Change management process for hospitals

Patient Safety, Culture Change and Change management
Topic: Hand Hygiene – Deployment Challenges and Strategies

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Change management process for hospitals


The healthcare industry’s emphasis on improving patient safety has increased in recent years. From the steady rise of hospital-acquired infections to infants receiving blood thinner, a variety of trends and events have thrust the issue into the public spotlight.

Hand Hygiene – Deployment Challenges and Strategies


Many factors have contributed to poor hand washing compliance among health care workers:

  • A lack of knowledge among personnel about the importance of hand hygiene in reducing the spread of infection and how hands become contaminated
  • Lack of understanding of correct hand hygiene technique
  • Under-staffing and overcrowding
  • Poor access to hand washing facilities
  • Irritant contact dermatitis associated with frequent exposure to soap and water
  • Lack of institutional commitment to good hand hygiene

The World Health Organization’s Guidelines on Hand Hygiene in Health Care reinforces the need for multidimensional strategies as the most effective approach to promote hand hygiene. Key elements include:

  • Staff education and motivation Adoption of an alcohol-based hand rub as the primary method for hand hygiene
  • Use of performance indicators
  • Strong commitment by all stakeholders, such as front-line staff, managers and health care leaders, to improve hand hygiene.
  • Testing use of gloves during patient care is an additional intervention to measure impact on help reduce transmission of infectious agents in high-risk situations.

In addition to frequency of use, it is also important to test proper use. The tool used to assess use of gloves is an important adjunct to, but not a replacement for, proper hand hygiene practice.  Numerous studies have suggested that hand hygiene compliance can be improved, at least modestly, by a variety of interventions, introduction of alcohol-based hand rub and educational and behavioral initiatives. Most authorities believe that multidimensional interventions are more effective. For example, some organizations have implemented a multidisciplinary, multimodal hand hygiene improvement program featuring promotion of alcohol-based hand rub and achieved substantial improvement in hand hygiene compliance. Much of the improvement in compliance was attributed to increased use of the alcohol-based hand rub.


Difficulties associated with the project and plans to address such difficulties


A key challenge with the project and plans is ongoing monitoring of clinical staff practices with regard to hand hygiene and ensuring related accuracy of measures and outcomes. A key test of a change strategy would be a stronger perception of linkage between alcohol based hand rub, clean gloves and improved hand hygiene compliance. A tangible positive outcome would be a permanent change in behaviour in clinical staff with regard to hand hygiene practices.


There are two options to address this challenge. The first option is to use volunteer survey mechanisms for feedback on compliance. The second option is to use the onsite observation method which may be intrusive in nature. Our methodology recommends a combination of both options. Constant and consistent education and reinforcement is a critical component within comprehensive training packages. Our experience has been that the “replacement” cost of training is important to management teams. Moreover, a process of peer group “continuous learning” is likely to have a greater impact than one-time training in a class room setting. Our recommendation is outlined below.


Hand hygiene environment assessment tools and comprehensive training packages


Our approach for testing and development of the hand hygiene environment assessment tools package would include a group of best practices that individually improve care, but when applied together should result in substantially greater improvement.

The science supporting each intervention is sufficiently established to be considered a standard of care. The following four components of the hand hygiene intervention package are critical aspects of a multidimensional hand hygiene program. Glove use is included in this package because proper glove use is inextricably linked to effective hand hygiene.


1. Demonstrate knowledge: Understand key elements of hand hygiene practice

Test health care workers on knowledge that their hands can become contaminated during patient care activities. Test awareness that compared to hand washing, alcohol-based hand rubs have been shown to be more effective in reducing the number of viable bacteria and viruses on hands, require less time to use, can be made more accessible at the point of care, and cause less hand irritation and dryness with repeated use. Health care workers should demonstrate accurate knowledge of the advantages of the use of hand rubs in most situations as well as the specific indications for hand washing.


» Successful strategies for tools, assessments and training: 

Probe the types of patient care activities that result in hand contamination as a supplement to educational material provided to health care workers
Evaluate clinical staff on knowledge of relative advantages and disadvantages of hand washing and use of alcohol-based hand rubs at the point of care
Gauge awareness of the important role that contaminated hands play in transmission of health-care-associated pathogens, including multidrug-resistant pathogens and viruses
Test awareness levels of clinical staff regarding the morbidity and mortality caused by health-care associated infections.

2.   Demonstrate competence: Ensure use appropriate technique when cleansing their hands

Clinical staff should demonstrate competency in performing hand hygiene correctly. Studies have found that compliance by health care workers was significantly greater when dispensers for alcohol-based hand rub were adjacent to each patient’s bed than when there was only one dispenser for every four beds. In critical care, availability of alcohol-based hand rub at the point of care proved to minimize the time constraint associated with hand hygiene during patient care and to predict better compliance. In addition, in a study of hand hygiene among physicians, it was found that easy access to an alcohol-based hand rub was an independent predictor of improved hand hygiene compliance. The tools may include a periodic test and report of availability of alcohol-based products at the point of care, supplemented by availability of gloves in appropriate sizes for use in the high-risk situations.


» Successful strategies for tools, assessments and training:

A key test of a change strategy would be to test perception of linkage between alcohol based hand rub, clean gloves and improved hand hygiene compliance. Testing placement of dispensers for alcohol-based hand rub and boxes of clean gloves of various sizes near the points of care will provide clear indications of success of specific options.

Assessment of how responsibility is assigned for checking alcohol-based hand rub dispensers and glove boxes on a regular basis is also important. Lack of this measurement can affect hand hygiene compliance rates.


3. Verify competency: Hand hygiene is performed at the right time and in the right way and gloves are used appropriately.

Tracking the frequency that clinical staff clean their hands according to recommendations is important. The tests may include feedback measures such as washing hands with plain soap or with antimicrobial soap and water; use of alcohol-based hand rub for routinely decontaminating hands and decontamination when leaving the patient’s bedside or room.


» Successful strategies for tools, assessments and training:

Test impact of specific messages and educational materials include periodic lectures given by knowledgeable personnel, including interactive and Interactive, computer-assisted learning available to clinical staff via the hospital’s Intranet

  • Test recall of educational programs for personnel that include instructions for proper technique when washing hands with soap and water, or when using an alcohol-based hand rub
  • Test understanding of providers about the rationale for hand hygiene, gloves and compliance with best practices and improve patient outcomes.
  • Initiating a multi-component publicity campaign (e.g., posters with photos of celebrated hospital doctors/staff members recommending hand hygiene and use of gloves; drawings by children in pediatric hospitals; screen savers with targeted messaging)
  • Test impact of opinion leaders as role models and educators (“academic detailing);
  • Test influence of a culture where reminding each other about hand hygiene and use of gloves is encouraged and makes compliance the social norm.



The hand hygiene assessment tools will include three feedback mechanisms:

  • Hand Hygiene Knowledge Assessment Questionnaire
  • Checklist of availability of alcohol sanitizers, Clean Gloves, waste bins and staff hand washing sinks
  • Hand Hygiene and Glove Use Monitoring


Measure 1. The percentage of caregivers who answer all questions correctly on a standardized hand hygiene knowledge assessment survey 

This measure assesses the proportion of clinical staff who demonstrate adequate knowledge of the key elements of hand hygiene and glove use. A simple, rapid, and low technology strategy is to assess the knowledge of caregivers in real time on the ward. Arcus recommends a selection of a random sample of 10 clinical providers from diverse disciplines each month (or at other intervals specified by the hospital) to answer a five-question survey in tandem with a competency check. Specific questions can be designated by Arcus and/or selected from examples of best practices. An alternative strategy is to assess knowledge using an internet-based learning or knowledge management system. The clear advantage of this approach is that a larger base of clinical staff can be tested, or a sample may be tested at more frequent intervals. Completion of the assessment can be documented electronically.


Measure 2. The percentage of caregivers who perform all three key hand hygiene procedures correctly 

This is a simple, rapid, low technology strategy that can be used in tandem with the method described in measure 1. A sample of 30 clinical providers from diverse disciplines and representative organization size and geographic area will be randomly selected. The respondents will be surveyed to determine if they perform the three key hand hygiene procedures correctly: hand washing, alcohol-based hand rub, and gloves. Options for direct evaluation/online feedback mechanisms for the training package will be explored.


Measure 3. The percentage of bed spaces at which there are clean gloves in appropriate sizes and dispensers (wall-mounted or free-standing bottles) for alcohol-based hand rub/gel/foam that contain product, are functional, and dispense an appropriate volume of product 

A probe area will be to determine use of a standardized procedure and data form on the same nursing units where measures 1 and 2 are monitored. According to best practices, for a successful test, the dispenser of alcohol-based product must be present, readily accessible at the point of care. At least two sizes of gloves should be available and readily accessible at the point of care. Mobile, portability of product and sizes of the dispenser will be tested.


Measure 4. The percentage of patient encounters in which there is compliance by health care workers with all components of appropriate hand hygiene and glove practices 

Compliance is monitored with phone/online/direct observation by a trained observer using a standardized procedure and data form. Independent observers are strongly recommended, preferably individuals who routinely are on the ward for other purposes and are not part of the care team. (This independent monitoring can be reinforced with monitoring by the care team during routine multidisciplinary rounds, which permits immediate assessment and feedback.) Observation periods could be 20-30 minutes (repeated if necessary) so that approximately 25-30 patient encounters are observed.