American Journal of Medical Quality http://ajm.sagepub.com/

Patient Empowerment and Multimodal Hand Hygiene Promotion: A Win-Win Strategy Clair M. Callan American Journal of Medical Quality 2011 26: 6 DOI: 10.1177/1062860610387047 The online version of this article can be found at: http://ajm.sagepub.com/content/26/1/6

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Editorial

Patient Empowerment and Multimodal Hand Hygiene Promotion: A Win-Win Strategy

American Journal of Medical Quality 26(1) 6­-7 © 2011 by the American College of Medical Quality Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860610387047 http://ajmq.sagepub.com

Clair M. Callan, MD, MBA, CPE, FACPE1

Health care is facing several challenges. Some of these, such as faster diagnostic machines or robotic surgery machines, are decidedly high tech and expensive, whereas others lie at the opposite end of the spectrum. Many of the former will no doubt enhance health care, but the latter should not be ignored. Some low-tech interventions have the capacity to provide even greater rewards. One such area is hand hygiene—washing or sanitizing one’s hands between every patient encounter. Most agree that hand hygiene/washing before and after every patient encounter is simple, low tech, and cheap. No special skills or medical training are required. Parents have drilled the technique into most children from a very early age—at least since the advent of running water. Few adults today can say that, as children, they did not hear their parents harp “Wash your hands!” after using the bathroom or before eating. But the 2006 Minnesota Hand Washing Tool Kit has some disturbing statistics.1 American Society of Microbiology studies showed that although 97% of females and 92% of males said they washed their hands, only 75% and 58%, respectively, actually did so. And although 50% of middle school and high school students say they wash, only 33% of females and 8% of males used soap when washing their hands. Monitoring hand washing at the Minnesota State Fair showed an equally poor response. If hand washing is easy, why is it so hard to get everyone to do it? The goal of most health care facilities is to achieve 90% compliance—not 100%—with the Centers for Disease Control and Prevention guidelines; they believe that is as good as they can get. But the unpalatable truth is that many institutions fall woefully short of 90%. Secret shopper observations in hospitals have found that compliance is often a dismal 70% or less, and there can be variability on different nursing units. A study by Bishoff et al2 of hand washing compliance by health care workers in different settings showed very disappointing results even after education. With the introduction of an accessible, alcohol-based hand antiseptic, compliance increased from 14% to 25% in the medical intensive care unit and from 6% to 13% in the cardiac surgery intensive care unit. What about the percentage of compliance in other settings such as physician offices, during home care visits, or when patients are caring

for themselves at home? So far, these sites do not seem to have been studied. It is reasonable to conclude that even though hand hygiene seems simple, it is not as simple as it at first seems, or the statistics would be better. What are the barriers to success? It seems that while people agree it is a good thing to do, too often things get in the way of doing it. People may be rushed and this technique is forgotten about or ignored. Or perhaps individuals are not convinced that it is necessary to sanitize all the time when there has been no obvious exposure to contamination and hands appear to be clean. What is required is a commitment to sanitization—a commitment on the part of health care workers from the highest to the lowest in the patient care chain. It is an approach that should be universally adopted. The push for patient empowerment and their increased involvement in their care will continue as health care reform wends its way through the expansion process. Hand washing as often as is necessary can become automatic if it is easy to do. The hand sanitizing dispensers that are springing up everywhere in hospitals and doctors’ offices are reminders that we all need to continually reinforce the importance of this simple technique. We can train patients to monitor our compliance and to remind us, if necessary, that we need to wash our hands—and make it safe for them to do so. How do we get everyone involved in a hand washing campaign? At first glance, a program to promote hand hygiene seems so simple—a no-brainer. It makes sense. Everyone can not only be taught why, how, and when to do it, but will follow simple instructions and want to do it. Then why has it not become more universal? McGuckin et al3 looked at the issue from the patient empowerment perspective, researching several articles. Although the World Health Organization has a multimodal hand hygiene strategy and several countries have patient empowerment in their 1

Callan Consulting, Lake Forest, IL

Corresponding Author: Clair M. Callan, MD, MBA, CPE, FACPE, Callan Consulting, 1800 Amberley Court, Suite 208, Lake Forest, IL 60045 Email: [email protected]

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Editorial national hand hygiene promotion campaigns, patients still need help from health care workers who may themselves need help to comply with hand hygiene standards. It is up to all of us to recognize and remove any barriers to compliance with a clean hands campaign. We must monitor ourselves, our coworkers, and our patients and their families for compliance. Although the situation is better now than it was, there is still plenty of room for improvement. Encouraging patients to challenge health care workers about clean hands is an important step to ensure widespread compliance, but before we empower patients we must empower ourselves. The article in this issue by McGuckin et al effectively supports a win-win strategy by increasing the amount of hand washing that currently occurs in health care environment. The World Health Organization table included in the article delineates key strategy components necessary for a successful hand hygiene multimodal promotion strategy. Patient empowerment is something that many talk about but few have really figured out how to achieve. A big question is how much empowerment do patients really want? Are they willing to become more accountable for many aspects of their health care? As McGuckin et al point out, Empowerment can be defined as a process in which patients understand their opportunity to contribute

and are given the knowledge and skills by their health care provider and other educational sources to perform a task in an environment that recognizes community and cultural differences and encourages patient participation. In other words, patients can be encouraged to be like clinicians in their behavior and can watch clinician behavior and safely ask questions. McGuckin et al have raised an important topic in their article. What seems easy to achieve is still far from universal. It is up to everyone to learn how to follow through— we as clinicians to practice what we preach and our patients to become empowered and help us achieve improved hand hygiene. Better infection control will surely follow. References 1. Minnesota Department of Health. Hand hygiene. http://www .health.state.mn.us/handhygiene. Accessed October 4, 2010. 2. Bishoff WE, Reynolds TM, Sessler CN, Edmond MB, Wenzel RP. Handwashing compliance by health care workers: the impact of introducing an accessible, alcohol-based hand antiseptic. Arch Inter Med. 2000;160:1017-1021. 3. McGuckin M, Storr J, Longtin Y, Allegranzi B, Pittet D. Patient empowerment and multimodal hand hygiene promotion: a win-win strategy. Am J Med Qual. 2011;26:10-17.

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