RESEARCH ARTICLE

Good to Great: Quality-Improvement InitiativeIncreases and Sustains Pediatric Health CareWorker Hand Hygiene ComplianceHeather S. McLean, MD,a Charlene Carriker, BSN, CIC,b William Clay Bordley, MD, MPHa

A B S T R A C T OBJECTIVE: The Joint Commission, the Centers for Disease Control and Prevention, and theWorld Health Organization challenge hospitals to achieve and sustain compliance with effectivehand hygiene (HH) practice; however, many inpatient units fail to achieve a high level of reliability.The aim of the project was to increase and sustain health care worker (HCW) compliance withHH protocols from 87% (level of reliability [LOR] 1) to $95% (LOR 2) within 9 months on2 pediatric inpatient units in an academic children’s hospital.

METHODS: This study was a time-series, quality-improvement project. Interventions weretested through multiple plan-do-study-act cycles on 2 pediatric inpatient units. HH complianceaudits of HCWs on these units were performed randomly each week by the hospital infectionprevention program. Control charts of percentages of HCW HH compliance were constructed with3-s (data within 3 SDs from a mean) control limits. These control limits were adjusted afterachieving significant improvements in performance over time. Charts were annotated withinterventions including (1) increasing awareness, (2) providing timely feedback, (3) empoweringpatients and families to participate in mitigation, (4) providing focused education, and (5) developinginterdisciplinary HH champions.

RESULTS: HH compliance rates improved from an average of 87% (LOR 1) to $95% (LOR 2)within 9 months, and this improvement has been sustained for .2 years on both pediatricinpatient units.

CONCLUSIONS: Significant and sustained gains in HH compliance rates of $95% (LOR 2)can be achieved by applying high-reliability human-factor interventions.

aDivision of Hospital andEmergency Medicine,

Department of Pediatrics,and bDuke Program for

Infection Prevention, DukeUniversity Medical Center,Durham, North Carolina

www.hospitalpediatrics.orgDOI:10.1542/hpeds.2016-0110Copyright © 2017 by the American Academy of Pediatrics

Address correspondence to Heather S. McLean, MD, Division of Hospital and Emergency Medicine, Duke University Medical Center,2301 Erwin Rd, Box 100501, Durham, NC 27710. E-mail: heather.mclean@duke.edu

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Dr McLean conceptualized and designed the study, participated in the study development, analyzed the data, and drafted the initialmanuscript; Ms Carriker participated in the study development and data analysis; Dr Bordley participated in the data analysis andcritically reviewed the manuscript; and all authors approved the final manuscript as submitted.

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According to the World Health Organization,7 out of every 100 hospitalized patientswill acquire health care–associatedinfections (HAIs). Infection-control measuressuch as effective hand hygiene (HH) canreduce the frequency of HAIs by .50%.1–3

The Centers for Disease Control andPrevention and the World HealthOrganization have supported improvementsby providing recommendations and best-practice and implementation guidesdesigned to improve HH compliance, withlimited success. Nevertheless, health careworker (HCW) compliance with HHguidelines remains below benchmarkspreviously set by The Joint Commission.4

Despite widespread availability ofevidence-based HH implementation tools,physicians and other HCWs do not reliablyfollow guidelines.5–7 Common barriers toguideline adherence include lack ofawareness, familiarity, agreement, self-efficacy, outcome expectancy, and inabilityto overcome inertia of previous practice.8

Building on a general understandingof these barriers and using knownimprovement methods to develop atargeted approach is key to achieving theproject aim.9

Principles of reliability science can beused to understand complex health careprocesses, measure performance, anddesign interventions to achieve desiredresults. The Institute for HealthcareImprovement has a 3-step model (prevent,identify-and-mitigate, redesign) that healthcare organizations can use to achievelevels of reliability (LORs) of compliance$95% (LOR 2) to improve patient safety.10

Targeting safety culture and usingchampions are examples of successful LOR2 interventions for improving processes oroutcomes for patients.11–13 We used theseconcepts in the design of the project toimprove and sustain HH compliance ratesof $95% (LOR 2).14,15

Despite previous attempts to improve HHperformance on the 2 pediatric inpatientunits, compliance remained below thehospital goal of 95% and lagged behind allother areas in the children’s hospital.Posted signs and intermittent educationalprograms for staff were in place to achieve

LOR 1 performance. However, specificinterventions aimed at the desired compliancerate of $95% were needed to improve ratesfrom “good” (LOR 1) to “great” (LOR 2). Withthis in mind, we designed our project toinclude high-reliability concepts. The Specific,Measureable, Achievable, Relevant, and Time-bound (SMART) aim16 of the study was toincrease HCW compliance with HH protocolsfrom 87% (LOR 1) to $95% (LOR 2) within9 months in the 2 pediatric inpatient units.

METHODSSetting

Duke Children’s Hospital is a 190-bedtertiary care children’s hospital, within alarge academic medical center, that has∼7500 admissions per year in Durham,North Carolina. The project focused onthe 2 pediatric medical surgical unitswith 31 rooms each; 1 unit had morehematology/oncology patients, whereasthe other had more solid-organ transplant,pulmonary, and cardiology patients.These units were chosen as the studylocation because of the mixed patientpopulation and the desire of nursing andphysician unit leaders to improve HHcompliance rates.

Before the project began, both units hadsinks with antimicrobial soap and papertowel dispensers, hospital-approvedalcohol-based hand sanitizer near thepatient door entrance, and signs remindingHCWs to clean their hands. HCWs wererequired to complete the hospital’s annualonline infection prevention (IP) educationalmodule. In addition, periodic education wasprovided to HCWs from the hospital’s IPprogram in response to low compliancerates. Performance was measured weeklyby using a validated directly observed HHaudit (DOHA) program. HH compliance wasreported monthly as a percentage on unitscorecards.

Human Subjects Protection

The Duke University Health SystemInstitutional Review Board determinedthat this study did not meet the definitionof research and satisfied the PrivacyRule because the study was consideredpart of hospital quality-improvementefforts.

Study Design

We used a time-series, quality-improvementdesign to evaluate the effectiveness ofinterventions to improve HCW HHcompliance on 2 inpatient pediatric units.Testing of the interventions occurred on1 unit and was expanded to the other.Because of the diverse patient population,we hypothesized that other centers couldsuccessfully replicate interventions in othersimilar inpatient units.

Planning the Intervention

In the fall of 2013, a multidisciplinaryproject team was assembled that included2 nurse managers, an IP nurse, and apediatric hospitalist, who was also themedical director of the inpatient units. Adhoc membership on the improvement teamincluded a pediatric chief resident, bedsidenurse, nursing assistant, and HH auditor.The team mapped the process,17 conducteda modified failure mode and effectsanalysis, examined key drivers, andprioritized interventions in a key driverdiagram (Fig 1).14

First, the team observed noncompliantencounters and categorized them by HCWtype in a Pareto chart (Fig 2). We foundthat although nurses were the mostfrequent noncompliant HCW type, manynoncompliant encounters were fromnursing students and hospital volunteerswho are less familiar with HH protocols.Understanding the frequency anddistribution of noncompliant HHencounters allowed us to target ourinterventions accordingly.

Data for both units were aggregated anddisplayed together because the sample sizefor many of the weeks was too small tomeasure the effect of changes. Interventionswere prioritized on the basis of commonreasons for noncompliance as observed bymembers of the improvement team,available evidence,3,9,13,18 and desire toimplement high-level-reliability designconcepts. To achieve compliance rates of$95%, we tested and implemented thefollowing 3 LOR 2 change concepts19: (1)development of a redundant HH supplysystem, (2) implementation of an HHchampion program to provide real-time

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mitigation, and (3) empowering families andpatients to remind HCWs to perform HH.

Improvement Activities

Interventions focused on the following 5 keydrivers: (1) HH supplies consistentlyavailable at the point of care, (2) HCWs

knowledgeable about how and when tobe compliant with HH, (3) compliancewith HH is the norm, (4) real-timeidentification of noncompliance, and (5)leadership committed to improving HHcompliance. Interventions were developedand tested by using multiple plan-do-study-

act (PDSA) cycles.14 On the basis of ourobservations of noncompliant encounters,we performed several PDSA cyclestargeting these drivers as shown in Fig 1.PDSA cycles are summarized in Table 1 andare described below as they relate to thedrivers.

FIGURE 1 Key driver diagram summarizing the project aims, drivers, and interventions.

FIGURE 2 Pareto chart categorizing HH compliance failures by HCW type on 2 pediatric units from August 1, 2013, through December 30, 2013.

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HH Supplies Consistently Availableat the Point of Care

During observations of HH practice onthe units, the project team found thathand sanitizer available in and outsideof each patient room was not replacedconsistently. PDSA cycles resulted in thedevelopment of a standardized checklistand a redundant supply process fornursing assistants and environmentalservices workers. Implementation ofthis LOR 2 intervention created a reliablehand sanitizer supply system thatsupported the HH practice of HCWs onboth units.

HCWs Knowledgeable About How andWhen To Be Compliant With HH

The project team learned that HCWs knewhow to clean their hands but did not always

do so with each room entry and exit andwhen using contact and droplet isolationmaterials. We also learned about a behaviorwe called “popping in.” HCWs wouldenter and exit a patient’s room withoutperforming HH to quickly speak with thepatient or family. HCWs were unaware thatthis practice was noncompliant, because hisor her intent was to avoid touching thepatient or room contents. Education andawareness interventions targeted differentHCW groups on the basis of their commonreason for noncompliance. For example,visual reminders were found to be mosthelpful for nursing students, volunteers, andother less common HCW types who do notregularly work in these units, whereasnurses were given education to mitigate“popping in.” We observed a qualitativeimprovement in HCW HH practice knowledge

during staff meetings and other informaldiscussions.

Compliance With HH Is the Norm

We learned that HCWs responded well toreceiving weekly feedback by e-mail andposting annotated control charts withdetailed narrative information aboutnoncompliance. Project team membersdiscussed performance during staffmeetings, in the weekly resident e-mailnewsletter, at monthly pediatric hospitalmedicine faculty meetings, and atmultidisciplinary unit safety meetings. Theseefforts helped improve the transparency ofdata by providing frequent, detailed feedbackand showed that complying with HH was thenorm by reinforcing good practice.

An HH champion program was tested andimplemented on the basis of the formal

TABLE 1 Summary and Timeline of Interventions

Tests of Change Intervention Start Dates Lessons Learned Interventions

Visual reminders 10/7/2013 (screensaver) –Important to use multiple types such asscreensavers, door signs

–Placed “Wash Your Dukes” screensaver onall patient and staff computers

2/2/2013 (door signs) –Make the image simple and visually appealing –Created and posted bright, laminated “WashYour Dukes” signs on all patient doors–Rotate types of signs if able to keep reminders

“fresh”

Feedback of performance 10/21/2013 –Provide feedback frequently to target audience –Provided weekly feedback to all HCWs bye-mail, posted in work rooms, discussedduring monthly unit safety meeting

–To reach all HCWs, used e-mail, postingannotated control charts, discussed duringstaff meetings

–Important to include information about specifictypes of noncompliance (who, when, why)

Standardizing the hand sanitizersupply system

12/29/2013 – Discovered a lack of protocol or ownership forwho would resupply and maintain stock ofhand sanitizer

–Developed standardized checklist for supplysystem–Developed redundant supply system fornursing care assistants and janitorial staff

Isolation protocol remindersigns

1/19/2013 –Learned that HCWs did not understand properprotocol and wanted posted information

–Created and posted signs with the isolationcarts showing how to perform isolationprotocol

Use of safety champions 4/13/2014 –Role clarification of champions is needed forconsistency

–Recruited champions, adapted “champion”nursing role, created expectations, andimplemented role–Adaptation of hospital nursing “champion” role

and reporting structure to unit leadership–Multidisciplinary teams should include nurses,attending physicians, case managers, nursingcare assistants

–Use of hospital medicine attending physiciansfor leadership, educational, and continuitypurposes

Empowering patients andfamilies using signs

5/4/2014 –Testing signage with target audience wasimportant

–Developed and posted signs in each patientroom inviting families to speak up if they didnot see staff cleaning hands–Some staff considered language asking them if

they washed their hands to be offensive–Some families did not notice whether staffwere compliant with HH

–Families on oncology service more likely tosupport importance of good HH compliance

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nursing champion role used for otherpurposes. We theorized that identifying,training, and empowering nurses, nursingcare assistants, hospitalists, and casemanagers to become HH experts andprovide peer-to-peer reinforcement ofcorrect practice would influence unitculture. These HCWs were chosen becauseof their impact on the largest HCW types,frequency of contact with new employees,visibility on the units, and leadershipcharacteristics. As a result of thesechanges, we observed a qualitativechange in the culture of the units thatperforming correct HH every time wasthe norm.

Real-Time Identification ofNoncompliance

Although delivering regular feedback ofperformance resulted in improvedcompliance with HH protocols, creating aprogram to provide real-time identificationof noncompliance and mitigation resulted ina higher level of reliability. Testing thistheory resulted in implementation of amultidisciplinary HH champion program andposting signs inviting families to enforceHH practice. During this test of change,we observed that some families were notaware of HH compliance and seemeduninterested in reinforcing this practicewith HCWs. However, families and patientswith medical complexity, central lines, ora compromised immune system were, ingeneral, enthusiastic about participatingin the mitigation of noncompliance.

Leadership Committed To ImprovingHH Compliance

Unit nursing and physician leaders weremotivated to improve HH performance ontheir units, acting as champions, rolemodels, and educators. Testing of theseroles focused on how and when unit leadersshould show their commitment andcommunicate expectations to HCWs.As mentioned previously, incorporatingcommunication of HH performance intoexisting safety and operational meetingsshowed the commitment of unit nursing andmedical director leadership. In addition,unit leaders discovered the value ofunofficial leadership of a staff member by

empowering a motivated nursing assistantto serve as a unit champion to provide real-time mitigation and feedback.

Measurement

Data were collected from August2013 through March 2016 and tests ofchange occurred between September2013 and May 2014. DOHA auditors collectedHH performance data in accordance withthe Centers for Disease Control andPrevention guidelines2,20 on the 2 pediatricinpatient units. They used random, covertaudits to collect and enter data into adatabase with the use of Web-enabled hand-held devices.

A compliant HH encounter was defined ascleaning ungloved hands with soap andwater or hospital-approved hand sanitizerimmediately before and after the HCWenters a patient room or care area. Forpatients with isolation precautions,compliance was defined as first donninggown and/or surgical mask, followed byproper cleaning by rubbing hands andwrists with sanitizer or using soap andwater, and then the application of cleangloves before room entry. Upon departurefrom the room, a compliant encounterincluded first removal of isolationequipment followed by proper HH.

Data for all HCW types, by clinical servicearea and time and date of observation bythe DOHA auditors, were available to theproject team on a secure Web site for thecalculation of the project measure. The HHperformance measure was defined as theratio of compliant observations divided bythe total number of observations, which wasreported as a percentage continuously overtime in a percentage control chart (p-chart)(Fig 2). In addition, central line–associatedbloodstream infections (CLABSIs) weremeasured for each unit as CLABSI rate per1000 line-days during the project period.

Analysis

This study used a time-series, quality-improvement project design. Analysis of HHcompliance measures was performed byusing a statistical process control (SPC)chart p-chart.18,21 During the baseline andintervention phases of the project, weeklypercentages of HH compliance for HCWs

on both units were plotted on an SPC chart(Fig 3). Starting June 2014, HH compliancewas plotted monthly rather than weeklyonce the project entered the controlphase. Monitoring performance with theuse of an SPC chart allowed fordifferentiation between normal andspecial-cause variation. Special-causevariation was defined as $8 points aboveor below the mean, according to standardSPC rules.22 The upper and lower controllimits of the SPC chart defined the regionin which 99% of the data will be located.The SPC chart was annotated with the startdate of each intervention so its impactcould be correlated with HH compliancerates. Microsoft Excel (MicrosoftCorporation, Redmond, WA) withcustomized macros was used to performthe analysis and construct the p-chart.Interventions impacting HH compliance foreach unit were compared with baselineperformance over time.

RESULTS

Baseline HH compliance rates were variable,ranging from 61% to 99% with an average of87% (LOR 1). The relationship of variousinterventions to HCW HH compliance isshown in the annotated SPC chart (Fig 3).The first 3 interventions (visual reminderson all computer monitors and patient doors,unit leaders serving as role models andeducators, and weekly feedback of data)resulted in special-cause variation andperformance of $95% (LOR 2). Additionalinterventions, including standardizing thesupply system, displaying isolationprecaution information and patient doorsign reminders, and development of an HHsafety champion, resulted in special-causevariation and a second upward shift of themean line. HH protocol compliance wassustained at $95% (LOR 2) for .2 years.Furthermore, the decrease in variabilityshown by the narrowing of the controllimits from the baseline period, August2013, through the end of interventions inJune of 2014 suggested that the processbecame more stable over time. CLABSI ratesper 1000 line-days remained unchanged oneach unit, with averages of 1.35 and 1.08from August 2013 through March 2016,despite improvements in HH compliance.

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DISCUSSION

The implementation of evidence-basedinterventions improved HH practicereliability from a compliance rate of 87%(LOR 1) to $95% (LOR 2) on 2 pediatricinpatient units, and these results weresustained for .2 years. The inclusion of alltypes of HCWs working on units with amixed population of pediatric patientsmakes this work generalizable to otherhospitals.

Effective, reliable completion of HH witheach patient encounter is a deceptivelycomplex task and is influenced by manyfactors in the real world of hospital care.This study, like previous initiatives,3,9,13,18

successfully implemented multipleinterventions targeting education, increasedawareness, data feedback, and strongleadership support to improve HH. However,previous studies either targeted a specifictype of HCW13 or failed to achieve sustained

performance as high as $95% (LOR 2).3 Thework required to design a system to achieveLOR 2 that targets all HCWs is more difficultand, as shown by this project, requiredseveral LOR 2 interventions. This project wasunique in that it used high-reliability changeconcepts to improve performance from LOR1 to LOR 2 on 2 pediatric units and alsosustained the LOR 2 performance level for.2 years.

Previous interventions in our hospitalachieved LOR 1 performance by improvingawareness, monthly feedback ofperformance, and providing educationresulting in HH compliance rates in the mid-80% on both units with a variability of 61%to 99%. Our project successfully improvedand sustained compliance at $95% byimplementing LOR 2 interventions, includingcreating a culture in which HH complianceis the norm, implementing interdisciplinaryHH safety champions to provide real-time

feedback and mitigation, and creatingredundancy in the hand sanitizer supplysystem. Although it is difficult to determinewhich intervention caused the largest effect,we believe that weekly feedback ofperformance data that included specific,narrative feedback displayed with anannotated SPC, rather than as a percentageon dashboards, was critical to our success.The timely, accurate measurement byHCW type made it possible to change unitculture and to sustain it by creating asystem of interdisciplinary HH champions.These HH safety champions identifiednoncompliance and provided remindersto the HCW to comply with protocolsimmediately at the time of the event. As aresult, HCWs became more aware of theirown behavior, contributing to an overallimprovement in unit culture.23 HCWs wereempowered to speak up and establish asocial norm for behavior on these units.

FIGURE 3 Percentage of compliant HH encounters on 2 inpatient units: p-chart shows the primary outcome measure with annotations of test of change.The x axis is labeled with every other week or month, and data points are weekly until June 2014 when they were measured monthly.

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In addition, the Hawthorne effect, which is asocial phenomenon described as behaviorchange due to an awareness of beingobserved,24 was likely a major contributor toour project improvements. Althoughmedical researchers are careful tominimize this effect, individuals who want tochange... health care systems can use theHawthorne effect to their advantage.25,26

Previous studies have measured the positiveeffect that auditors alone27 or coupled withattention to improvement can have on HHcompliance.28,29 Our project combines theinfluence of performance auditing,leadership commitment, HH champions,informational signage, reminders, andempowering patients and families to speakup to create a powerful Hawthorne effect.Furthermore, these interventions have beenincorporated into the operation of the unitscontributing to sustained HH performance.

Our study had several limitations. This wasa single-center study, and our results maynot be generalizable to other settings. Wedid not measure the cost-effectiveness ofthis improvement project or other balancingmeasures, such as staff satisfaction. Wealso did not quantify how often patients andfamilies or HH champions reminded HCWsto comply with HH protocols, nor did wemeasure HH knowledge. Finally, we wereunable to link improvements in HHcompliance to HAIs such as CLABSIs.

The Duke Program for Infection Preventionand pediatric unit leadership continue tomonitor HH compliance to ensure sustainedperformance on these units. At the time ofthis publication, HH performance hasremained at $95% for .2 years. Efforts toimprove HH compliance in other areas ofthe hospital were occurring in parallelduring this project. Some of theinterventions developed in this project,including the screensaver reminders, wereexpanded across the hospital. Compliancerates in all areas of the hospital haveremained between 90% and 95%.

CONCLUSIONS

The use of proven improvement methods,including high-reliability concepts, created aHawthorne effect, which was key toimproving and sustaining HCW compliancewith HH protocols at $95% (LOR 2). Next

steps include the continued control ofpractice in these well-performing units andacross the hospital.

Acknowledgments

We thank the Duke Program for InfectionPrevention’s DOHA team for providing HHdata; Sharlotte West, Jennifer Quinn, andMichelle Bullock for help in completing thisproject; and Carol Stanley for review of themanuscript. We also thank the CincinnatiChildren’s Hospital Medical Center,Intermediate Improvement Science Series(I2S2), for providing guidance, tools, andimprovement science expertise.

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DOI: 10.1542/hpeds.2016-0110 originally published online March 9, 2017; 2017;7;189Hospital Pediatrics 

Heather S. McLean, Charlene Carriker and William Clay BordleyHealth Care Worker Hand Hygiene Compliance

Good to Great: Quality-Improvement Initiative Increases and Sustains Pediatric

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