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hand hygiene compliance among HCWs.18–20 These studies suggest that different types of interventions could increase hand hygiene compliance in healthcare organizations. Despite these efforts, it remains challenging to sustain long-term effects.21,22 To date, few studies have included friendly competition within
organizations are determinants for hand hygiene compliance.13–16 Studies that have investigated hand hygiene compliance among different types of HCWs have found that compliance is higher among nurses than physicians and other HCWs.17 Multiple intervention studies have been performed to increase
Manon D. van Dijk et al
and between hospitals in their intervention designs to encourage HCWs to improve hand hygiene.21 For example, Salman et al22 implemented a motivation scoreboard with hand hygiene com- pliance results of HCWs to improve the compliance rate. Gaynor et al23 examined the impact of competition between hospitals on efficiency and concluded that length of stay decreased more for hospitals in a competitive market.24 In conclusion, interventions to increase hand hygiene com-
pliance in healthcare organizations are an important but complex topic. To our knowledge, interventions in a natural setting with the involvement of different healthcare organizations in friendly competition are rare. We aimed to investigate the effects of friendly competition on hand hygiene compliance by imple- menting a WHO multimodal regional intervention strategy framed as a friendly competition intervention program. The second objective was to gain insight into the differences in hand hygiene compliance between wards and types of HCWs.
Methods Study design
In 2014, the “Collaborating Rijnmond Hospitals” program “Roll Up Your Sleeves” started in 10 healthcare organizations (9 hos- pitals and 1 rehabilitation center) in the greater Rotterdam region. During this prospective comparative observational study, the effect of friendly competition (between and within the healthcare organizations) on hand hygiene compliance was observed as the primary outcome. Compliance with hand hygiene was observed on different wards and among different HCWs within each healthcare organization at 5 time points between May 2014 and September 2016.
Study population
The “Roll Up Your Sleeves” project was implemented in 10 healthcare organizations. Only HCWs that had physical contact with patients were included in the observations. In total, 20,286 hand hygiene opportunities were observed on 120 wards. Figure 1 shows a hierarchical overview of the 3 levels in the study: the organizational level, the ward level, and observed hand hygiene opportunities.
Intervention
The “Roll Up Your Sleeves” intervention was based on mon- itoring and feedback of achievement at 6-month intervals over 2 years. In addition, multiple (optional) training elements were offered. (1) Individual e-learning was provided about hand hygiene techniques and opportunities, different for nurses and physicians. (2) A kick-off workshop was conducted in which stakeholders (primarily infection control staff, ward managers, or
head nurses) from each organization defined the implementation strategy for their organization by setting up a framework with rules, priorities, and goals regarding hand hygiene. (3) Team training was offered in a train-the-trainer setting; several stake- holders (usually infection control staff and ward nurses) from each organization were trained to train other HCWs in their own organization on how to improve hand hygiene team performance on wards. (4) In observer training, infection prevention specialists and HCWs were trained to perform their own internal audits. All interventions were delivered by an external trainer of the “Col- laborating Rijnmond Hospitals” program, and the observer training was based on the “Hand Hygiene Australia” protocol.11 As a fifth (and compulsory) core element of the program, the stakeholders of each organization received the standardized feedback report on hand hygiene compliance after each round of observations. In total, 5 observation rounds were conducted over a 2-year period at 6-month intervals. At the director level, the results were presented during annual meetings of the hospital collaborative to which all institutions belonged. Furthermore, the program leader within each organization (usually an infection control practitioner) received a feedback report and was responsible for distributing the results within the organization, usually via newsletters, ward reports or hospital websites. This report included the hand hygiene compliance rate on the orga- nization level (aggregated) and the ward level. During an annual conference, the overall results were presented and the organiza- tions and wards with best results received a prize. The added value of this friendly competition setting is that healthcare organizations can learn from each other and keep challenging themselves to improve.
Data collection
HCWs were unobtrusively observed by trained observers at 5 time points (at 6-month intervals) from May 2014 to September 2016. New independent (medicine) students and research assis- tants were trained for each round of observations. The students had to participate in a training by an external trainer of the “Collaborating Rijnmond Hospitals” program. At the end of the training, observers were tested on their knowledge and observa- tion skills using an auditor test developed by Hand Hygiene Australia. For the observations, the Hand Hygiene Australia observation instrument was used. This instrument is based on the Five Moments of Hand Hygiene described by the World Health Organization (WHO).10,11 Data were collected during a 2-hour period (8:00–10:00 A.M.), and at least 3 nurses were followed and observed. Physicians and other HCWs who assisted the observed nurses were also included in the observations.
Statistical analysis
The dependent variable in this study was hand hygiene com- pliance, calculated by dividing the number of correct hand hygiene opportunities by the total number of hand hygiene opportunities. The independent variables in this study were the 5 time points, different ward types, and type of HCW (ie, physician, nurse, or other). Hand hygiene compliance was coded as “missed” or “rub/washed.” A χ2 analysis was performed to investigate the association
between the dependent variable and each individual independent variable, comparing time point 1 with 5. Univariable and
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