At Nationwide Children's Hospital in Columbus, OH, patient safety is a hospital-wide priority. Since 2008, our Zero Hero patient safety program has focused on reducing, preventing, and ultimately eliminating any type of complications that occur. Our overall goal is to improve patient care and eradicate preventable harm.
In 2010, there was one that needed improvement. During "secret shopper" observations, we found hand hygiene compliance rates were consistently below 60% at our institution. In the US, hospital-acquired infections occur in about 5% to 10% of all patients, and result in approximately 2 million infections per year. They are estimated to claim nearly 100,000 American lives per year and cost ~$20 billion dollars.1 We brainstormed solutions and looked outside of healthcare for the answer. In doing so, we discovered a best practice used in the military and followed their model to institute a safety stand-down. A "stand-down" is when everyone stops what they're doing, especially if they're doing something wrong (in our case, not washing their hands), so that the issue can be immediately addressed with frontline staff and leadership.2 Stand-downs are used by other industries including oil and gas, commercial aviation, and public safety departments.
With this approach, we successfully achieved dramatic, rapid, and sustained increases in hand hygiene compliance. Today, our hand washing compliance is well above 90%, and a recently published study in The Journal of Patient Safety demonstrated how we have sustained those results for more than 3 years.3 Here are a few cost-effective and easily implemented approaches we took to increase compliance.
Starting a Stand-down
First, hospital leadership took action to increase the number of sanitizer gel dispensers throughout the hospital and made sure they were easily accessible. Second, we re-educated all staff about proper hand hygiene practice and the clear expectation for 100% compliance. Third, clinical unit competitions were conducted to increase visibility regarding hand hygiene practices.
To help our efforts, a "Hand-Hygiene Leadership Safety Summit" convened. Attendance was mandatory for all nurse managers, as well as physician section/department chiefs, and ancillary department directors. The summit was used to prepare hospital leaders for the upcoming stand-down. Leaders were instructed to identify barriers to achieving 100% hand hygiene in their respective areas and develop a tentative action plan that would be discussed during the upcoming 15-minute stand-down. Action plans were expected to be easily and quickly implemented and have an owner with a timeline.
At the Safety Summit, executive leadership emphasized that the hospital would significantly increase "secret shopper" hand hygiene observations. If a unit had less than 90% compliance, its nurse manager would have to discuss reasons for their unit's poor performance and develop corrective action plans with the chief nursing officer (CNO). Similarly, medical and surgical chiefs whose sections were less than 90% compliant would have to discuss their physician group's performance with the chief medical officer (CMO).
Five days following the Leadership Summit, the stand-downs occurred. Hospital administrators and quality improvement staff observed the stand-down discussions to emphasize administrative support. They were led by the manager or section chief and lasted no longer than 15 minutes. The focus was on confirming or revising the proposed action plan - and addressing any specific barriers to implementing the action plan - and consequences for noncompliance were explained.
The Role of Nursing
Before the safety stand-down, our nursing staff was noncompliant 37% of the time. One month following the Safety Summit and hand hygiene stand-down, overall hospital hand hygiene compliance increased to 94%. Nurses were critical to achieving our compliance goals at every level, from nursing leadership down. Our CNO helped to shape and enforce our plan. She held several meetings with staff, which occurred in the months following the stand-down. The "big splash" associated with stopping all nonessential clinical activity captured the staff's attention and made it clear that this was important to everyone. If hand hygiene compliance rates dropped below 90% for a patient care area, increased auditing and reporting noncompliers to senior management was remarkably effective at inspiring improvement. In noncompliance meetings with administration, both unit leaders and individuals cited no system problems, but rather simple forgetfulness among staff. All were contrite and stated they would improve their efforts. No individual suggested that hand hygiene compliance expectations were unreasonable. To date, no employee has needed to meet with senior administration a second time.
The Keys to Success
A unique aspect to our approach includes the fact that all staff members, including physicians, are held accountable for their own actions. With this approach, the only punitive element for noncompliant individuals is a discussion with senior administration - no fines or privilege suspension. Once a few employees were identified as not complying with the new effort and reported to the CMO or CNO, word spread among hospital staff about their meeting, as an indication that senior hospital leadership was serious about 100% hand hygiene compliance.
We believe other keys to success, in addition to the Stand-down, included the robust effort to increase hand sanitizer gel dispenser availability, visible and strong support from senior administration, and a significant increase (particularly after the Stand-down) in clandestine hand hygiene compliance monitoring. A final factor was the hospital attitude toward safety and accountability. Because of our other Zero Hero initiatives, we believe implementing change such as expecting 100% hand hygiene compliance is better received in an organization where accountability coupled with an expectation for highly reliable clinical care practices is prominent.
1. Centers for Disease Control and Prevention. Preventing healthcare-associated infections. 2015. https://www.cdc.gov/washington/~cdcatWork/pdf/infections.pdf.
2. Occupational Safety and Health Administration. National safety stand-down. 2016. https://www.osha.gov/StopFallsStandDown/.
3. Cunningham D, et al. The safety stand-down: A technique for improving and sustaining hand hygiene compliance among health care personnel. J Patient Saf. 2015. [e-pub ahead of print.]
At the time this article was written, Dennis Cunningham was the director of Epidemiology, Division of Infectious Diseases at Nationwide Children's Hospital, Columbus, Ohio.