Infection Control & Hospital Epidemiology
more responsive to the less accurate, but more familiar HHC rates calculated via overt observation. Another possibility is that, similar to the “unskilled and unaware” phenomenon in which individuals with the lowest levels of skill significantly over- estimate their abilities,35 hospitals with the largest discrepancies between HHC estimates from overt and covert observations may have the highest risk of patients developing HAIs. Which of these possibilities is true is currently an open question and should be addressed in future research exploring the Hawthorne effect in HHC to demonstrate the superiority of assessing HHC using overt observations, covert observations, or both. Relatedly, this research could also try to determine the influence of the Hawthorne effect relative to other potential sources of bias, such as observers ‘selectively’ observing compliance to avoid con- frontations with staff. Our study was not without limitations. First, the study was
limited to a specific region of the United States and VA hospitals. However, our results were consistent with the growing body of evidence for the Hawthorne effect in HHC. Additionally, we purposefully allowed each site to determine how they would use the feedback tool which a priori excludes generalizability. Another potential limitation was our decision to not feedback a site’s numeric HHC rate based on the new audit method. It is possible that HHC information provided in numeric form (1) may have been more widely disseminated and/or (2) may have had a stronger effect on HHC rates. Although we wanted the sites to focus on improving HHC, rather than simply striving for a target value, future research should compare the efficacy of feedback tools with and without numeric HHC rates. The current study contributes to the growing body of research highlighting that HHC rates from overt observation, which many consider the current “gold standard,” should be highly suspect. Our initial attempt at providing feedback about a site’s HHC from rapid, covert observations, which produced substantially lower estimates than those obtained from overt observation, appeared to have no impact on HHC. Despite the apparent failure of our feedback tool to improve HHC, the rates observed through the new audit method highlight that hospitals and healthcare systems should take the impact of the Hawthorne effect seriously, while researchers should continue to develop and test better ways of accurately measuring and meaningfully communicating HHC rates.
Financial support. This work was supported by Quality Enhancement Research Initiative (QUERI) Award QUE 15-269 (grant no. 1IP1HX001993) from the US Department of Veterans Affairs Health Services Research and Development Service. The contents do not represent the views of the US Department of Veterans Affairs or the US government.
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
References
1. Chassin MR, Loeb JM. The ongoing quality improvement journey: next stop, high reliability. Health Aff 2011;30:559–568.
2. Chen LF, Vander WegMW, Hofmann DA, Reisinger HS. The Hawthorne effect in infection prevention and epidemiology. Infect Control Hosp Epidemiol 2015;36:1444–1450.
3. Walker JL, Sistrunk WW, Higginbotham MA, et al. Hospital hand hygiene compliance improves with increased monitoring and immediate feedback. Am J Infect Control 2014;42:1074–1078.
93
4. Haessler S. The Hawthorne effect in measurements of hand hygiene compliance: a definite problem, but also an opportunity. BMJ Qual Saf 2014;23:965–967.
5. Gould DJ, Creedon S, Jeanes A, Drey NS, Chudleigh J, Moralejo D. Impact of observing hand hygiene in practice and research: a methodological reconsideration. J Hosp Infect 2017;95:169–174.
6. Maury E, Moussa N, Lakermi C, Barbut F, Offenstadt G. Compliance of health care workers to hand hygiene: awareness of being observed is important. Intensive Care Med 2006;32:2088–2089.
7. Dhar S, Tansek R, Toftey EA, et al. Observer bias in hand hygiene compliance reporting. Infect Control Hosp Epidemiol 2010;31:869–870.
8. Eckmanns T, Bessert J, Behnke M, Gastmeier P, Rüden H. Compliance with antiseptic hand rub use in intensive care units: the Hawthorne effect. Infect Control Hosp Epidemiol 2006;27:931–934.
9. Kohli E, Ptak J, Smith R, Taylor E, Talbot EA, Kirldand KB. Variability in the Hawthorne effect with regard to hand hygiene performance in high- and low-performing inpatient care units. Infect Control Hosp Epidemiol 2009;30:222–225.
10. Pan SC, Tien KL, Hung IC, et al. Compliance of health care workers with hand hygiene practices: independent advantages of overt and covert observers. PLoS One 2013;8:e53746.
11. Wu K-S, Chen Y-S, Lin H-S, et al. A nationwide covert observation study using a novel method for hand hygiene compliance in health care. Am J Infect Control 2016;45:240–244.
12. Srigley JA, Furness CD, Baker GR, Gardam M. Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf 2014;23:974–980.
13. Yin J, Reisinger HS, vander Weg M, et al. Establishing evidence-based criteria for directly observed hand hygiene compliance monitoring programs: a prospective, multicenter cohort study. Infect Control Hosp Epidemiol 2014;35:1163–1168.
14. WardMA, SchweizerML, Polgreen PM, Gupta K, Reisinger HS, Perencevich EN. Automated and electronically assisted hand hygienemonitoring systems: asystematicreview. Am J Infect Control 2014;42:472–478.
15. Schweizer ML, Reisinger HS, Ohl M, et al. Searching for an optimal hand hygiene bundle: a meta-analysis. Clin Infect Dis 2014;58:248–259.
16. Pronin E. Perception and misperception of bias in human judgment. Trends Cogn Sci 2007;11:37–43.
17. Scopelliti I, Morewedge CK, McCormick E, Min HL, Lebrecht S, Kassam KS. Bias blind spot: structure, measurement, and consequences. Manage Sci 2015;61:2468–2486.
18. Morgan DJ, Pineles L, Shardell M, et al. The effect of contact precautions on healthcare worker activity in acute care hospitals. Infect Control Hosp Epidemiol 2013;34:69–73.
19. Chang N-CN, Reisinger HS, Jesson AR, et al. Feasibility of monitoring compliance to the My 5 Moments and entry/exit hand hygiene methods in US hospitals. Am J Infect Control 2016;44:938–940.
20. Joint Commission. Update: Citing observations of hand hygiene noncompliance. Joint Commission website.
https://www.jointcommis-
sion.org/assets/1/18/Update_Citing_Observations_of_Hand_Hygiene_- Noncompliance.pdf. Published 2018. Accessed April 13, 2018.
21. Thirkell G, Chambers J, Gilbart W, Thornhill K, Arbogast J, Lacey G. Pilot study of digital tools to support multimodal hand hygiene in a clinical setting. Am J Infect Control 2018;46:261–265.
22. Willemsen I, Kluytmans J. The infection risk scan (IRIS): Standardization and transparency in infection control and antimicrobial use. Antimicrob Resist Infect Control 2018;7:38.
23. Zikmund-Fisher BJ, Scherer AM, Witteman HO, et al. Graphics help patients distinguish between urgent and non-urgent deviations in laboratory test results. J Am Med Informatics Assoc 2017;24:520–528.
24. Zikmund-Fisher BJ, Scherer AM, Witteman HO, Solomon JB, Exe NL, Fagerlin A. Effect of harm anchors in visual displays of test results on patient perceptions of urgency about near-normal values: experimental study. J Med Internet Res 2018;20:e98.
25. Huis A, van Achterberg T, de BruinM,Grol R, Schoonhoven L, HulscherM. Asystematic review of hand hygiene improvement strategies: a behavioural approach. Implement Sci 2012;7(1). doi:10.1186/1748-5908-7-92.
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