AAMC Reporter: February 2007

Hand Washing Takes Center Stage

Robert Jackson, M.D., is an internist and quality control officer at the Methodist Hospital in Houston

Even with an issue as complex as the quality of clinical care, there are simple steps hospitals can take that pay big dividends.

The Methodist Hospital in Houston is a case in point. Using a few relatively humble tools that are sometimes more commonly associated with shopping malls than major teaching hospitals, they have seen infection rates plummet.

It started in 2006, when hospital leaders launched a comprehensive effort to improve quality, which included infection-tracking software and 24-hour medical robots in the intensive care units (ICUs).

But according to officials, the most effective thing they did was also the least complicated. Following a September announcement by the Joint Commission, a health care accreditation body focused on patient safety and quality, that it would work to identify best practices for hand-washing compliance in hospitals, leaders at The Methodist Hospital chose hand hygiene as a cornerstone of their quality efforts.

"It's a fundamental blocking and tackling exercise, to use a football analogy, that can have a real impact," said Marc Boom, M.D., executive vice president of the hospital. "And as we looked nationally, we saw that all hospitals had an opportunity to improve hand hygiene, so we tried to get out in front on the issue."

Since the report, the hospital's approximately 7,000 employees have united around the issue and instituted a "no-blame" culture that gently encourages hand washing.

"It's something we've had fun with," Boom said. "We have tried to make it non-punitive. But we have set it as a priority from the top on down, and we have communicated on it regularly."

Perhaps the most novel aspect—and secret weapon—of the effort is its means of measuring compliance. The hospital employs what hospital officials and many in the public often think of as "secret shoppers"—anonymous third parties charged with blending into the background and silently monitoring certain behaviors. Often thought of more as shoplifting deterrents or customer service enforcers in the retail sector, these individuals—formally called observers—are watching to see that employees follow through on hand-washing goals.

"Our observers blend in with the health care worker staff at the hospital," said Virginia Kennedy, who heads Houston-based Infection Prevention and Management Associates, which performs the service for Methodist.

"They observe as doctors, nurses, therapy professionals, radiologists, and all the other health care professions. They have valid hospital badges and appear completely legitimate. And they literally walk the floors, looking for compliance on hand washing."

While private rooms and situations are obviously off limits, the six or so observers who work in the hospital each week take a methodical approach using rigorous observational guidelines. Two-thirds of the observations happen weekdays between 7 a.m. and 7 p.m., with the remaining third taking place on nights and weekends. Infection Prevention and Management Associates collects and feeds the hand-washing data back to Methodist each month.

"When people are supposed to wash their hands, do they? That's the measurement," Boom said. "Everyone knows to wash their hands before or after touching a patient, but do they do it after they touch a chart or a keyboard?"

Boom said he preferred to have workers from an outside firm act as the observers.

"Sometimes, people will use their own staff for this kind of activity, but we thought they would ultimately have bias, so we went with a third party," he said. "I'm the hospital administrator, and I have no idea who these people are or what they look like."

Of course, cultural changes are not effective unless employees have the physical resources to carry out the goals. That is where the new hand-sanitizer dispensers come in. Approximately 3,000 dispensers have been installed throughout the hospital and are kept stocked by housekeeping staff with alcohol-based, bacteria-killing sanitizer.

"We realized the biggest barrier to improving in this area was simply the availability of soap and water," said Robert Jackson, M.D., president of medical staff and an internist at the hospital. "[Hand sanitizers] are mostly alcohol, so it evaporates. That makes water unnecessary. And it kills just about everything."

The dispensers were installed in front of each patient room, in front of elevators, and throughout hospital corridors.

"You literally cannot walk five feet without seeing a dispenser," Jackson said. "And when you see something on the wall like that, it's a visual reminder."

Taken together, the physical and cultural changes are working. As of December, The Methodist Hospital enjoyed a 91 percent hand-washing compliance rate, with the goal of reaching total compliance in the near future. Real results are also evident in patient outcomes. Central line infections in ICUs, for example, have fallen sharply since the start of the hand-washing initiative. In the cardiovascular ICU, officials said, there have been no central line infections through 11 months.

"We're really seeing a change," Jackson said. "The handwashing initiative has definitely made a big difference for us."

Overall, the hospital's quality initiatives led to its being ranked 14th in the University HealthSystem Consortium's 2006 Quality and Accountability Ranking, up from 49th the previous year.

"It is low cost, and high return, and it's something that everyone understands," Boom said. "Quality can be so hard to define sometimes, but here's something that every doctor, nurse, employee, and patient can grasp."

According to Boom, the hospital has not performed a cost analysis for the hand-washing effort, although he said the observer costs are "not that high," and the sanitizer dispensers are "part of our core expenses."

"It certainly is not as expensive as central line infections, wound infections, and the like," Jackson said. "I would be very surprised if the return on our investment was not enormous."

Boom said he hoped to continue to see improvements. "The bottom line is that quality is our core business …and we have ingrained this into our culture."

—By Scott Harris

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