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An interesting trend I have observed during hand hygiene audits is that staff are more likely to wash their hands after a patient encounter than before the patient encounter. This observation may be due to the perception that hand hygiene is essential to protect oneself from a potentially infected patient, more so than they are a risk to the patient.”
— Keith St. John
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so compliance in areas like before patient care or before accessing an intravenous line may be missed. SSI rates have decreased although the complex patient increases the opportunity for the rates to climb again. There are instances whereby the surgeon may perform a closing technique for a colon surgery that differs from another and that is an uncontrollable variable.”
Part of the answer, according to St. John, involves having enough devoted resources to educate, train and monitor staff for compliance with core IP & C strategies on all shifts. [ See related article on page 20 ]“ We need more competent IPs engaged at the bedside and where care is otherwise provided,” he adds.“ Being data entry clerks does not advance improvement in outcomes. Another significant hurdle is the ability to create champions for change who can serve as role models for their peers. I have a real-life example when I was the director of IP & C. We were struggling with unacceptable CLABSI rates in our neonatal intensive care unit( NICU). Ironically, some neonatologists found the rate acceptable and blamed it on the acuity status of their patients. I found one neonatologist that believed we needed to and could lower our CLABSI rate by at least 50 percent. With that champion for change among his medical staff colleagues, we assembled a multi-disciplinary CLABSI team that included nurses, respiratory therapists, administration, etc. I assigned one of my IPs to focus on the NICU and freed her from other responsibilities. In essence, with this team in place that met multiple times per week, we were able to make the 50 percent reduction goal a reality and beyond. It is critical to cultivate‘ champions for change’ among clinical team members that can serve as role models for others to follow.”
For an issue such as hand hygiene, Kalp notes,“ Developing the habit of hand hygiene compliance, both before and after patient care, can take some intentional preparation and planning. Breaking old patterns requires cognitive effort and intentionality. An interesting trend I have observed during hand hygiene audits is that staff are more likely to wash their hands after a patient encounter than before the patient encounter. This observation
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may be due to the perception that hand hygiene is essential to protect oneself from a potentially infected patient, more so than they are a risk to the patient. I believe there is complex psychology involved, which affects behavioral expression. IPs are not necessarily trained in addressing psychological and behavioral modification strategies, which can create a gap.”
Alhumaid, et al.( 2021) alludes to the fact that healthcare personnel tend to be selective in adhering to IP & C measures rather than practicing comprehensive, safe, standard precautions when engaging in contact with patients which may result in an unnecessary risk. As they note,“ In particular, during performing procedures that carry more exposure to blood products and body fluid or when dealing with sharps, compliance is good. While many researchers have investigated compliance with IP & C guidelines and reasons for non-adherence, with a lack of knowledge regularly being identified by staff as affecting their compliance, the opinions of healthcare workers about what would improve their own practice may need to be questioned further.”
Many researchers have pointed to the challenge of varying IP & C behavior among healthcare personnel, thus suggesting that individual features could play a role in determining behavior. As Alhumaid, et al.( 2021) observe,“ There is a danger in ignoring all-important‘ individual differences’ and a call to limit this approach within health psychology has previously been made. To improve healthcare workers’ compliance with practices, IP & C personnel should learn from the behavioral sciences. Social psychology attempts to understand these features, and individual factors such as social cognitive determinants may provide additional insight into IP & C behavior. Application of social cognitive models and psychological principles in intervention strategies has resulted in a change toward positive behavior in IP & C … A multifaceted approach( e. g. education, training, observation, feedback, easy access to hand hygiene supplies, dedication of financial resources, praises by superior, strong hospital leadership, prioritization to IP & C needs, collaborating with a private advertising firm in a marketing campaign and active participation at
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institutional level) is highly suggested to reduce HAIs by improving compliance among healthcare workers with IP & C measures.”
Establishing Accountability on All Sides of the IP & C Equation
It’ s important to establish accountability in healthcare settings among all stakeholders – conducting a culture of safety in a way that is neither punitive nor allows healthcare workers to shirk their responsibility to do no harm.
“ Accountability isn’ t a punishment, it’ s alignment,” says Woodall.“ It’ s really simple, set the expectation, measure the performance, give honest feedback in a two-way street and not a silo, and repeat. One of my biggest problems is that I see IPs try to protect morale by avoiding hard conversations and in doing so, we lower the bar. Accountability works when it’ s paired with clarity, support and consistency. You can’ t create a culture of safety without reinforcing expectations. And you can’ t reinforce expectations if no one’ s willing to say,‘ This isn’ t okay.’”
“ Accountability is always important,” Goss agrees, adding,“ It is hard not to be punitive though. Audits are tremendously helpful in raising awareness; however, correcting the deficiencies without accountability delays the improvement process. No one wants a situation where improvement is forced and the motivation for healthcare workers to be accountable starts with executive leadership. Leaders must set an example and they have to set the accountability standard and demonstrate how to achieve improvement.”
St. John concurs that system change that starts at the top is the answer.“ This requires a culture change that must begin at the top-- the executive team needs to set expectations,” he says.“ This can then cascade down the ranks among the diverse disciplines who interact daily with patients and residents. In academic medical centers, don’ t forget to gain the support of the dean of the medical school, too. In academic settings, physicians typically answer to the dean of the medical school, not the chief medical officer( CMO) of the hospital. Another important caveat is to engage the patient / resident and their family members in being empowered to speak up
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