THE BATTLE to get hand hygiene right has been raging for over 150 years. Although hand hygiene has been studied, taught, investigated, and promoted, its failure rate among healthcare workers is still significant. In a large, multihospital study of healthcare workers, adherence to recommended hand-hygiene practices ranged from 36% to 59%.1

The CDC and The Joint Commission built a case for all healthcare institutions to strive for healthcare worker compliance with hand hygiene.1 This article describes tips learned at a large academic facility to achieve consistent compliance with hand-hygiene at the patient care unit level.

Many early hand-hygiene campaigns failed to make what was ultimately needed-a culture change. In this instance, organizational leadership drove an institutional level improvement initiative in 2007 and set acceptable compliance rates high in order to drive a culture change. Sen ior leadership declared hand-hygiene improvement essential and expected it of all staff.

A small group of nursing leaders and staff developed a multifaceted approach to consistent performance of hand hygiene. All healthcare roles were included in this initiative. The following seven tips are geared to both inpatient and outpatient settings.

1. Keep it simple. Format the CDC guidelines into simple messages for all healthcare workers. Define dirty and clean zones. Use a comprehensive approach that ranges from the use of gloves and other personal protective equipment to properly cleaning equipment.

* Through the use of simulation, we learned that staff perceived CDC hand-hygiene guidelines to be overly complex for the simple task of hand hygiene. By simplifying the guidelines into easy-to-remember messages and staying true to the intent, hand hygiene became easier for the team to integrate consistently. This was accomplished by paying attention to hand-hygiene product placement within the work unit and using simple messages to integrate hand hygiene into healthcare workers' practice.

* Specify dirty and clean activities to ensure clear guidance. Many activities, such as medication administration, involve multiple steps; some require glove use. In any setting or activity, clarify what's clean or dirty by observing care and discussing the application of guidelines.

2. Place hand-hygiene products where they're needed. These should be available at the point of care and at the entrance to and exit from the patient environment.

* Incorporating access to hand-hygiene products in healthcare workers' workflow at the point of care improves hand-hygiene compliance.2 Product location is critical to performing hand hygiene at the moment it's needed. Without standardized locations, providers search for hand gel as they leave the patient environment. A caregiver distracted by other pressing patient needs may quickly move on. Not having a standarized location can be even more frustrating for staff members who work in multiple areas or transport patients.

* Providers are likely to be consistent and reflexive with their hand-hygiene practice when hand gel is conveniently placed at the foot of every patient bed and next to every exam table. Any interaction with patients can be immediately preceded or followed by using hand gel.

* Hand gel placed at the foot of every bed reassures patients and families. This placement helps create an open environment for patients and families to see healthcare workers performing hand hygiene at the right time and to request hand hygiene during missed opportunities.

* Another useful location for products is at the entrance to or exit from each patient room. A simplified message such as "Clean Hands In and Out" in all patient rooms helps to fulfill CDC guidelines.

* 3. Integrate workflow. Recognize that hand-hygiene needs must be integrated into workflow.

* Recognize the many interactions nurses and direct care providers have with patients and their environment. Clarify what point among care activities prevents transmission. For example, before using a medication-dispensing station, is hand hygiene required? How can hand hygiene be completed before entering a room if the caregiver's hands are full? Purposefully integrate hand hygiene into workflow. Deliberately work through care and points of hand-hygiene activity to address the questions that will arise.

* Include multidisciplinary staff on teams addressing hand-hygiene issues to ensure hand-hygiene expectations are consistent among all healthcare workers. Spend time observing and working with staff in various roles to address role-specific questions, while maintaining the integrity of the simplified messages developed from CDC guidelines.

* Prioritize care from clean to dirty activities whenever possible to decrease the need for hand hygiene. For instance, when assisting a patient with a meal tray, taking vital signs, and performing I.V. site care, work from clean to dirty tasks. Think through activities needing to be performed and classify them to improve hand-hygiene efficiency.

4. Lead and involve the team. Multidisciplinary involvement is important to success.

* Ensure the entire multidisciplinary team works in unison with requirements to promote hand hygiene. A consistent and unified message reinforces changes needed to value and practice excellent hand hygiene. For example, in multidisciplinary patient/family rounds, the physician leader must be a role model for the resident team, nurse leaders must model and promote hand hygiene, and all team members must speak up about inconsistencies in hand-hygiene practices. Enlist a group of dedicated staff to champion the movement, promote and facilitate education, engage leadership, and establish resources.

* Role models help drive and promote hand-hygiene requirements. Hand-hygiene promoters within nursing can provide education, be a just-in-time resource, and encourage peers and colleagues. Many healthcare providers aren't aware of hand-hygiene opportunities they've missed. Promoters bring attention to personal technique through respectful interactions. They speak up and clarify hand-hygiene practices.

* Use role models currently in practice. For example, preceptors instruct new orientees and model best practices. Nurse managers transform ways of thinking about and believing in the critical nature of excellent hand-hygiene practices. Direct care nurses stress the importance of hand hygiene to patients and families during many interactions. Nursing education specialists and clinical nurse specialists model hand hygiene in practice and integrate hand hygiene into education, practice guidelines, and equipment handling.

5. Provide ongoing education about hand hygiene to healthcare providers. Lack of knowledge, culture, and habits can easily prevent awareness and compliance. Providing education to reinforce current guidelines ensures clear understanding of expectations.

* A program intended for all staff reinforces requirements and the importance of CDC and World Health Organization hand-hygiene guidelines. Including information about current infection control issues, such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and Clostridium difficile infections, encourages clinicians to change their practices to prevent disease transmission. While a component of education should be dedicated to guidelines for hand hygiene, isolation precautions, glove use, and equipment cleaning, also engage healthcare workers at a personal level by including compliance stories and actual hand-hygiene observations.

* Important communication techniques include speaking up about missed opportunities and encouraging patients and families to speak up.

* In addition to formal educational offerings, provide education informally at work areas and clinical meetings. The goal is to reach as many staff members as possible and address unique challenges in which purposeful thought is required to optimize hand hygiene.

* "Walking the practice" means observing and providing real-time feedback and reinforcing correct technique. Having a dedicated group that champions hand hygiene and encourages leadership to understand and walk their practice helps move the cause forward.

6. Observe and share. Monitor hand-hygiene compliance and share audit results through compliance reports and real-life anecdotes.

* Audit hand-hygiene compliance. To maintain objectivity, use non-unit-based observers. Like "secret shoppers," they drop in unannounced, then settle into the background to focus on hand-hygiene practices. These observers are trained on hand-hygiene requirements; their audits are verified and validated to ensure consistency across practice areas, providing interrater reliability.

* In the spirit of transparency, share audit results with staff. Results shared electronically through compliance reports let any care provider review them at any time. Be prepared for feedback: compliance data generate lots of questions, including those about validity and accuracy of audits. Be ready to answer these questions and share validity and the rationale of the method used.

* Share stories with staff of observed noncompliance to heighten their awareness. These stories can come from hand-hygiene observers, peers, patients, and families.

7. Human value. Bring it back to what matters-the direct impact of hand hygiene on patients and families.

* Information about performing hand hygiene facilitates behavior change in healthcare workers.3 The impact of hand hygiene on patients and patients' feelings of emotional and physical well-being can't be understated. Even one moment of missed hand hygiene can impact patients' trust in healthcare providers. The risk of infection, possibly with a multidrug-resistant organism, is real and impacts the lives of patients and their families. A recent study showed that healthcare workers are more motivated to perform hand hygiene to protect vulnerable patients than they are to protect their own health.4

Commitment to hand hygiene

For any program to improve hand hygiene, consider generating a commitment: being aware, speaking up, and fulfilling this obligation for hand hygiene to each patient, no matter what. To secure this commitment creatively, have each staff member make a handprint. Provide ink and paper before every hand-hygiene educational offering. Posting handprints of top leadership mixed in with those of healthcare providers generates a powerful sense of teamwork and pride.

Our experience shows that these seven factors can increase hand-hygiene compliance and improve consistency in hand-hygiene practices. By using simple messages, hand hygiene can easily be integrated into complex care environments.

REFERENCES