90
occurred most rapidly for exit compliance, shifting HHC from 56.2% to 60.5% after 14 minutes, and to 66.0% after 50 minutes of observation.13 These shifts, which occurred during covert obser- vation, are likely exacerbated when healthcare workers are being observed overtly. Electronic surveillance of HHC, which employees are aware of but habituate to, may be another method of reducing the Hawthorne effect. However, a recent systematic review concluded that there is not enough available evidence about the cost-effectiveness of these technologies, so the “secret shopper” methodology is currently the preferred method of covertly observing HHC.14 Despite evidence that standard audit methods produce inflated
HHC estimates, no studies have examined the impact of pro- viding feedback about HHC rates based on rapid, covert human observations. Feedback is a frequent fixture in bundled inter- ventions to improve HHC15 and should be incorporated into studies examining the impact of the Hawthorne effect on HHC estimates. While infectious disease specialists may be aware of the Hawthorne effect, it is unlikely that simply being aware of the effect would result in changes to audit methods. Most people exhibit a bias blind spot in which a person is aware of a bias that affects people but believe themselves to be immune or less sus- ceptible to the bias.16,17 Another potential issue is that designating additional resources to change audit methods may not be feasible if HHC is not a priority for the institution. As a result, further evidence is needed to highlight the influence of the Hawthorne effect on reported HHC estimates and whether feedback using the more accurate estimates obtained using rapid, covert observations impact HHC. Thus, the objectives of this study were (1) to compare HHC rates estimated using a rapid “secret shopper” methodology, which we refer to as the new audit method, to those using the standard audit method of overt observation and (2) to pilot test the impact of a novel feedback tool that communicated information obtained using the new audit method on HHC.
Methods Setting
Data were collected from October 2016 to September 2017 at 5 acute-care Veterans Health Affairs(VHA)hospitals in the Midwest, constituting a total of 17 wards and 5 intensive care units. Reported monthly hospital HHC rates using the standard audit method ranged from 52% to 99% prior to participation in the study.
Design
The new audit method and feedback tool (both described below) were implemented using a nonrandomized (quasi-experimental)
Aaron M. Scherer et al
stepped wedge design as part of a quality improvement project focused on monitoring and improving HHC. The purpose of this initial period was to establish a baseline HHC rate using covert observation prior to the introduction of feedback. The baseline period began in October 2016 (1 site), November 2016 (2 sites), and February 2017 (2 sites; see Table 1 for a visual timeline). After 3 months of baseline data collection at a site, the person in charge of HHC at the site was provided with a feedback tool at the beginning of each month in the form of a poster that commu- nicated information obtained from the new audit method. We purposefully provided no specific instructions on how the sites should use the feedback tool to get a sense of how hospitals might naturally utilize the tool. The Institutional Review Board of the University of Iowa granted an exemption for this quality improvement project.
Materials and procedures
Audit methods The new audit method, also described elsewhere,13,18,19 involved having an employee previously unknown to hospital staff covertly record entry and exit HHC for a maximum duration of 15 min- utes outside of a randomly determined room before moving to a new room on a different unit. Observers attempted to remain inconspicuous and were provided with a prepared story about observing human factors related to the healthcare worker move- ment, if asked (which happened rarely after the first few weeks of study). An average of 630 observations per month were recorded by the observer at each site. Observers received 2-day standar- dized virtual observation training conducted by the project coordinator. Day 1 included a 1.5-hour review of the study and observation protocol and 1 hour of practice observations on their units. Day 2 consisted of a review of their observations and time for questions and concerns. A recurring weekly call with the observers provided an opportunity to review the previous week and have any questions answered. The standard audit method consisted of the existing HHC monitoring protocol at each site, all of which included observations being recorded by a hospital employee known to the other hospital staff.
Novel feedback tool The research team members responsible for the design of the feedback poster included social scientists with experience designing feedback tools for HHC and laboratory test results (HSR, AMS), infectious disease specialists (MG, ARM, EP), and qualitative researchers (EEC, CCG). The feedback posters were designed to communicate 3 key pieces of information about the HHC rate obtained using the new audit method.
Table 1. Study Timeline Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Feedback
Site 1 Baseline Site 2 Site 3 Site 4 Site 5
Baseline Baseline
Feedback Feedback Baseline Baseline
Feedback Feedback
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