JPS Hand-Hygiene Initiative: A Multifactorial Assessment of Hand-Hygiene Compliance & Practices Across JPS Hospital




Do, Vincent
Reynolds, Conner
Schmeits, Brandon
Weiss, Stormy
Flowers, Ryan
Gaw, Mona
Bower, Eleena
Wright, Mickie
Fuhrmann, Greg
Pacheco, Debie


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Purpose: Preventable medical errors are the third leading cause of death in the United States annually. The Healthcare-Acquired Infections (HAI) Prevalence Survey estimated 722,000 HAIs occurred across all United States acute care hospitals in 2011, with nearly 10% mortality. Previous studies demonstrate that proper hand hygiene (HH) practices significantly reduce the incidence of HAIs. The present study aims to assess HH practices at John Peter Smith (JPS) Hospital through a mixed top-down and bottom-up approach. Methods: For the top-down assessment, UNTHSC students acted as secret observers recording employee compliance with the World Health Organization’s 1st & 5th moments of Hand Hygiene. These observations were performed on 2 Scope Units at the JPS Hospital. Phase 1 identified areas of low HH compliance based on time and date, with 3,461 opportunities observed. Phase 2 included data on HH compliance by roles as well (e.g. nurse, physician/PA, tech/MA, EVS, family), with 1,362 opportunities observed. For the bottom-up assessment, 71 employees on the observed units were surveyed to gain targeted feedback about their education in HH, compliance, culture, and ideas for improving HH in the workplace. Results: The Secret Observer Recordings found 41.3% overall compliance with HH protocols. The areas with most opportunity for improvement are: before entering the patient room (36.2% compliance), individual role (physician: 20.3%, and family member: 2.3%), certain days of the week (Sun, Wed, Fri) and times of the day (10:00–17:00, and 17:00–22:00). The post-observation survey noted that the top 4 reasons for not practicing HH were being in a hurry, lack of training/knowledge, forgetfulness, and lack of hand sanitizers/sinks. Conclusion: Identifying areas with the greatest potential for improvement will allow strategic policy development to enhance future HH compliance. Taking measures to ensure JPS personnel feel comfortable to telling others to “wash their hands” will further solidify behavioral changes. This comprehensive approach will foster a unique culture of safety that reduces the spread of HAIs, significantly improving quality of patient care patients.