Hand hygiene (HH) is the most effective measure for preventing hospital-associated infections. Despite this knowledge, hand hygiene adherence rates are low. Utilizing a covert observation program, HH was assessed in a rural community hospital. Initial Compliance was noted to be 54% at baseline, and steadily improved to 76.8% over 10 months with a multi-modal intervention technique, that included the development of a covert observation program, the utilization of a hand hygiene scorecard for all levels of employment, and leadership rounding and support.
Problem: By developing a covert hand hygiene observation program hand hygiene compliance will improve to a minimum of 80%.Measurement:We utilized PDSA cycles to improve HH adherence. Data was collected utilizing a standardized audit tool that all covert observers were trained and validated to use.
Analysis: We collected data by shift, department role, unit location, and entry vs. exit. This data was then analyzed and each department within the hospital was provided with their own hand hygiene scorecard for a period of no less than 1 year.
Implementation: To accomplish this goal the following evaluations were conducted: review of the existing HH collection methods, the statistical significance of pre-existing data, and hospital wide perception of hand hygiene compliance. Additionally, a covert hand hygiene observation program was developed, and a team was selected, trained and competency validated.
Results/Discussion: Baseline hand hygiene data was noted to be 54%, and in response to intervention 76.8% in September 2023. Next steps include a patient facing initiative that embodies an ‘it’s okay to ask’ campaign. This will serve to education the patient and family and include them in our HAI reduction initiative.
