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Tackling Hand-Hygiene Compliance: An Organizational Approach

Hand hygiene is one of the simplest yet most effective processes for reducing infections in patient care. Hand-hygiene compliance has been the subject of directives in VA and a visible priority in recent surveys of The Joint Commission, national standards by the CDC, and an extensive campaign by the World Health Organization. But despite this high priority and strong evidence that has been available for years, compliance is at best variable. This seemingly simple practice has proven very difficult to bring to reliably high levels of compliance across an organization.

In an effort to improve hand-hygiene compliance, the Center for Organization, Leadership and Management Research (COLMR) worked closely with VISN 23 on a recently completed, three-year intervention based on the premise that although hand hygiene is an individual act, achieving high rates of compliance requires interdependent organizational action.

Organizational Components to Facilitate Improvement

Consistent with our hypotheses, we found that hand-hygiene compliance was strengthened by the presence of three interacting organizational components that medical center managers and clinicians can affect:

1. robust clinical process redesign to engage staff and incorporate evidence-based practices in routine operations;
2. active top leadership commitment to the redesign effort; and
3. links to management structures and processes to support, align, and integrate redesign.

Among the seven participating medical centers in VISN 23, four facilities showed high presence of, or fidelity to, these components (fidelity scores of 3.17 to 3.95 on a 4-point scale) while three facilities had lower scores (1.42 to 2.15) showing only partial presence. The four high-fidelity facilities demonstrated statistically significant hand-hygiene improvement over the course of the project while the lower-fidelity facilities did not. The high-fidelity facilities also had consistently higher hand-hygiene scores at the end of the project. These fidelity scores reflect real differences between the high- and lower-fidelity groups in their patterns of behavior and activities across the three model components.

Clinical process redesign. All facilities in the study used a variety of education and awareness strategies to improve hand-hygiene compliance. However, the high-fidelity facilities went beyond education and awareness to also undertake process engineering and culture change. Clinical redesign was characterized by energetic, multidisciplinary improvement teams. Teams had strong leaders with excellent project management skills who often paired with clinical leaders and often included experienced improvement experts. All teams went beyond basic process redesign methods to explore higher reliability interventions as compliance plateaued. In the lower-fidelity group, clinical process redesign was often more ad hoc. Teams, if appointed, never got off the ground or fell away due to time constraints. Teams collected data but did not use them to help understand possible sources of non-compliance or the impact of their intervention activities. Often, lower-fidelity facilities felt their teams lacked the leadership, authority, or infrastructure to accomplish their goals.

Active top leadership commitment. In the high-fidelity group, senior facility leaders were supportive of and involved in hand-hygiene improvement efforts. Perhaps most important, senior leadership involvement and support was consistent over time. Senior leaders set clear expectations about target levels of compliance and sent the message that current practices were deficient. In the lower-fidelity group, senior leaders either did not see hand hygiene as a high priority or expressed support but were not consistent in their involvement. In some cases, they modeled good hand hygiene and, for example, addressed it if it came up on patient safety and environment-of-care rounds, but they generated little sense of urgency for improvement.

Links to senior management structures and processes. In the high-fidelity group, there were explicit strategies to link improvement efforts to senior management. All facilities identified a member of the leadership team as a champion to work actively with the hand-hygiene redesign team. There were clear lines of accountability for performance that did not meet its targets. Facility managers provided resources, such as staff time, for the hand-hygiene improvement efforts. Attention to hand hygiene was regularly rewarded and hand-hygiene success celebrated. In the lower-fidelity group, senior leadership champions were less consistently identified and involved. Hand-hygiene data tended to be reviewed by standing performance improvement or patient safety committees buried several layers below leadership. The result of such disconnection was that project teams felt they did not get consistent direction, cross-department issues went unresolved, and hard-won successes were not recognized.

Implications

Although the three components associated with significant hand-hygiene improvement are within managers' control, implementing them is not always easy. In this project, the presence of the three components varied despite an intervention that was consistent across facilities. Facilities with the highest fidelity to the three components — and through those components to improved hand-hygiene performance — were those that:

1. shared the urgency to improve compliance with hand hygiene and
2. had a positive improvement climate including staff experience with quality improvement and organizational values for improvement.

These factors suggest dimensions that a medical center might assess to determine the features on which it needs to build in order to implement the three components successfully.

While improved hand-hygiene compliance was the short-term project objective, the broader aim was to test whether focused organizational support of improvement initiatives and alignment of the initiatives with broader organizational goals strengthens the ability of VA medical centers to implement evidence-based clinical practices.