sweeney is an editorial assistant at HCPro. He manages and writes for Briefings on Infection Control, a monthly newsletter directed at IC compliance. He also blogs for OSHA Healthcare Advisor, a resource center for infection control and safety professionals, and regularly contributes to Medical Environment Update and OSHA Watch, which focus on healthcare employee safety and health.

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