ORIGINAL ARTICLE
The Safety Stand-down: A Technique for Improving and Sustaining Hand Hygiene Compliance Among Health Care Personnel Dennis Cunningham, MD,* Richard J. Brilli, MD, FAAP, FCCM,†|| Richard E. McClead, Jr, MD,‡|| and J. Terrance Davis, MD§ Objectives: Hand hygiene (HH) is critical to prevent health care–acquired infections. However, compliance by health care workers remains between 30% and 70% at most institutions. Most efforts to improve compliance have proven ineffective. The objective of this study was to determine whether a safety stand-down can improve HH compliance. Methods: We adapted and borrowed from the military an approach known as a stand-down. A mandatory Hand-Hygiene Leadership Safety Summit was called for all hospital leaders—physicians and nonphysicians. Four days later, a hospital-wide 15-minute–long safety stand-down occurred, during which all nonessential activity was suspended and action plans to improve HH compliance were discussed. All medical sections and hospital departments were required to submit written action plans. After the stand-down, HH compliance monitoring was increased, and noncompliers were required to speak to senior hospital administration. Results: Compliance increased from less than 65% to greater than 95% (P < 0.001) and has been sustained for 3½years. Conclusions: A health care safety stand-down can be an effective method to rapidly change and sustain culture change regarding HH in the inpatient hospital setting. Key Words: hand hygiene, hand hygiene compliance, preventable harm, stand-down, hospital-acquired infections (J Patient Saf 2015;00: 00–00)
H
ospital-acquired infections (HAIs) occur in approximately 5% of all patients and result in approximately 2 million infections per year. Hospital-acquired infections are estimated to claim almost 100,000 American lives per year and cost $5.7 billion.1,2 The types of infections that are most prevalent are urinary tract infections, followed by surgical site infections, central line–associated bloodstream infections, and ventilator-associated pneumonias, but there are many others.1,2 Of all the interventions aimed at reducing HAIs and their devastating consequences, hand hygiene (HH) is recognized in the literature as the single most important mechanism.3 Prevention of HAI is key to not only preventing spread of infection to patients by health care providers2,4 but also protecting health care workers (HCWs) and their families.5,6 The details of recommended HH protocols have changed over time but most recently include the use of soap and water or an alcohol-based antiseptic agent upon entering and leaving a patient's room.3 Despite the compelling case made in the literature, HH compliance rates in hospitals remain poor—ranging from 30% to 70%, and few institutions have sustained high compliance over time.7–10 From the *Director of Epidemiology, Division of Infectious Diseases, †Department of Pediatrics, Division of Critical Care, ‡Department of Pediatrics, Division of Neonatology, and §Assistant to the Chief Medical Officer and Emeritus Professor of Clinical Surgery, The Ohio State University, Columbus, Ohio; and ||Nationwide Children's Hospital, Columbus, Ohio. Correspondence: J. Terrance Davis, MD, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205 (e‐mail: [email protected]). The authors disclose no conflict of interest. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Although HH seems to be a simple thing to do, many different factors combine to keep compliance rates low4,11 and no single optimal interventional approach has emerged.7 Further, the literature supports the concept that individual accountability, not a system failure, generally underlies HH compliance issues.12 This has led to some proposals that include specific penalties for physicians who are noncompliant with HH, such as mandatory education or clinical privilege denial for 1 week.13 In the spring of 2010, Nationwide Children's Hospital (NCH) experienced a spike in HAI. Although our self-reported HH compliance rates were quite high, during a mock survey, outside observers noted spotty HH compliance. When we subsequently sent out unannounced clandestine observers to document actual compliance rates, we were astounded to find the overall rate at 50%. In an effort to rapidly and dramatically increase HH compliance, a novel intervention was undertaken: an HH Leadership Summit followed by an “all hands on deck” hospital-wide safety stand-down. A stand-down is a military term that refers to the temporary cessation of an offensive action, allowing senior leaders to meet with frontline workers to discuss safety issues.14 Standdowns are used by other industries including oil and gas, commercial aviation, and public safety departments. However, outside the military hospital setting, stand-downs used to improve patient safety are uncommon. It has been reported after a serious medical error to address specific issues15 but not to deal with ongoing cultural issues such as HH. For NCH, this was a microsystem-based, senior leadership–inspired approach to HCW accountability designed to rapidly increase and sustain HH compliance. Achieving this goal required a fundamental change in the individual accountability culture around HH: creating an expectation of 100% compliance. The objective of this study was to evaluate the effectiveness of this intervention.
METHODS “HH Compliance”: Definition Hand-hygiene compliance was defined using Centers for Disease Control and Prevention and World Health Organization recommendations.16,17 Specifically, washing hands with an approved antimicrobial soap for at least 15 seconds or using a hospital-approved alcohol-based waterless rub if hands were not visibly soiled upon entering and before leaving each patient's room was required. This was expected with or without any anticipated patient contact. For patients in units with cubicles (e.g., postanesthesia care unit and neonatal intensive care), HCWs were instructed to perform HH when crossing below the cubicle curtain tracks. During clandestine unannounced quality improvement (QI) auditing for HH compliance, an HCW was deemed compliant if HH was performed when entering and leaving a patient room or cubicle. If compliance could not be verified upon entrance and exit (e.g., the door was closed as the HCW entered the room and the auditor could not tell whether HH was performed inside the room), the encounter was not counted. www.journalpatientsafety.com
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Cunningham et al
HH Compliance Monitoring Before April 2010, institutional HH compliance measurements were determined by self-reporting or observations by inpatient unit managers. These reports indicated very high compliance rates, often exceeding 90%. However, there was reason to suspect that the data were incorrect because unbiased observers (e.g., during a mock Joint Commission Survey) noted poor HH practices. Therefore, in April 2010, trained personnel from the QI Department began conducting clandestine HH compliance observations in patient care units. These unannounced observations, conducted for several months, confirmed HH compliance rates consistently less than 60% (Fig. 1).
Early Interventions Beginning in the summer of 2010, hospital leadership instituted multiple interventions intended to improve HH compliance. The first was to remove the most important barrier to compliance by significantly improving access to alcohol gel dispensers. Although gel dispensers had always been available inside each patient room, their placement was not always convenient for those providing care. Within fire-code regulation limits, the hospital installed dispensers outside nearly every patient room, along all hospital hallways (clinical and nonclinical), and outside every elevator entrance in the hospital. Other initiatives included reeducation for all staff about the guidelines for HH via staff meetings, presentations at managers' meetings, as well as meetings with department and section chiefs of the medical staff. The clear and unambiguous expectation for 100% compliance was emphasized. In addition, clinical unit competitions were conducted to increase visibility regarding HH practices. Units achieving the highest HH compliance received public acknowledgment by hospital leadership and tangible rewards for all personnel including free food and pizza parties. Although these efforts yielded a modest improvement, compliance was not near 90% (Fig. 1).
HH Leadership Safety Summit A “Hand-Hygiene Leadership Safety Summit” was convened. Attendance was mandatory for all physician section/department chiefs, nurse managers, and ancillary department directors. The summit was used to prepare hospital leaders for the upcoming stand-down. The chief medical officer (CMO) presented data
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documenting the poor HH compliance, the potential relationship between the low HH compliance and increased HAIs, and the impact on the hospital's overall Preventable Harm Index.18 Both hospital-wide and unit-specific compliance rates were presented. Risk to patients, hospital staff, and staff's families related to poor HH compliance was emphasized. The purposes of the Leadership Safety Summit were to (1) make the case for action, (2) convey the seriousness with which senior executive leadership viewed HH, and (3) explain and describe the upcoming stand-down. During the Summit, leaders were instructed to identify barriers to achieving 100% HH in their respective areas and develop a tentative action plan that would be discussed during the upcoming 15-minute stand-down. The action plans were expected to be easily and quickly implemented and have an owner with a timeline.
Gaining Accountability At the Safety Summit, executive leadership emphasized that, after the stand-down, the hospital would significantly increase unannounced, clandestine HH observations. If a unit had less than 90% compliance, its nurse manager would have to discuss reasons for their unit's poor performance and develop corrective action plans with the chief nursing officer (CNO). Similarly, medical and surgical chiefs whose sections were less than 90% compliant would have to discuss their physician group's performance with the CMO. Any hospital personnel, including physicians, observed as noncompliant with HH policies would be required to have a faceto-face meeting with either the CNO or the CMO or their designates. The meeting's purpose would be for the employee to explain the reason for noncompliance and for the CNO or the CMO to emphasize the clear expectation for 100% HH compliance by all hospital staff. Second offenses would require an additional discussion, using the hospital's performance management accountability guidelines. This algorithm, based on Reason,19 asks a series of questions about an event that caused harm. It begins with, “Did the individual intend to cause the harm?” In that extremely rare case, law enforcement becomes involved. The next question is, “Was the individual impaired by a medical condition, drugs or alcohol?” In that case, remedial therapy is indicated. Several other questions are asked until the final one, “Would similarly trained and equipped co-workers have made the same choice?” If the answer is yes, this indicates
FIGURE 1. HH compliance at NCH from April 2010 to present: Change from baseline is statistically significant (P < 0.001).
2
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Stand-Down Improves Hand Hygiene Compliance
FIGURE 2. Stand-down in Perioperative Services. This was held in the postanesthesia care unit before beginning the surgical schedule for the day.
after the stand-down, and action plans were to be fully implemented within 10 days.
either unintended human error or a system problem. In that case, changing the system is indicated, as well as support for the individual. Unless the second offense was a system problem, a letter from executive leadership to the employee's immediate supervisor or chief would be sent, indicating a second observation for noncompliance with HH policies. A third offense would result in an official letter being placed in the HCW's personnel file or, for physicians, a letter in the medical staff's personnel file. The significance of a letter in the personnel file is that this record of noncompliant behavior would be a permanent part of his/her record and follow the physician throughout his/her career.
After the Stand-down Immediately after the stand-down, significantly increased monitoring occurred to maintain a sense of urgency concerning HH compliance. During the 2 months after the stand-down, more than 2000 separate HH observations were conducted on all shifts in each patient care area. After 2 months, observations continued but at a lower rate of not fewer than 200 to 400 observations per month. Weekly compliance rates were reported to the nurse managers and the medical directors for all units. Noncompliant hospital staff and poorly performing patient care units were reported to the CMO or the CNO, as appropriate. Meetings with noncompliant staff were conducted by the CMO and the CNO or their designates.
The Safety Stand-down Four days after the Leadership Summit, the stand-downs occurred at 8 AM and/or 8 PM in all hospital departments and medical staff sections unless an alternative time was specifically prearranged. Hospital administrators and QI staff observed the stand-down discussions to emphasize administrative support. They were led by the manager or the section chief and lasted no longer than 15 minutes. The focus was on confirming or revising the proposed action plan and addressing any unit-specific barriers to implementing the action plan. In addition, the process for enhanced HH compliance monitoring was reviewed, and consequences of noncompliance were explained. During the stand-down, all nonessential hospital activities ceased. The attention and “big splash” associated with stopping all nonessential clinical activity captured the hospital staff's attention and made it clear that this was important to everyone. Further, many staff members commented, “finally we are serious about this.” Figure 2 shows the stand-down that was held in Perioperative Services before beginning the elective schedule for the day. Finalized unit-specific action plans, which were intended to achieve at least 90% HH compliance, were presented to the CMO within 5 days
Statistical Analysis Compliance rates before and after the stand-down were compared using the Fisher exact test, Minitab version 16.2.4 (Minitab Inc., State College, PA) (P < 0.001). This is a 2-sample test that takes into account the differing numbers of observations in the 2 periods. The “pre–stand-down” period extends from April through August. The April beginning date coincided with the start of observations by trained clandestine observers and the end of self-reporting. September and October 2010 were regarded as “transition” points (not really part of either “pre” or “post”) and are not included in the test. The “post–stand-down” period is November 2010 through October 2013. Details of the statistical analysis are shown in Table 1.
RESULTS Before the safety stand-down, HCW compliance with expected HH practices was less than 60%. All professional groups were
TABLE 1. Pre–Stand-down Versus Post–Stand-down Observations
Pre–stand-down Post–stand-down
Period
Compliant Entry and Exit
Noncompliant
Total
Compliant, %
April 2010 to August 2010 November 2010 to June 2011
209 2048
157 122
366 2170
57.1 94.4
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FIGURE 3. Unit specific hand hygiene compliance rate comparison 6 months following the stand down.
represented and equally noncompliant (50% compliance by physicians, 37% by nurses, and 55% by other hospital staff ). One month after the Safety Summit and HH stand-down, overall hospital HH compliance increased to 94% (range by unit, 80%-100%) (Fig. 1). The increase in post–stand-down compliance was statistically significant (P < 0.001). Figure 3 demonstrates the compliance rate by hospital unit for the first 6 months after the stand-down, demonstrating that more than 50% of hospital units were 100% compliant. Overall HH compliance has continued at greater than 90% for almost 3½years, with 2 exceptions wherein compliance briefly decreased to less than 80% during the summers of 2011 and 2012 (Fig. 1). Our initial hypothesis was that this summer degradation was related to the influx of new trainees and staff. However, a closer look at the data leads to a different conclusion. Figure 4 compares overall hospital HH compliance in 2011 against the number of hospital units with 100% compliance. One can see that a degradation in the number of units that were 100% compliant actually began in March 2011 but did not show up in the overall rate until July. Thus, the July dip in overall rates was simply a reflection of an ongoing degradation beginning in March. This may have been related to decreasing the number of monitoring and cessation of taking and reporting the names of noncompliers. A similar trend recurred in 2012 (not depicted). In each case, overall compliance improved after a brief period of increased monitoring and reporting. In 2013, the hospital proactively increased educational reinforcement and monitoring in the spring and prevented a decrease in summer 2013. Approximately 10 meetings with the CMO (or designee) and physician staff and the CNO and nonphysician staff occurred in the weeks and months after the stand-down. Further, when HH compliance rates dropped to less than 90% for a patient care area, increased auditing and reporting noncompliers to senior management were remarkably effective at improving compliance. In these meetings with administration for noncompliance, both unit leaders and individuals cited no system problems—simply: “I/we just forgot.” All were contrite and stated that they would redouble their efforts. No individual suggested that HH compliance expectations were unreasonable. To date, no individual has needed to meet with senior administration a second time.
sustain it for 3½years. We speculate that this is because the highly visible and dramatic nature of the stand-down focuses the entire organization on the HH issue and has resulted in a permanent attitude change toward HH. Most articles in the literature pertaining to HH report follow-ups only in the range of weeks, with only 1 reporting sustained improvement for 6 months7,20 and 1 reporting sustained improvement for 18 months.8 One longer-lasting intervention, trialing various HH products in an effort to improve compliance, showed short-term benefit with a gradual decline back to baseline.20 The literature suggests that multiple interventions are more effective than single interventions.21 To date, there has been no evidence-based strategy that has demonstrated sustained HH compliance rates at high levels for years. Other unique aspects of our approach include the fact that all HCWs, including physicians, are held accountable for their own actions. Some other reported interventions have focused on either hospital employees7—excluding medical staff—or physicians exclusively.21 Finally, our approach is much less punitive than
DISCUSSION This article's unique contribution is to demonstrate that this technique (safety stand-down) can significantly and abruptly lead to increased HH compliance rates well greater than 90% and
4
FIGURE 4. For 2011—number of units at 100% compliance versus overall hospital compliance.
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J Patient Saf • Volume 00, Number 00, Month 2015
some others.13 With our approach, the only “punitive” element for individuals found noncompliant is a discussion with senior administration—no fines or privilege suspension. We believe that other keys to success, in addition to the standdown, included the robust effort to increase hand gel dispenser availability (making it easy to do the right thing), visible and strong support from senior administration, and a significant increase (particularly after the stand-down) in clandestine HH compliance monitoring. It was essential that a few individuals “caught” as noncompliant were called to the CMO's or the CNO's office to explain their noncompliance. Word spread among hospital staff about this relatively painless call to the “principal's office” as an indication that senior hospital leadership was serious about 100% HH compliance. A final factor was the hospital attitude toward safety and accountability. In 2009, NCH embarked on a comprehensive safety campaign targeting preventable harm elimination.22,23 The program focused on the use of high-reliability principles and fair and just accountability. We believe that implementing change such as “expecting 100% HH compliance” is better received in an organization in which accountability coupled with an expectation for highly reliable clinical care practices is prominent.
Study Limitations As with other studies of this type, this work was done using QI methodology, and therefore, no control group exists. Multiple interventions were undertaken in real time, and outcome changes were measured using statistical process control where applicable. Although we have documented a statistically significant increase in HH compliance, we are not able to directly link the hospitalwide safety stand-down to that increase in compliance. Other factors may have contributed, including the overall increase in individual accountability related to the hospital's comprehensive patient safety program. The stand-down methodology may have its greatest effect in a hospital with a culture focused on high reliability and just and fair accountability.
CONCLUSIONS In this report, we describe an approach to improving HH compliance among HCWs that is adapted from non–health care industries. An important part of our process was a hospital-wide safety stand-down: a 15-minute cessation of all nonessential hospital activity to discuss unit-specific plans to obtain high levels of compliance with the policy. After the stand-down, increased monitoring identified noncompliers; they were required to have a discussion with upper-level hospital administration. With this approach, we obtained dramatic, rapid, and sustained increases in HH compliance. This program can be easily implemented, costs little, and is relatively nonpunitive. We suggest that other organizations, still struggling to achieve high levels of HH compliance, can use this relatively simple technique to improve their results. REFERENCES 1. Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. 2009. Available at: www.cdc. gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf. Published 2009. Accessed May 14, 2011. 2. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care–associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122:160–166. 3. Larson EL, Quiros D, Lin SX. Dissemination of the CDC's hand hygiene guideline and impact on infection rates. Am J Infect Control. 2006;34:666–675.
Stand-Down Improves Hand Hygiene Compliance
4. Graham PL. Simple strategies to reduce healthcare associated infections in the neonatal intensive care unit: line, tube, and hand hygiene. Clin Perinatol. 2010;37:645–653. 5. Sepkowitz KA. Occupationally acquired infections in health care workers. Part I. Ann Intern Med. 1996;125:826–834. 6. Sepkowitz KA. Occupationally acquired infections in health care workers. Part II. Ann Intern Med. 1996;125:917–928. 7. Naikoba S, Hayward A. The effectiveness of interventions aimed at increasing handwashing in healthcare workers—a systematic review. J Hosp Infect. 2001;47:173–180. 8. Doron SI, Kifuji K, Hynes BT, et al. A multifaceted approach to education, observation, and feedback in a successful hand hygiene campaign. Jt Comm J Qual Patient Saf. 2011;37:3. 9. Chassin MR. Improving the quality of health care: what's taking so long? Health Aff (Millwood). 2013;32:1761–1765. 10. Harrington L, Lesh K, Doell L, et al. Reliability and validity of hand hygiene measures. J Healthc Qual. 2007;29:20. 11. Gould DJ, Moralejo D, Drey N, et al. Interventions to improve hand hygiene compliance in patient care. The Cochrane Library–Gould–Wiley Online Library. 2014. Available at: http://onlinelibrary.wiley.com/ doi/10.1002/14651858.CD005186.pub3/abstract;jsessionid= 7989E8B742DC0EEF41012C9F412EB70D.f01t04. Accessed May 10, 2014. 12. Goldmann D. System failure versus personal accountability—the case for clean hands. N Engl J Med. 2006;355:121–123. 13. Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med. 2009;361:1401–1406. 14. Memorandum for all U.S. Army Installation Management Command Personnel, Subject: Policy Memorandum 385-10-1-Safety Policy. 2010. Available at: http://www.campbell.army.mil/campbell/Safety/Documents/ IMCOM%20Safety%20Policy.pdf. Accessed May 10, 2014. 15. KOMO Staff. Children's Hospital releases safety plan. 2010. Available at: http://www.komonews.com/communities/viewridge/195942031.html. Accessed July 8, 2011. 16. Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee. Society for Healthcare Epidemiology of America. Association for Professionals in Infection Control. Infectious Diseases Society of America. Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol. 2002;23(Suppl 12):S3–S40. 17. World Health Organization. WHO guidelines on hand hygiene in health care: first global patient safety challenge. Clean care is safer care. Clean care is safer care. World Health Organization, 2009 Available at: http:// whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf. Accessed May 10, 2014. 18. Brilli RJ, McClead RE, Davis T, et al. The Preventable Harm Index: an effective motivator to facilitate the drive to zero. J Pediatr. 2010;157:681. 19. Reason JT. Managing the Risks of Organizational Accidents. Aldershot, England: Ashgate, 2009. 20. Linam WM, Margolis PA, Atherton H, et al. Quality-improvement initiative sustains improvement in pediatric health care worker hand hygiene. Pediatrics. 2011;128:e1542. 21. White CM, Statile AM, Conway PH, et al. Utilizing improvement science methods to improve physician compliance with proper hand hygiene. Pediatrics. 2012;129:e1042. 22. Crandall WV, Davis JT, McClead R, et al. Is preventable harm the right patient safety metric? Pediatr Clin N Am. 2012;59:1279–1292. 23. Brilli RJ, McClead RE, Crandall WV, et al. A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality. J Pediatr. 2013;163:1638–1645.
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5
The Safety Stand-down: A Technique for Improving and Sustaining Hand Hygiene Compliance Among Health Care Personnel Dennis Cunningham, MD,* Richard J. Brilli, MD, FAAP, FCCM,†|| Richard E. McClead, Jr, MD,‡|| and J. Terrance Davis, MD§ Objectives: Hand hygiene (HH) is critical to prevent health care–acquired infections. However, compliance by health care workers remains between 30% and 70% at most institutions. Most efforts to improve compliance have proven ineffective. The objective of this study was to determine whether a safety stand-down can improve HH compliance. Methods: We adapted and borrowed from the military an approach known as a stand-down. A mandatory Hand-Hygiene Leadership Safety Summit was called for all hospital leaders—physicians and nonphysicians. Four days later, a hospital-wide 15-minute–long safety stand-down occurred, during which all nonessential activity was suspended and action plans to improve HH compliance were discussed. All medical sections and hospital departments were required to submit written action plans. After the stand-down, HH compliance monitoring was increased, and noncompliers were required to speak to senior hospital administration. Results: Compliance increased from less than 65% to greater than 95% (P < 0.001) and has been sustained for 3½years. Conclusions: A health care safety stand-down can be an effective method to rapidly change and sustain culture change regarding HH in the inpatient hospital setting. Key Words: hand hygiene, hand hygiene compliance, preventable harm, stand-down, hospital-acquired infections (J Patient Saf 2015;00: 00–00)
H
ospital-acquired infections (HAIs) occur in approximately 5% of all patients and result in approximately 2 million infections per year. Hospital-acquired infections are estimated to claim almost 100,000 American lives per year and cost $5.7 billion.1,2 The types of infections that are most prevalent are urinary tract infections, followed by surgical site infections, central line–associated bloodstream infections, and ventilator-associated pneumonias, but there are many others.1,2 Of all the interventions aimed at reducing HAIs and their devastating consequences, hand hygiene (HH) is recognized in the literature as the single most important mechanism.3 Prevention of HAI is key to not only preventing spread of infection to patients by health care providers2,4 but also protecting health care workers (HCWs) and their families.5,6 The details of recommended HH protocols have changed over time but most recently include the use of soap and water or an alcohol-based antiseptic agent upon entering and leaving a patient's room.3 Despite the compelling case made in the literature, HH compliance rates in hospitals remain poor—ranging from 30% to 70%, and few institutions have sustained high compliance over time.7–10 From the *Director of Epidemiology, Division of Infectious Diseases, †Department of Pediatrics, Division of Critical Care, ‡Department of Pediatrics, Division of Neonatology, and §Assistant to the Chief Medical Officer and Emeritus Professor of Clinical Surgery, The Ohio State University, Columbus, Ohio; and ||Nationwide Children's Hospital, Columbus, Ohio. Correspondence: J. Terrance Davis, MD, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205 (e‐mail: [email protected]). The authors disclose no conflict of interest. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Although HH seems to be a simple thing to do, many different factors combine to keep compliance rates low4,11 and no single optimal interventional approach has emerged.7 Further, the literature supports the concept that individual accountability, not a system failure, generally underlies HH compliance issues.12 This has led to some proposals that include specific penalties for physicians who are noncompliant with HH, such as mandatory education or clinical privilege denial for 1 week.13 In the spring of 2010, Nationwide Children's Hospital (NCH) experienced a spike in HAI. Although our self-reported HH compliance rates were quite high, during a mock survey, outside observers noted spotty HH compliance. When we subsequently sent out unannounced clandestine observers to document actual compliance rates, we were astounded to find the overall rate at 50%. In an effort to rapidly and dramatically increase HH compliance, a novel intervention was undertaken: an HH Leadership Summit followed by an “all hands on deck” hospital-wide safety stand-down. A stand-down is a military term that refers to the temporary cessation of an offensive action, allowing senior leaders to meet with frontline workers to discuss safety issues.14 Standdowns are used by other industries including oil and gas, commercial aviation, and public safety departments. However, outside the military hospital setting, stand-downs used to improve patient safety are uncommon. It has been reported after a serious medical error to address specific issues15 but not to deal with ongoing cultural issues such as HH. For NCH, this was a microsystem-based, senior leadership–inspired approach to HCW accountability designed to rapidly increase and sustain HH compliance. Achieving this goal required a fundamental change in the individual accountability culture around HH: creating an expectation of 100% compliance. The objective of this study was to evaluate the effectiveness of this intervention.
METHODS “HH Compliance”: Definition Hand-hygiene compliance was defined using Centers for Disease Control and Prevention and World Health Organization recommendations.16,17 Specifically, washing hands with an approved antimicrobial soap for at least 15 seconds or using a hospital-approved alcohol-based waterless rub if hands were not visibly soiled upon entering and before leaving each patient's room was required. This was expected with or without any anticipated patient contact. For patients in units with cubicles (e.g., postanesthesia care unit and neonatal intensive care), HCWs were instructed to perform HH when crossing below the cubicle curtain tracks. During clandestine unannounced quality improvement (QI) auditing for HH compliance, an HCW was deemed compliant if HH was performed when entering and leaving a patient room or cubicle. If compliance could not be verified upon entrance and exit (e.g., the door was closed as the HCW entered the room and the auditor could not tell whether HH was performed inside the room), the encounter was not counted. www.journalpatientsafety.com
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Cunningham et al
HH Compliance Monitoring Before April 2010, institutional HH compliance measurements were determined by self-reporting or observations by inpatient unit managers. These reports indicated very high compliance rates, often exceeding 90%. However, there was reason to suspect that the data were incorrect because unbiased observers (e.g., during a mock Joint Commission Survey) noted poor HH practices. Therefore, in April 2010, trained personnel from the QI Department began conducting clandestine HH compliance observations in patient care units. These unannounced observations, conducted for several months, confirmed HH compliance rates consistently less than 60% (Fig. 1).
Early Interventions Beginning in the summer of 2010, hospital leadership instituted multiple interventions intended to improve HH compliance. The first was to remove the most important barrier to compliance by significantly improving access to alcohol gel dispensers. Although gel dispensers had always been available inside each patient room, their placement was not always convenient for those providing care. Within fire-code regulation limits, the hospital installed dispensers outside nearly every patient room, along all hospital hallways (clinical and nonclinical), and outside every elevator entrance in the hospital. Other initiatives included reeducation for all staff about the guidelines for HH via staff meetings, presentations at managers' meetings, as well as meetings with department and section chiefs of the medical staff. The clear and unambiguous expectation for 100% compliance was emphasized. In addition, clinical unit competitions were conducted to increase visibility regarding HH practices. Units achieving the highest HH compliance received public acknowledgment by hospital leadership and tangible rewards for all personnel including free food and pizza parties. Although these efforts yielded a modest improvement, compliance was not near 90% (Fig. 1).
HH Leadership Safety Summit A “Hand-Hygiene Leadership Safety Summit” was convened. Attendance was mandatory for all physician section/department chiefs, nurse managers, and ancillary department directors. The summit was used to prepare hospital leaders for the upcoming stand-down. The chief medical officer (CMO) presented data
J Patient Saf • Volume 00, Number 00, Month 2015
documenting the poor HH compliance, the potential relationship between the low HH compliance and increased HAIs, and the impact on the hospital's overall Preventable Harm Index.18 Both hospital-wide and unit-specific compliance rates were presented. Risk to patients, hospital staff, and staff's families related to poor HH compliance was emphasized. The purposes of the Leadership Safety Summit were to (1) make the case for action, (2) convey the seriousness with which senior executive leadership viewed HH, and (3) explain and describe the upcoming stand-down. During the Summit, leaders were instructed to identify barriers to achieving 100% HH in their respective areas and develop a tentative action plan that would be discussed during the upcoming 15-minute stand-down. The action plans were expected to be easily and quickly implemented and have an owner with a timeline.
Gaining Accountability At the Safety Summit, executive leadership emphasized that, after the stand-down, the hospital would significantly increase unannounced, clandestine HH observations. If a unit had less than 90% compliance, its nurse manager would have to discuss reasons for their unit's poor performance and develop corrective action plans with the chief nursing officer (CNO). Similarly, medical and surgical chiefs whose sections were less than 90% compliant would have to discuss their physician group's performance with the CMO. Any hospital personnel, including physicians, observed as noncompliant with HH policies would be required to have a faceto-face meeting with either the CNO or the CMO or their designates. The meeting's purpose would be for the employee to explain the reason for noncompliance and for the CNO or the CMO to emphasize the clear expectation for 100% HH compliance by all hospital staff. Second offenses would require an additional discussion, using the hospital's performance management accountability guidelines. This algorithm, based on Reason,19 asks a series of questions about an event that caused harm. It begins with, “Did the individual intend to cause the harm?” In that extremely rare case, law enforcement becomes involved. The next question is, “Was the individual impaired by a medical condition, drugs or alcohol?” In that case, remedial therapy is indicated. Several other questions are asked until the final one, “Would similarly trained and equipped co-workers have made the same choice?” If the answer is yes, this indicates
FIGURE 1. HH compliance at NCH from April 2010 to present: Change from baseline is statistically significant (P < 0.001).
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Stand-Down Improves Hand Hygiene Compliance
FIGURE 2. Stand-down in Perioperative Services. This was held in the postanesthesia care unit before beginning the surgical schedule for the day.
after the stand-down, and action plans were to be fully implemented within 10 days.
either unintended human error or a system problem. In that case, changing the system is indicated, as well as support for the individual. Unless the second offense was a system problem, a letter from executive leadership to the employee's immediate supervisor or chief would be sent, indicating a second observation for noncompliance with HH policies. A third offense would result in an official letter being placed in the HCW's personnel file or, for physicians, a letter in the medical staff's personnel file. The significance of a letter in the personnel file is that this record of noncompliant behavior would be a permanent part of his/her record and follow the physician throughout his/her career.
After the Stand-down Immediately after the stand-down, significantly increased monitoring occurred to maintain a sense of urgency concerning HH compliance. During the 2 months after the stand-down, more than 2000 separate HH observations were conducted on all shifts in each patient care area. After 2 months, observations continued but at a lower rate of not fewer than 200 to 400 observations per month. Weekly compliance rates were reported to the nurse managers and the medical directors for all units. Noncompliant hospital staff and poorly performing patient care units were reported to the CMO or the CNO, as appropriate. Meetings with noncompliant staff were conducted by the CMO and the CNO or their designates.
The Safety Stand-down Four days after the Leadership Summit, the stand-downs occurred at 8 AM and/or 8 PM in all hospital departments and medical staff sections unless an alternative time was specifically prearranged. Hospital administrators and QI staff observed the stand-down discussions to emphasize administrative support. They were led by the manager or the section chief and lasted no longer than 15 minutes. The focus was on confirming or revising the proposed action plan and addressing any unit-specific barriers to implementing the action plan. In addition, the process for enhanced HH compliance monitoring was reviewed, and consequences of noncompliance were explained. During the stand-down, all nonessential hospital activities ceased. The attention and “big splash” associated with stopping all nonessential clinical activity captured the hospital staff's attention and made it clear that this was important to everyone. Further, many staff members commented, “finally we are serious about this.” Figure 2 shows the stand-down that was held in Perioperative Services before beginning the elective schedule for the day. Finalized unit-specific action plans, which were intended to achieve at least 90% HH compliance, were presented to the CMO within 5 days
Statistical Analysis Compliance rates before and after the stand-down were compared using the Fisher exact test, Minitab version 16.2.4 (Minitab Inc., State College, PA) (P < 0.001). This is a 2-sample test that takes into account the differing numbers of observations in the 2 periods. The “pre–stand-down” period extends from April through August. The April beginning date coincided with the start of observations by trained clandestine observers and the end of self-reporting. September and October 2010 were regarded as “transition” points (not really part of either “pre” or “post”) and are not included in the test. The “post–stand-down” period is November 2010 through October 2013. Details of the statistical analysis are shown in Table 1.
RESULTS Before the safety stand-down, HCW compliance with expected HH practices was less than 60%. All professional groups were
TABLE 1. Pre–Stand-down Versus Post–Stand-down Observations
Pre–stand-down Post–stand-down
Period
Compliant Entry and Exit
Noncompliant
Total
Compliant, %
April 2010 to August 2010 November 2010 to June 2011
209 2048
157 122
366 2170
57.1 94.4
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Cunningham et al
FIGURE 3. Unit specific hand hygiene compliance rate comparison 6 months following the stand down.
represented and equally noncompliant (50% compliance by physicians, 37% by nurses, and 55% by other hospital staff ). One month after the Safety Summit and HH stand-down, overall hospital HH compliance increased to 94% (range by unit, 80%-100%) (Fig. 1). The increase in post–stand-down compliance was statistically significant (P < 0.001). Figure 3 demonstrates the compliance rate by hospital unit for the first 6 months after the stand-down, demonstrating that more than 50% of hospital units were 100% compliant. Overall HH compliance has continued at greater than 90% for almost 3½years, with 2 exceptions wherein compliance briefly decreased to less than 80% during the summers of 2011 and 2012 (Fig. 1). Our initial hypothesis was that this summer degradation was related to the influx of new trainees and staff. However, a closer look at the data leads to a different conclusion. Figure 4 compares overall hospital HH compliance in 2011 against the number of hospital units with 100% compliance. One can see that a degradation in the number of units that were 100% compliant actually began in March 2011 but did not show up in the overall rate until July. Thus, the July dip in overall rates was simply a reflection of an ongoing degradation beginning in March. This may have been related to decreasing the number of monitoring and cessation of taking and reporting the names of noncompliers. A similar trend recurred in 2012 (not depicted). In each case, overall compliance improved after a brief period of increased monitoring and reporting. In 2013, the hospital proactively increased educational reinforcement and monitoring in the spring and prevented a decrease in summer 2013. Approximately 10 meetings with the CMO (or designee) and physician staff and the CNO and nonphysician staff occurred in the weeks and months after the stand-down. Further, when HH compliance rates dropped to less than 90% for a patient care area, increased auditing and reporting noncompliers to senior management were remarkably effective at improving compliance. In these meetings with administration for noncompliance, both unit leaders and individuals cited no system problems—simply: “I/we just forgot.” All were contrite and stated that they would redouble their efforts. No individual suggested that HH compliance expectations were unreasonable. To date, no individual has needed to meet with senior administration a second time.
sustain it for 3½years. We speculate that this is because the highly visible and dramatic nature of the stand-down focuses the entire organization on the HH issue and has resulted in a permanent attitude change toward HH. Most articles in the literature pertaining to HH report follow-ups only in the range of weeks, with only 1 reporting sustained improvement for 6 months7,20 and 1 reporting sustained improvement for 18 months.8 One longer-lasting intervention, trialing various HH products in an effort to improve compliance, showed short-term benefit with a gradual decline back to baseline.20 The literature suggests that multiple interventions are more effective than single interventions.21 To date, there has been no evidence-based strategy that has demonstrated sustained HH compliance rates at high levels for years. Other unique aspects of our approach include the fact that all HCWs, including physicians, are held accountable for their own actions. Some other reported interventions have focused on either hospital employees7—excluding medical staff—or physicians exclusively.21 Finally, our approach is much less punitive than
DISCUSSION This article's unique contribution is to demonstrate that this technique (safety stand-down) can significantly and abruptly lead to increased HH compliance rates well greater than 90% and
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FIGURE 4. For 2011—number of units at 100% compliance versus overall hospital compliance.
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some others.13 With our approach, the only “punitive” element for individuals found noncompliant is a discussion with senior administration—no fines or privilege suspension. We believe that other keys to success, in addition to the standdown, included the robust effort to increase hand gel dispenser availability (making it easy to do the right thing), visible and strong support from senior administration, and a significant increase (particularly after the stand-down) in clandestine HH compliance monitoring. It was essential that a few individuals “caught” as noncompliant were called to the CMO's or the CNO's office to explain their noncompliance. Word spread among hospital staff about this relatively painless call to the “principal's office” as an indication that senior hospital leadership was serious about 100% HH compliance. A final factor was the hospital attitude toward safety and accountability. In 2009, NCH embarked on a comprehensive safety campaign targeting preventable harm elimination.22,23 The program focused on the use of high-reliability principles and fair and just accountability. We believe that implementing change such as “expecting 100% HH compliance” is better received in an organization in which accountability coupled with an expectation for highly reliable clinical care practices is prominent.
Study Limitations As with other studies of this type, this work was done using QI methodology, and therefore, no control group exists. Multiple interventions were undertaken in real time, and outcome changes were measured using statistical process control where applicable. Although we have documented a statistically significant increase in HH compliance, we are not able to directly link the hospitalwide safety stand-down to that increase in compliance. Other factors may have contributed, including the overall increase in individual accountability related to the hospital's comprehensive patient safety program. The stand-down methodology may have its greatest effect in a hospital with a culture focused on high reliability and just and fair accountability.
CONCLUSIONS In this report, we describe an approach to improving HH compliance among HCWs that is adapted from non–health care industries. An important part of our process was a hospital-wide safety stand-down: a 15-minute cessation of all nonessential hospital activity to discuss unit-specific plans to obtain high levels of compliance with the policy. After the stand-down, increased monitoring identified noncompliers; they were required to have a discussion with upper-level hospital administration. With this approach, we obtained dramatic, rapid, and sustained increases in HH compliance. This program can be easily implemented, costs little, and is relatively nonpunitive. We suggest that other organizations, still struggling to achieve high levels of HH compliance, can use this relatively simple technique to improve their results. REFERENCES 1. Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. 2009. Available at: www.cdc. gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf. Published 2009. Accessed May 14, 2011. 2. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care–associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122:160–166. 3. Larson EL, Quiros D, Lin SX. Dissemination of the CDC's hand hygiene guideline and impact on infection rates. Am J Infect Control. 2006;34:666–675.
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