Hand Hygiene Practices: Quality and Safety at St Vincent's Hospital

This report examines hand hygiene practices as a critical quality indicator in healthcare, particularly within St Vincent’s Private Hospital. It highlights the significance of hand hygiene in preventing hospital-acquired infections and improving patient safety. The report discusses methods for measuring hand hygiene compliance, including direct observation and electronic monitoring, and reviews literature on interventions to improve compliance. It identifies factors affecting compliance, such as staff education, environmental conditions, and workload distractions. A quality improvement plan is proposed, focusing on reducing distractions through training, code words, and environmental modifications to enhance adherence to hand hygiene protocols and ultimately improve patient outcomes. This document is available on Desklib, a platform offering a variety of study resources for students.

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Introduction:
Hospital acquired infection is regarded as the leading cause of mortality, hospital stay and
health care cost. Hand hygiene practices is one quality indicator that predicts the quality and
safety in health care service. Compliance to hand hygiene practices is crucial to the prevention of
hospital acquired infection as this practice breaks the chain of infection that is transmitted from
staff to patient by direct contact. It is regarded as one major indicator of healthcare quality and
patient safety as it is an integral component of infection control standard (Mumford et al. 2014).
However, interventions implemented to improve hand hygiene and prevent infection differ based
on contextual setting and different cause of non-compliance. This report aims to discuss about
the quality indicator of hand hygiene and methods used for measurement of the indicator in a
specific clinical setting. Literature review on chosen indicator and quality improvement plan
related to the chosen indicator is also provided to improve quality and safety of care.
Discussion on indicator of quality and safety:
Hand hygiene practices relates to the use of soap and water, hand sanitizers or
disinfectants to prevent transmission of infection in clinical setting. Compliance with Hand
hygiene is regarded as one of the pillar of infection control and adequate hand hygiene practice is
crucial to reduce risk of infection, mortality, morbidity and health care cost. Health care
practitioners are looking back to the basics of hand hygiene to reduce transmission of infection in
hospitals (Mathur 2011). Compliance to hand hygiene can be regarded as an appropriate
indicator of quality and safety in a hospital’s quality improvement programme as improving
hand hygiene compliance rate has been found to decrease the rate of health care associated
infection (Sickbert-Bennett et al. 2016) According to World Health Organization (2017), empty

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alcohol dispense, failure to educate staffs regarding hand hygiene technique and failure to
practice hand hygiene after glove removes results in serious failure at important phases in the
patient care system. Failure to comply with hand hygiene practices at critical point results in
patient safety issues and poor clinical performance. Apart from patient and staff, the environment
of hospitals also plays a role in compliance to hand hygiene practice (Mathur 2011). Hence,
assessment of links between hand hygiene and compliance rate is crucial to identify the factors
affecting quality and patient safety and develop appropriate intervention to address individual,
organization and environment level barrier to hand hygiene practice.
There are different methods to assess compliance with hand hygiene practices among
health care staffs at St Vincent’s Private Hospital Melbourne. Monitoring and improving each
hand hygiene action can prevent sepsis in health care stetting and lead to optimal patient
outcome. This section provides an overview about methods used to measure the quality indicator
within St Vincent’s Private Hospital Sydney. The hospital is renowned for delivery of quality
patient care since the past 100 years. It has achieved optimal performance through the
commitment of experience team of health care professionals consisting of clinicians, support
staff and nurses. The hospital has an Infection Prevention and Control (IPC) team that works
with different staffs within the hospital to promote health and safety of patient, staffs and
visitors. The main aim of this collaboration is to eliminate risk of transmission of infection. The
environmental context that has helped the hospital to sustain hand hygiene practices includes
presence of appropriate hand hygiene culture and accessibility of hand foam dispensers at the
clinical setting. All nurse and staffs are training in correct hand hygiene procedure and hand
foam dispensers are available to each ward thus eliminating common barrier to hand hygiene
compliance (St. Vincent’s Private Hospital 2018). Hence, it can be said that that the hospital has

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a multi-disciplinary approach to improve hand hygiene practices and promote quality and safety
in care. Monsalve et al. (2014) states that individual and institutional factors are interdependent
in terms of behavioral change and improve hand hygiene practices in clinical setting.
The procedure that the IPC team has implemented to prevent infection includes education
of staff, infection prevention advice, audits, surveillance and development of IPC policies and
guidelines. The advantage of these activities for infection prevention is that it has the potential to
address individual as well as organizational barrier to infection control. Performance of staffs in
hand hygiene practices is measured by recruitment of trained observers and their role in looking
for moment or opportunities at which hand hygiene should occur. The number of audited
moments at the hospital was taken as a method to estimate compliance rate (myhospitals.gov.au
2017). The hand hygiene and infection prevention program indicates use of soap to keep hands
clean. The hospital also provides directive to patients to prevent infection. They encourage
visitors to clean hands before visiting hospital to prevent transmission of infection from outside
source. The screening program for carriage of MRSA has been the most beneficial initiative at
the hospital that has increased identification of infection risk and early treatment for patient (St.
Vincent’s Private Hospital 2018). The most effective measurement method at the hospital is use
of direct observation to measure quality indicator of hand hygiene. However, as the process is
time consuming, improvement in direct observation method is needed to gain accurate results.
Summary of literature on chosen indicator:
There are much research evidence that has used different hand hygiene protocol to
improve quality of care and reduce hospital-acquired infection. Chassin, Mayer and Nether,
(2015) used hand hygiene as an indicator to prevent infection and identify causes of non-

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compliance to hand hygiene protocol. The research gave data regarding eight hospital’s
identification of specific causes of hand hygiene non-compliance at their setting and targeting
interventions to solve the problem. By means of implementation of a 22 month Hand Hygiene
Project, compliance to hand hygiene was collected from eight hospitals. The compliance to hand
hygiene was measured by two ways. Firstly, the cause of non-compliance was identified by
secret observers. The second method was to observe for instance of non-compliance and inquire
the reasons for not cleaning the hands. The analysis of compliance data by means of above two
methods revealed inconvenient location of hand rubs, poor hand hygiene culture and poor supply
of dispensers as some of the cause of non-compliance. Incomplete education and poor safety
culture was also the reason for non-compliance. This outcome helped in planning appropriate
intervention to improve hand hygiene practices and quality of care. For example, some hospitals
implemented training program to educate on relation between hand hygiene and gloves when it
was reported by staffs that hand hygiene is not necessary while wearing gloves. For difference
cause identified in seven hospitals, different solutions were proposed. The strength of the
literature was that it emphasized on identify most important cause on non-compliance and
implement targeted approach to improve quality of care. Mumford et al. (2014) suggested
development of framework as important to identify what quality indicator can encourage quality
improvement in hospital setting.
The study by Gould et al. (2017) clarified regarding the effectiveness of different
intervention to evaluate hand hygiene practices and its impact on patient outcome. The study
reported that hand hygiene audit can be done by direct observation or by utilization of direct
alcohol based hand rub. Direct observation is regarded as gold standard methodology to
evaluate hand hygiene. The benefit of direct observation method is that it can detect all

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opportunities of hand hygiene, identify barriers to compliance and improve performance in real
time. However, the disadvantage of the method is that it is time consuming and cannot capture
large data. Other approach to hand hygiene monitoring is product uptake rate which regarded as
more sensitive indicator to evaluate impact of alcohol based antiseptic on hospital associated
infection rate. The advantage of the product uptake method is that the process is cheaper and
large amount data related to factors disrupting patient’s care can be identified. Electronic
monitoring by the use of computerized devices has also been proposed and the advantage of this
method is that it increases compliance rates. The research indicates that one challenge in the
process is conducting auditing by different staffs.
Marra and Edmond (2014) gave the evidence that compliance with hand hygiene is a
good quality indicator for hospital patient safety programmes. Hand hygiene is necessary to
control infection however the compliance rate of in many hospital is less than 50%. As direct
observation to measure compliance to hand hygiene is regarded as inefficient and time
consuming method, the researcher suggested several new technologies to monitor hand hygiene
compliance. The study showed that by the use of electronic hand hygiene sensors. The research
gave example of one study where nurse wore a credit card size badge that detects alcohol vapors
and if the nurse used alcohol hand rub within 8 seconds of entering the patient room, the badge
light turns green. This data was transmitted to a centralized database to monitor individual
compliance data. However, the intervention cannot work if other agents are used by nurses.
Hence, it is necessary that other important factors such as five moments for hygiene be
incorporated in the electronic process to support health care workers to improve hand hygiene
compliance and enhance patient safety in hospital setting.

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Carter et al. (2016) measured hand hygiene compliance by looking for relationship
between environmental conditions and proper hand hygiene in clinical setting. By means of a
single-site observational study, trained observers recorded hand compliance among staffs. The
observed also recorded other variable associated with hand hygiene compliance such as glove
used, shift of observation, location, crowding and type of health worker type. The study proved
links between environment and hand hygiene practices by showing that highest hand hygiene
compliance rate was seen during non-crowding periods and among patients in private areas.
Hence, the strength of the methodology was that it proved crowding as a barrier to hand hygiene
compliance in the ED. It reflects the need to change health care environment and analyze role if
crowding on infection transmission in hospital setting. Environmental modifications may help to
support proper infection prevention practice and sustain high level of hand hygiene compliance
Quality improvement plan:
Plan: The process of direct observation method has been used as an audit method to evaluate
compliance to hand hygiene practices among staffs at the St Vincent Hospital. The staffs were
trained regarding hand hygiene practices too. However, one barrier that leads to non-adherence
despite training staffs and implementation of hand hygiene protocol is the issue that staffs fail to
conduct hand hygiene because of distraction or failure to implement hand hygiene protocol at
critical moments during emergency situations or because of busy shift. Rees (2016) explains that
multiple demands during shift and interruptions during the process affects compliance to hand
hygiene (Quality indicator) Hence, the main purpose of quality improvement initiative is to
address distractions during the process of hand hygiene and plan activities to reduce distraction
and reduce moments of failure to hand hygiene practices. It is planned to reduce distractions
during the process by training health care workers regarding the use of code work to signal

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missed opportunities of hand washing. It is planned to make changes in environment too so that
staffs get the right support to comply with hand hygiene during critical moments.
Do:
To implement the plan, the desired action is to arrange safety training program where
each staffs is educated regarding the need to complete all five moments of hand hygiene and
remind other peer regarding performing hand hygiene at all times. The staffs will be trained
regarding the use of code words while any peers missed an opportunity to hand wash. To make
the process easier, it is also planned to use new technologies like automatic reminders and RFID
to ensure that health care workers clean their hands during all critical moments. Evidence shows
that electronic hand hygiene reminder system has the potential to increase hand hygiene activity
and provide real time feedback regarding the procedure too (Ellison et al. 2015). To track
distractions and effectiveness of new technologies in preventing distraction during hand hygiene,
coaches will be also appointed so that feedback could be provided to staffs regarding the way to
manage distraction and maintain hand hygiene practices at the hospital.
With regard to the plan of making environmental changes in hand hygiene, the suggested
action is to reinforce visual cues throughout the hospital setting so that nurses and other staffs do
miss hand hygiene protocol during normal time as well as during a busy shift. Stickers and
posters related to hand washing can be posted in important areas where hand hygiene is
necessary. Nurses can use this to get reminders too. Evidence has shown the effectiveness of
simple visual cue in improving hand washing compliance. It states that an environment that
provides visual cues are effective strategies to minimize barrier to hand washing compliance
(Ford et al., 2014).

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Study:
The effectiveness of above mentioned plan of activities can be done by collecting data on
number of missed opportunities to hand hygiene and reduction in infection rate at the hospital.
The strategy of peer reminders and use of new technology to remind peers about hand hygiene
can track the reduction in hand hygiene non-compliance rate. The electronic reminded system
can be adjusted to collect data related to real time hand hygiene activity. In addition, the
effectiveness of peer reminder can be judged by recruitment of a trained observer who can assess
the manner in which staffs provided reminders to their peers and the rate of reduction in missed
cases due to the activity. Furthermore, the effectiveness of visual cue can be done by evaluating
the volume of hand hygiene products that has been used by the worker after implementation of
the quality improvement initiative.
Act:
After the evaluation of the effect of changes proposed to reduce distraction and improve
hand hygiene, the above mentioned activities will be repeated every year at the clinical setting to
sustain hand hygiene practices.
Evaluation of quality improvement activity:
The effectiveness of the quality improvement initiative can be done by extracting real
time data related to hand hygiene activity after providing electronic reminders to staff. The
comparison of number of hand hygiene activity before and after the use of electronic reminder
can help to detect improvement in hand hygiene events. The benefits of the change process can
be confirmed when increase in hand hygiene activity is seen in clinical setting due to electronic
reminder. The effectiveness of visual cues as the stimulus to increase hand washing can be

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judged by the analysis of volume of hand wash and alcohol rubs used during the change process.
The increase in use of dispenser will give idea about the effectiveness of the strategy in
improving one element of hand hygiene practices.
Conclusion:
Hand hygiene is one of the important health care activities to control infection and
prevent quality and patient safety issues in practice. The report discussed about the quality
indicator of compliance to hand hygiene to determine the impact of indicator in improve quality
of care. With support from evidence, the report gave insight into different methods to measure
hand hygiene compliance and gave about strength and weakness of each method. The report
regarded disruption as one care element that influence hand hygiene practices and proposed a
quality improvement plan to improve issues related to disruptions during the process of hand
hygiene.

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Reference:
Chassin, M.R., Mayer, C. and Nether, K., 2015. Improving hand hygiene at eight hospitals in the
United States by targeting specific causes of noncompliance. Joint Commission journal on
quality and patient safety, 41(1), pp.4-12.
Gould, D.J., Creedon, S., Jeanes, A., Drey, N.S., Chudleigh, J. and Moralejo, D., 2017. Impact of
observing hand hygiene in practice and research: a methodological reconsideration. Journal of
Hospital Infection, 95(2), pp.169-174.
Ellison III, R.T., Barysauskas, C.M., Rundensteiner, E.A., Wang, D. and Barton, B., 2015,
August. A prospective controlled trial of an electronic hand hygiene reminder system. In Open
forum infectious diseases (Vol. 2, No. 4, p. ofv121). Oxford University Press.
Ford, E. W., Boyer, B. T., Menachemi, N., & Huerta, T. R. (2014). Increasing Hand Washing
Compliance With a Simple Visual Cue. American Journal of Public Health, 104(10), 1851–
1856. http://doi.org/10.2105/AJPH.2013.301477
Rees, L., 2016. Exploring the Barriers and Levers to Hand Hygiene of Nursing and Medical Staff
in Emergency Departments: A Mixed Methods Study.
World Health Organization, 2017. WHO guidelines on hand hygiene in health care. First global
patient safety challenge clean care is safer care. 2009. Retrieved from whqlibdoc. who.
int/publications/2009/9789241597906_eng. pdf.
Sickbert-Bennett, E.E., DiBiase, L.M., Willis, T.M.S., Wolak, E.S., Weber, D.J. and Rutala,
W.A., 2016. Reduction of healthcare-associated infections by exceeding high compliance with
hand hygiene practices. Emerging infectious diseases, 22(9), p.1628.

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St. Vincent’s Private Hospital (2018). Infection Prevention and Control. Retrieved from:
http://svph.ie/visitors/announcements/
myhospitals.gov.au 2017. Safety and Quality. Retrieved from:
https://www.myhospitals.gov.au/hospital/016150J/st-vincents-private-sydney/hand-hygiene
Monsalve, M.N., Pemmaraju, S.V., Thomas, G.W., Herman, T., Segre, A.M. and Polgreen, P.M.,
2014. Do peer effects improve hand hygiene adherence among healthcare workers?. Infection
Control & Hospital Epidemiology, 35(10), pp.1277-1285.
Mathur, P., 2011. Hand hygiene: back to the basics of infection control. The Indian journal of
medical research, 134(5), p.611.
Carter, E.J., Wyer, P., Giglio, J., Jia, H., Nelson, G., Kauari, V.E. and Larson, E.L., 2016.
Environmental factors and their association with emergency department hand hygiene
compliance: an observational study. BMJ Qual Saf, 25(5), pp.372-378.
Marra, A.R. and Edmond, M.B., 2014. New technologies to monitor healthcare worker hand
hygiene. Clinical Microbiology and Infection, 20(1), pp.29-33.
Mumford, V., Greenfield, D., Hogden, A., Debono, D., Gospodarevskaya, E., Forde, K.,
Westbrook, J. and Braithwaite, J., 2014. Disentangling quality and safety indicator data: a
longitudinal, comparative study of hand hygiene compliance and accreditation outcomes in 96
Australian hospitals. BMJ open, 4(9), p.e005284.