Infection Control & Hospital Epidemiology (2019), 40,89–94 doi:10.1017/ice.2018.277
Original Article
Testing a novel audit and feedback method for hand hygiene compliance: A multicenter quality improvement study
Aaron M. Scherer PhD1, Heather Schacht Reisinger PhD1,2, Michihiko Goto MD, MSCI1,2, Cassie Cunningham Goedken MPH2, Gosia S. Clore MPH1, Alexandre R. Marra MD1,2,3, Emily E. Chasco PhD2,
Charlesnika T. Evans PhD, MPH4,5, Michael A. Rubin MD, PhD6,7 and Eli N. Perencevich MD, MPH1,2 1Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States, 2Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, United States, 3Division of Medical Practice, Hospital Israelita Albert Einstein, São Paulo, Brazil, 4Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr Veterans Affairs Hospital, Chicago, Illinois, United States, 5Center for Healthcare Studies and Department of Preventive Medicine Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States, 6Salt Lake Veterans Affairs Informatics, Decision Enhancement, and Surveillance (IDEAS) Center, Salt Lake City, Utah, United States and 7Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
Abstract
Objective: Although most hospitals report very high levels of hand hygiene compliance (HHC), the accuracy of these overtly observed rates is questionable due to the Hawthorne effect and other sources of bias. In the study, we aimed (1) to compare HHC rates estimated using the standard audit method of overt observation by a known observer and a new audit method that employed a rapid (<15 minutes) “secret shopper” method and (2) to pilot test a novel feedback tool. Design: Quality improvement project using a quasi-experimental stepped-wedge design. Setting: This study was conducted in 5 acute-care hospitals (17 wards, 5 intensive care units) in the Midwestern United States. Methods: Sites recruited a hand hygiene observer from outside the acute-care units to rapidly and covertly observe entry and exit HHC during the study period, October 2016–September 2017. After 3 months of observations, sites received a monthly feedback tool that communicated HHC information from the new audit method. Results: The absolute difference in HHC estimates between the standard and new audit methods was ~30%. No significant differences in HHC were detected between the baseline and feedback phases (OR, 0.92; 95% CI, 0.84–1.01), but the standard audit method had significantly higher estimates than the new audit method (OR, 9.83; 95% CI, 8.82–10.95). Conclusions: HHC estimates obtained using the new audit method were substantially lower than estimates obtained using the standard audit method, suggesting that the rapid, secret-shopper method is less subject to bias. Providing feedback using HHC from the new audit method did not seem to impact HHC behaviors.
(Received 27 June 2018; accepted 6 October 2018; electronically published 15 November 2018)
Despite the critical importance of hand hygiene in the prevention of healthcare-associated infections (HAIs), the extent to which healthcare workers engage in appropriate levels of hand hygiene is unclear. The standard audit method of overtly measuring hand hygiene compliance (HHC) is subject to observer biases, and many hospitals report HHC rates that are misleadingly high. For example, in 2009 The Joint Commission led a quality improve- ment study targeting HHC, in which facilities reported com- pliance as high as 85%, rather than the 48% measured using more accurate methods.1 One reason that data collected using standard audit methods might overestimate compliance is that audits are frequently conducted during a scheduled time by an auditor that
Author for correspondence: Aaron M. Scherer, Department of Internal Medicine,
University of Iowa, 200 Hawkins Dr, Iowa City, IA 52241. E-mail: aaron-scherer@uiowa. edu
Cite this article: Scherer AM, et al. (2019) Testing a novel audit and feedback method
for hand hygiene compliance: A multicenter quality improvement study. Infection Control & Hospital Epidemiology 2019, 40, 89–94. doi: 10.1017/ice.2018.277
is known by the unit staff. Thus, HHC rates observed using standard audit methods may be susceptible to bias from the Hawthorne effect.2–6 The Hawthorne effect is a phenomenon in which people engage in higher levels of socially desirable behavior when they feel like they are being observed. The consequence of the Hawthorne effect for hand hygiene is that any HHC mea- surement that occurs when individuals are actively aware of being observed will likely lead to higher HHC estimates.7–13 Consistent with this prediction, a recent review of studies highlighted that HHC rates are significantly lower when observations are unannounced, short (<15 minutes), and conducted by “secret shoppers”: individuals hired to covertly observe HHC by surreptitiously appearing as a member of the public or as researchers studying a topic unrelated to HHC.2 This rapid (<15-minute) benchmark using covert observations
was first established in a study at 5 ICUs and 6 medical/surgical wards.13 A “secret shopper” sat and “read” in a hallway, recording entry and exit HHC covertly for 1 hour. The Hawthorne effect
This work is classified, for copyright purposes, as a work of the U.S. Government and is not subject to copyright protection within the United States.
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