Infection Control & Hospital Epidemiology
1. Relative change in monthly HHC rates. Our motivation to present relative change in HHC rate, rather than the exact numeric HHC rate, was inspired by The Joint Commission recommendation that facilities should focus on improving their HHC rates each month, rather than on hitting a specific target percentage.20 An upward arrow was used to indicate improvement in HHC relative to the previous month, a downward arrow was used for decreased HHC, and a dash was used to indicate no change (Fig. 1). Relative change information was provided for each month going back a maximum of 6 months. To increase the salience of the most recent HHC rate, each arrow became smaller and increased in transparency as the temporal distance increased.
2. “Gist” of the absolute HHC rate. After viewing a generic version of the feedback tool during the baseline phase, some sites expressed concern about the absence of the exact numeric HHC rate. As a result, we indicated the gist (ie, the essential take-away) of the site’s numeric HHC rate in 2 ways. The first method involved the arrows and dashes indicating the relative change in HHC rates being colored to indicate whether the site’s numeric HHC was in the “good” (green), “okay” (yellow), or “bad” (red) range. The values in each range (0– 50% = bad; 50%–75% = okay; 75%–100%=good) were determined by the infectious disease specialists on the research team (M.G., A.R.M., and E.P.), and the stoplight color theme was selected based on previous research testing feedback tools.21–24 The legend communicated the color-evaluative label correspondence without specifying what values constituted those ranges (Fig. 1). The second method, which was never mentioned to the participating sites, was a picture containing a Petri dish with bacteria growth from a handprint. The picture of the Petri dish contained a small, moderate, or large amount of bacteria to indicate that HHC was in the “good,”“okay,” or “bad” range, respectively (see Fig. 1 for an example of a “bad” range Petri dish). Gist information represented via color was provided for each month going back a maximum of 6 months, whereas the Petri dish picture only represented the gist information for the current month.
3. Social-comparison information. Comparisons to others can serve as a motivator to positive behavior change, including HHC.25 We included how the site’s HHC rate for the current month compared to a 3-month weighted average (based
91
on facility size) for all 5 participating VHA hospitals. This social-comparative information was communicated in a stand- alone box indicating whether the current HHC rate at the site was “above average” in green font, “average” in yellow font, or “below average” in red font (see Fig. 1 for an example).
Measures
HHC rate. HHC was calculated as the percentage of times hos- pital staff washed their hands with soap and water or used alcohol-based hand sanitizer prior to entering or after exiting a patient’s room. HHC rates from both audit methods were cal- culated monthly and for each study phase (ie, baseline and feedback phases).
Statistical analyses
Using the power formula of Hussey and Hughes26 and assuming a type I error rate of 5% for a 2-sided test, we calculated that our planned sample size (200 observations per month) had 87.9% power to detect a 0.05 (eg, 60% to 65%) difference in HHC. We used descriptive statistics to report HHC rates using data from both audit methods. We used a generalized linear mixed model to examine changes in HHC rates based on study phase and audit method, controlling for calendar month and bed size as fixed effects and facility as a random effect. Data weights were calcu- lated by dividing the number of beds at a site by the total number of beds at the 5 sites.
Results
In total, 9,301 observations were recorded using the standard audit method for the baseline phase and 28,457 were recorded for the feedback phase. In addition, 3,281 observations were recorded using the new audit method for the baseline phase, and 7,576 observations were recorded for the feedback phase. The overall unweighted and weighted HHC rates for the 2 study phases obtained via both audit methods are presented in Fig. 2, and Fig. 3 presents the HHC rates from both audit methods for each study month (study month 1 = first month of site participation). Although the weighted HHC rates for the baseline and feedback phases using the standard audit method were ~80%, the rates from the new audit method were both slightly less than 50%, an
Fig. 1. Example of the feedback tool. VISN, Veterans Integrated Service Network. Notes: Arrow direction indicates whether rate improved, stayed the same or decreased; Color indicates whether HH rate is good (green), ok (yellow), or bad (red); VISN average based on 3-month weighted average based on facility sizes.
Fig. 2. Unweighted and weighted hand hygiene compliance rates by audit method and study phase.
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116 |
Page 117 |
Page 118 |
Page 119 |
Page 120 |
Page 121 |
Page 122 |
Page 123 |
Page 124 |
Page 125 |
Page 126 |
Page 127 |
Page 128 |
Page 129 |
Page 130 |
Page 131 |
Page 132 |
Page 133 |
Page 134 |
Page 135 |
Page 136
