Using military-style discipline to enforce hand hygiene standards

After seeing a spike in hospitalacquired infections, leaders at Nationwide Children’s Hospital decided they needed to take drastic action.

The 604-bed pediatric hospital in Columbus, Ohio, had excellent hand hygiene, according to self-reported surveys. But when leaders installed observers to covertly monitor handwashing and hand sanitization habits, compliance was less than 60%.

“So we knew that what we were doing to date was not working,” said Dr. Terrance Davis, assistant to the chief medical officer at Nationwide Children’s. “We were looking for some way of dramatically getting hand hygiene high on everyone’s agenda.”

Dirty hands are linked with healthcare-acquired infections, which are both deadly and costly. In 2011, nearly 722,000 such infections occurred in hospitals, and about 75,000 patients with those infections died. These infections cost hospitals anywhere from $28 billion to $45 billion annually.

Proper hand hygiene is considered one of the most basic elements of infection control, but the average healthcare provider cleans his or her hands less than half the number of times they ought to, according to the Centers for Disease Control and Prevention.

To effectively draw its staff’s attention to hand hygiene, Nationwide Children’s ultimately decided on a stand-down, an intervention borrowed from the military. In the 15-minute drill, which took place twice— once in the morning and once in the evening—on a single day in spring 2010, everyone and everything except essential patient care ground to a halt.

Everyone on a unit, from aides to attending physicians, convened and discussed an action plan delivered by a manager, Davis said. And if they, as units and as individuals, did not meet 90% compliance rates or were caught failing to comply, they would have to meet with the chief medical officer or chief nursing officer, or their desig- nates, to explain why.

“We didn’t know how effective that would be,” Davis said. “It turns out it’s pretty embarrassing to be called to the principal’s office to explain why you’re not doing your job.”

Even before the stand-down, there was a lot that hospital leaders had to change to ensure that everyone—not just nurses and doctors but also employees working in food and cleaning services—could comply with proper hand hygiene. That entails cleaning one’s hands before entering and after leaving a room, either with soap and water if hands are soiled or with hand sanitizer if they’re not—whether or not the hands will be touching a patient.

But dispensers of sanitizer gel were inconveniently placed around the hospital. They were inside patients’ rooms and located behind the door. So the hospital re-installed those dispensers outside nearly every patient room, along hallways and outside elevator entrances.

“We had to make it really, really, easy to find that gel,” Davis said.

Also before the stand-down, hospital leaders convened a mandatory safety summit of medical and nursing unit directors and other department heads. There, directors were told they needed to come up with an action plan to improve compliance.

Within a month of the stand-down, compliance rates hit 90%, and they’ve stayed that way for six years. Davis and his colleagues published the results of their intervention in the Journal of Patient Safety. Davis said separately that healthcare-acquired infection rates had dropped significantly in several categories, including surgical site infections and central line infections.

It was not the dramatic stand-down alone that was so effective. The entire culture shift was well-engineered and planned out, Davis said, and hospital leadership took it seriously. The fact that staff and providers were heavily monitored helped enforce the new culture of strict adherence to hygiene protocols, too.

“That whole combination of things—taking it seriously, leadership engagement and accountability—really had some meaning to it,” Davis said.

One way the hospital knew the new approach was working was when a specific brand of feedback began trickling in. “We began getting a lot of complaints of skin irritation,” Davis recalled. “We had to go through several different types of cleaning gel until we got one that had enough lotion in it.”