Eliminating the Hawthorne Effect: Leveraging Existing Resources for a Novel Approach to Hand Hygiene Auditing

Background According to the Centers for Disease Control and Prevention healthcare-associated infections (HAI) affect 1 in 31 hospitalized patients. Despite the correlation between hand hygiene adherence and HAI reduction, compliance in hospitals is less than 40%. The gold standard method for a robust hand hygiene compliance program is to directly observe staff. However this is labor intensive and results can be confounded by the Hawthorne Effect. Methods Existing staff and technology were leveraged in novel ways to improve observation power. Infection prevention auditors were augmented by staff recruited from accreditation, quality and light duty nursing. Formalized auditor training fostered inter-rater reliability. Inpatient hallway security camera software was used by decentralized auditors to complete observations across all shifts. A digital hand hygiene survey was designed and implemented for real-time data entry. Total observation counts, compliance and trends were communicated to leadership and staff. Competition and reward recognition were used to facilitate change. A two-month pilot on select units was completed in 2018. This study was then expanded to all inpatient units and is ongoing. Results A total of 20 trained auditors (11 outside of infection prevention) have participated in this program. Over 1,000 observations per reporting period were recorded; this increased to over 2,000 monthly observations since September 2019. Hospital hand hygiene compliance has increased from 39% in 2018 to above 84% in 2019. Conclusions Current staff and existing security camera software support a robust hand hygiene direct observation program while minimizing resources invested and preventing the Hawthorne Effect. Ongoing data feedback to leadership and staff, competition, and staff recognition have maintained hand hygiene compliance rates above 84% exceeding the CDC 80% compliance threshold for significantly decreasing HAI risk.