Healthcare Hygiene magazine October 2019 | Page 35

hand hygiene
opportunities, which is not a statistically valid sample. The
result is that compliance rates are dramatically overstated
– typically by up to 300 percent based on studies, 1 and this
means that compliance measured as 90 percent with direct
observation may in reality be only 30 percent.
Many electronic systems to measure compliance were
launched during the 2010s. These systems eliminated many
of the shortcomings of direct observation, such as the
Hawthorne effect and small sample size, since electronics
can capture virtually 100 percent of hand hygiene events
at all times. Die-hard defenders of direct observation may
ridicule and oppose the technology’s adoption, citing direct
observation as the “gold standard” (which it was until this
more accurate, reliable, and effective technology category
came along). While a nascent category that is still in the early
adopter phase, the migration from human direct observation
or secret shoppers, to validated, automated, systems that
constantly measure healthcare worker performance is here
to stay. The scientific evidence is becoming clear that the
future “gold standard” will be the combination of direct
observation as a “coaching and obstacle identification tool”
with electronic monitoring as the “measurement tool.” 2-3
Further, overstated rates, such as those reported by Srigley
et al, enable a false sense of complacency that unacceptably
puts patients at risk. Given the ability to mitigate the risk
of patient harm with this new technology, it is likely that it
will overcome the ridicule and opposition phases and move
towards widespread acceptance.
And the market is moving too. For instance, a growing
number of progressive health systems have gone with full
commercial implementations (The Greenville Health System,
now Prisma Health Upstate, in South Carolina and the Atlantic
Health System in New Jersey among them). Moreover, most
of the major group purchasing organizations that have added
the category of e-monitoring and studies have demonstrated
its clinical and economic benefits. 4
Whether e-monitoring will become the standard of care
will depend on whether a system that is simple, affordable,
and overcomes some of the inherent implementation and
cultural barriers in currently available systems is developed
– and there is no reason why this should not happen.
Despite these innovations, healthcare hand hygiene still
has a lot of room for improvement, given that compliance
is only about half of what it should be. For instance, health-
care workers who must clean hands 40 to 50 times a shift
should be confident that the products they use improve
skin health, but products that dry their skin remain a barrier
to compliance.
Additionally, healthcare hand hygiene should be mul-
tidisciplinary, drawing from fields such as human factors
engineering, behavioral science, and data science to propel
the next innovations.
An inventory of the prospective attributes of that best
in class, next generation hand hygiene approach might
look like this:
www.healthcarehygienemagazine.com • october 2019
• Hand hygiene products (soaps, sanitizers and lotions)
that are “skin friendly,” with the lowest possible risk of
healthcare worker intolerance
• Dispensers that are not only able to measure compliance,
but indicate product levels and any performance issues,
ensuring product is always available and empty dispensers
are a thing of the past
• Training and educational tools based on sound behav-
ioral science that drive high levels of sustainable performance
improvement with requisite culture change
• Affordable, validated methodology for measuring
compliance accurately and reliably, with feedback approaches
that foster psychological safety (everyone feels safe reminding
anyone to do hand hygiene when an opportunity is missed)
and the development of a just safety culture
• Predictive analytics that forecast hot spots (risk of
low compliance and/or healthcare-associated infection
transmission) before they occur
• Artificial intelligence, learning systems and the Internet
of Things are likely to have leading roles in the future of
hand hygiene
One would hope that we are about to put all the learning
and capabilities to work and that by the 200th anniversary
of Semmelweis’s seminal research (if not much sooner),
proper hand hygiene will be a habit for every healthcare
worker around the world.
Whatever the next disruptive innovation brings, it is time
to get hand hygiene right. We live in an age of value-based
healthcare, and variability of performance should not and
cannot be tolerated. It will take early adopter pioneers who
are willing to accept the ridicule, knowing that what they
are doing represents the truth for themselves and those
they care for, to usher in this new age of highly reliable
hand hygiene performance.
Paul Alper, BA, led the launch of GOJO’s PROVON® and
PURELL® brands in the late 1980s and 1990s. He invented
and was highly involved in the clinical research behind the
first hand-hygiene electronic monitoring system. He is now
the vice president of patient safety Innovation for Medline
Industries, Inc. through an exclusive engagement with his
consulting practice, Next Level Strategies, LLC.
References:
1. Srigley JA, Furness CD, Baker GR and Gardam M. Quantification of
the Hawthorne Effect in Hand Hygiene Compliance Monitoring Using an
Electronic Monitoring System: a Retrospective Cohort Study. BMJ Qual Saf.
23, 974-80. 2014.
2. Boyce JM. Electronic Monitoring in Combination with Direct Obser-
vation as a Means to Significantly Improve Hand Hygiene Compliance. Am
J Infect Control. 45(5), 528-535. 2017.
3. Kelly JW, Blackhurst D, McAtee W and Steed C. Electronic Hand
Hygiene Monitoring as a Tool for Reducing Health Care Associated Methi-
cillin-Resistant Staphylococcus aureus Infection. Am J Infect Control. 44(8),
956-957. 2016.
4. Kelly W, Blackhurst D, Steed C, Boeker S and McAtee W. Use of
the Targeted Solutions Tool and Electronic Monitoring to Improve Hand
Hygiene Compliance. Paper presented at the 2016 SHEA annual meeting.
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