Discussion: View Thread

  • 1.  Hand Hygiene Audits

    Posted 20 days ago

    Hello, at our most recent CMS audit, we were STRONGLY advised to document names of individuals we observe for hand hygiene audits. They say is to help identify if we are auditing the same person or if any coaching had the desired effect. Does your facility record their names? It feels punitive to me. Curious to hear thoughts on this.



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    Jennifer Rowland, BSN, RN, CIC
    Nurse Epidemiologist
    Oregon State Hospital
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  • 2.  RE: Hand Hygiene Audits

    Posted 19 days ago
    Edited by Larkin Miers 19 days ago

    I don't agree with the surveyor's suggestion. I have never heard of recording names for general hand hygiene audits and agree it could be seen as punitive. It is also not realistic in many environments. Do the people submitting hand hygiene observations know every single person's name in the department? Sometimes I am the one recording observations and I do not know everyone's name. It isn't feasible to try and check the person's badge - staff are on the move and sometimes badges flip over. 

    For the hand hygiene programs I've worked on, we do not record the individual's name, but we do try to record their job role. We have a variety of categories, such as RN/LPN, CNA, Tech, Provider (MD, DO, PA, NP), etc. This helps ensure data includes a variety of staff members and makes it easier to provide targeted feedback without singling someone out. 

    Rather than recording someone's name, developing a speak-up culture would be much more meaningful (if you don't already have one). I haven't rolled this out myself, but I've heard of organizations designating a code word for hand hygiene to help staff provide each other with just-in-time feedback. If you see someone miss a hand hygiene opportunity, say the code word and that person will know you are asking them to perform hand hygiene. It makes feedback easier, especially in front of patients/visitors. I found this article from Cleveland Clinic that discusses their "SNAP" campaign. 

    https://consultqd.clevelandclinic.org/all-in-with-successful-hand-hygiene-program

    I hope this helps!



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    Larkin Miers, MS, CIC
    Infection Preventionist IV
    Oregon and SW Washington
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  • 3.  RE: Hand Hygiene Audits

    Posted 16 days ago

    HI Jennifer,

    Our current hand hygiene audit tool is the Joint Commission Hand hygiene Targeted Solution Tool (TST).  It is a direct observation collection tool. The collection is on role, not individual; however, since it is direct observation - there is an opportunity for just in time coaching when hand hygiene practices are missed.

    We have been using the JC TST program for a year now.  

    Previously we used the passive reminder badge system, Biovigil. The system provided tons of data that was helpful for contact tracing back in COVID days -- because each badge was assigned to an individual.  The staff member-specific information was used occasionally for rewarding top performers with cookie cards, or to assist the department manager with coaching individuals on opportunities identified.   The system was a hand hygiene reminder system, as it provided visual and vibrations if hands had the risk of cross contamination. 

    Our goal for hand hygiene is to measure for improvement, we using our direct observations to identify the trends in 'why' hand hygiene was missed (eg., hands full of meds or supplies, etc).

    Improvement can still occur without documenting names.



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    Lori Graber
    Infection Preventionist
    La Grande, Oregon
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