SummaryPatients in outpatient clinics at Johns Hopkins Hospital observe the hand hygiene habits of providers. Patients willing to serve as observers receive a card when they check in, with check boxes to indicate whether the providers follow appropriate hand hygiene procedures before initiating contact with the patient. The card is dropped off in a prominently marked box as the patient leaves the clinic. Aggregated performance data (calculated from the cards) is fed back to participating clinics and to other relevant departments within Johns Hopkins to stimulate quality improvement, with additional education and support given to underperforming clinics. The program led to modest improvements in already high rates of adherence to appropriate hand hygiene procedures and to more departments meeting the 90-percent adherence goal; using patients as observers also proved to be a low-cost, accurate means of monitoring hand hygiene (a requirement for any organization accredited by The Joint Commission).Suggestive: The evidence consists of post-implementation trends in adherence to appropriate hand hygiene among clinic providers.
Developing OrganizationsJohns Hopkins Hospital
Date First Implemented2008
Problem AddressedProviders often fail to adhere to recommended hand hygiene procedures, which can lead to health care–associated infections and increased risk of morbidity and mortality. Although most attention has been paid to improving hand hygiene in the inpatient setting, similar efforts in the outpatient arena are needed, where logistical issues can create challenges to monitoring and improving adherence.
- Poor hand hygiene, leading to infections and associated morbidity, mortality: Adherence to hand hygiene protocols remains low in many inpatient settings; a recent 12-month, multicenter study found baseline adherence rates of 26 percent among providers in intensive care units and 36 percent in other inpatient units.1 (Data on adherence to proper hand hygiene in the outpatient setting are not available.) Although still a topic of debate, the evidence suggests that poor hand hygiene contributes to the development of health care–associated infections, which are a major source of mortality and morbidity.2 Several studies show that the risk of contamination and infection declines when providers adhere more closely to appropriate hand hygiene procedures.1,3,4 In fact, effective hand hygiene has been cited as the "single most important factor" in preventing health care–acquired infections,1 and The Joint Commission in 2005 made the reduction of such infections a National Patient Safety Goal, citing the need for greater adherence to Centers for Disease Control and Prevention (CDC) hand hygiene recommendations (and making the monitoring of adherence a requirement for all Joint Commission-accredited facilities).5
- Special challenges in outpatient settings: The logistics of most ambulatory settings can create some unique challenges to monitoring and improving hand hygiene. For example, in many outpatient clinics, including at Johns Hopkins, sinks and hand sanitizers are located inside examination rooms, making direct observation by an outsider impractical, because the door is typically closed during examinations and having observers inside the room can be considered intrusive. (Use of direct observers is also expensive, regardless of setting.) Other common methods for monitoring and encouraging adherence to appropriate hand hygiene tend to be inaccurate, including self-reporting (which can be subject to bias) and measuring product usage (which cannot accurately determine the extent to which all providers consistently practice hand hygiene or follow appropriate procedures when they do).6
Description of the Innovative ActivityPatients in outpatient clinics at Johns Hopkins Hospital observe the hand hygiene habits of providers. Patients willing to serve as observers receive a card when they check in, with check boxes to indicate whether the providers follow appropriate hand hygiene procedures before initiating contact with the patient. The card is dropped off in a prominently marked box as the patient leaves the clinic. Aggregated performance data (calculated from the cards) is fed back to participating clinics and to other relevant departments within Johns Hopkins to stimulate quality improvement, with additional education and support given to underperforming clinics. Key elements of the program include the following:
- The observation process: At present, clinics participate in the program approximately 1 week out of every 2 months, with roughly 2,000 patient observations being processed each month. Eventually, adopting clinics will likely make the program a regular part of routine care. The observation process works as outlined below:
- Asking patients to be observers: When a patient arrives to check in for an appointment, a patient service coordinator asks if he or she would be willing to observe and record whether the provider performs appropriate hand hygiene before initiating contact. The coordinator, with the support of scripts, briefly explains to the patient the importance of hand washing and the role that observation can play in encouraging adherence. A survey of 50 patients conducted before program implementation found that 86 percent indicated a willingness to perform such observation. During the pilot study, however, participation rates across clinics were significantly lower, ranging from 12 percent to 71 percent, with an average of 22 percent.6 (These figures represent the percentage of total patient encounters in which a card is filled out and returned; some patients may agree to be observers but then not complete and return the card.) These rates have improved somewhat since the end of the pilot study in June 2009; a minimum 10-percent rate is required to consider patient observations valid, although this minimum might be raised to 20 percent in the future.
- Monitoring adherence and recording observations: Patients who agree receive a pencil and a bright yellow card for recording their observations, along with a single-use antibacterial hand wipe with the words "be a partner in your health care" printed on it. (The wipe is intended as a thank-you gift to those who participate.) The card also includes explanations of the importance of appropriate hand hygiene and the observation process. The card has an easy-to-complete form in which the patient lists the clinic name and visit date and indicates by a check mark whether the physician, nurse, tech/therapist and others performed appropriate hand hygiene before initiating contact (boxes can be checked to indicate "yes," "no," or "unsure"). The card also asks if any staff member verified their name and date of birth and includes space for any other comments the patient may have.
- Dropping off card: Patients drop the filled-out card in an easy-to-see yellow drop box as they leave the clinic; the color matches that of the cards, thus serving as a reminder for patients to drop off the card.
- Performance monitoring, feedback, and recognition: All returned cards are scanned into the computer system. Data from all returned cards are evaluated to determine overall, department-specific, and clinic-specific performance with respect to provider hand hygiene. Performance reports go back to the individual patient care departments, to clinics within these departments, and to other relevant departments and individuals within Johns Hopkins responsible for quality improvement, including the patient safety committee, the Quality Improvement Council, and department quality improvement representatives. Reports are reviewed and discussed at relevant meetings and included in the Johns Hopkins Center for Innovations' Weekly Report of Harm. Clinics that achieve adherence rates above the 90-percent target for three consecutive months receive special recognition, with a picture of the clinic and a description of its strong performance displayed in several visible locations throughout the outpatient center and the concourse in the main hospital. As of January 2012, clinics who consistently performed above the 90 percent goal were moved to quarterly reporting.
- Additional questions added: Scanning technology has significantly reduced the time it takes to tabulate results; with the reduction in tabulation time, more fields were added to the survey such that results can be broken down by type of provider (physician, nurse, tech/therapist and other) In addition, a new question was added asking the patient if someone had verified their name and date of birth in an effort to monitor patient identification in the outpatient setting.
- Blind surveying: In January 2012, clinics began blind surveying. In previous years, each clinic received a schedule for the year telling them what week they were to provide surveys to the patients, allowing them time to prepare staff and faculty. Now, they are only told which month that surveys will run. Supplies are sent ahead of time, and each clinic provides a number of contacts who can trigger the survey. Then, these contacts are notified by email to begin the survey and run it through the end of the week.
- Quality improvement support: Clinics with relatively poor performance receive additional support designed to boost adherence. For example, quality improvement teams and/or infection control specialists may visit to provide education and training on appropriate hand hygiene.
References/Related ArticlesBittle MJ, LaMarche S. Engaging the patient as observer to promote hand hygiene compliance in ambulatory care. Jt Comm J Qual Patient Saf. 2009;35(10):519-25; AP1-AP3. Online version with appendix. [PubMed]
Contact the InnovatorSuzanne LaMarche, MBA
Ambulatory QI Team Leader
Quality Improvement Department
Johns Hopkins Hospital
600 N. Wolfe Street-Phipps 550
Baltimore, MD 21287
Phone: (443) 287-2088
Fax: (410) 502-9878
Innovator DisclosuresMs. LaMarche reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.
ResultsThe program led to modest improvements in already high rates of adherence to appropriate hand hygiene procedures and to more departments meeting the 90-percent adherence goal; using patients as observers also proved to be a low-cost, accurate means of monitoring hand hygiene in the outpatient setting.
Suggestive: The evidence consists of post-implementation trends in adherence to appropriate hand hygiene among clinic providers.
- Modest improvements in (already high) adherence rates: The percentage of patient visits in which providers performed hand hygiene rose from 86 percent in December 2008 (when the program began) to 92 percent 1 year later. Information provided in March 2012 indicates that since the blind survey began, as suspected, there has been a decrease in the overall compliance rate.
- More departments meeting 90-percent goal: When the program began, only 8 out of 18 participating departments met the goal of 90-percent adherence to appropriate hand hygiene. One year later, 13 of the 18 departments met the goal. Among the five additional departments meeting the goal after program implementation, one raised its adherence rate by 22 percentage points (from 74 to 96 percent), three others increased by 10 percentage points, and another jumped by 7 percentage points.
- A relatively low-cost, accurate means of monitoring adherence: The program costs only about 17 cents per patient encounter, making it significantly less expensive than using paid observers. In addition, a small study comparing this approach to the use of independent observers found 100-percent concordance between the observations of patients and those of trained observers.6 In other words, compared to other potential monitoring methods, use of patients as observers represents a low-cost, accurate way of measuring adherence to recommended hand hygiene procedures.
Context of the InnovationThe Johns Hopkins Hospital is a 1,015-bed tertiary care facility in Baltimore, MD, that treats more than 250,000 inpatients annually; the hospital attracts patients from across the United States and from 126 nations. In addition to offering inpatient services, the hospital runs an extensive network of 225 ambulatory clinics, most of which are located in the Johns Hopkins Outpatient Center on the hospital campus. In response to The Joint Commission's making the reduction of health care–associated infections a National Patient Safety Goal [and requiring monitoring of adherence to CDC or World Health Organization (WHO) hand hygiene guidelines as a way to reduce such infections], hospital leaders developed and announced a policy in 2008 stipulating that all members of inpatient care teams must wash their hands before entering and immediately after leaving a patient's room. The hospital developed and launched a massive communication plan to educate care team members about this new responsibility and recruited and trained existing employees to monitor adherence through direct observation. The program resulted in significant improvements in hand hygiene in Johns Hopkins' inpatient facilities, with average adherence rising from less than 40 percent in July 2008 to more than 60 percent in June 2009.6 In the spring of 2008, the hospital's Ambulatory Quality & Patient Safety Division made monitoring of hand hygiene in the outpatient setting an essential goal for the year. Recognizing the previously described logistical challenges and expenses associated with other monitoring strategies, division leaders began looking for another way to monitor adherence to appropriate hand hygiene.
Planning and Development ProcessKey steps in the planning and development process included the following:
- Evaluating alternative monitoring strategies: In the fall of 2008, the ambulatory quality and patient safety task force considered various strategies for monitoring hand hygiene in the outpatient setting, with the goal of finding a low-cost method that provided accurate data with minimal disruption to the care process. The task force considered and rejected the idea of using independent trained observers, believing this approach was too costly, impractical, and disruptive in a setting where most hand washing occurs in the examination room (meaning that observers would have to be in the room). The task force also considered use of provider self-reporting and monitoring of product usage (both of which represent low-cost approaches), but ultimately believed that data accuracy might be lacking, creating the need for frequent, costly audits to confirm performance.6
- Researching best practices: At the task force's direction, the manager of ambulatory quality and patient safety contacted The Joint Commission to get recommendations on potential best practices. The Joint Commission recommended Tripler Army Medical Center in Hawaii, which had successfully used patients to monitor adherence. The manager contacted representatives of the medical center to learn about the program and to review sample tracking and reporting tools.
- Discussing concept with executive leadership and task force: Program developers (the aforementioned manager and the vice president of ambulatory services) approached system executives and the task force about the patient-as-observer approach, sharing information on how it would work and its potential to reduce health care–associated infections. The task force expressed some concerns about the program's potential impact on the patient–provider relationship and about patients' willingness to participate and their ability to report accurate results.
- Addressing task force concerns: To address task force concerns, program developers surveyed 50 patients, finding that 86 percent were willing to act as observers. Among those, just over half (55.8 percent) indicated they would feel comfortable speaking up if a provider did not follow appropriate hand hygiene. However, the task force decided not to encourage patients to speak up as a formal part of the program.
- Pilot testing and assessing accuracy: In December 2008, a pilot test of the approach began in two practices (an otolaryngology and internal medicine clinic); program leaders chose these sites because managers had expressed enthusiasm for the program, and clinic physicians expressed a willingness to participate. Before commencing the process, the manager visited the clinics to meet with physicians and frontline staff to explain the program and provide staff with training and tools (e.g., scripts) to assist in recruiting patient observers. In response to task force concerns about the accuracy of patient observations, the pilot test included selected use of an independent observer who accompanied the patient into the examination room of a subset of physicians who agreed to be observed. (Patients also had to agree but were not told why the observer was present.) As noted, this test confirmed the accuracy of the patient-as-observer approach.
- Sharing success stories, expanding program: After the initial pilot, hospital administrators invited program leaders to educate physician and nurse leaders about the initiative and the successful pilot; the vice president of ambulatory services and the manager of ambulatory quality and patient safety attended various meetings over a period of several months, explaining the program and sharing results from the pilot. Some physicians initially expressed skepticism and resistance to the idea, fearing it would negatively affect patient–provider relationships. However, after hearing these presentations, many departments became supporters. The program has now been adopted by 141 outpatient clinics, 2 satellite outpatient centers with one more location expected to be added in June 2013, outpatient clinics at Johns Hopkins Bayview Medical Center, a 350-bed community hospital, and 41 Johns Hopkins Community Physicians locations. Participation remains voluntary.
- Implementing scanning system: Although all tabulations and analysis have previously been done by hand, a scanning system currently under development will allow automated tabulation of results, thus reducing the labor effort involved and freeing up resources to focus more on quality improvement.
Resources Used and Skills Needed
- Staffing: To date, the quality improvement team leader has spent roughly half time on the program, primarily to coordinate the bimonthly, weeklong observation periods in each participating clinic (e.g., securing and distributing appropriate supplies, sending out reminder notices, etc.) and to tabulate and analyze results from the cards. Although the new scanning process has been implemented, program staffing remains at 0.5 full-time equivalents. Other outpatient clinic staff (e.g., patient service coordinators) participate in the program as part of their regular duties.
- Costs: As noted, the program costs approximately 17 cents per patient encounter (excluding the labor costs outlined above). Major program expenses include the paper cards (currently 8 cents per encounter, although costs should decline once the scanning system is in place, because it requires less thick card stock), wipes for patients (5 cents per encounter), these will be phased out as the supply dwindles, and pencils (4 cents per encounter). In addition, the ballot boxes represent a one-time cost of $10 per clinic.
Funding SourcesThe program was funded internally by the Ambulatory Quality & Patient Safety Division through the Center for Innovation, the Johns Hopkins Outpatient Center, and the Quality Improvement Department.
Tools and Other ResourcesThe appendix to the footnoted article includes materials to assist would-be adopters, including a survey to gauge patient interest in serving as observers, a copy of the observation data collection card, and an implementation checklist.6
A Joint Commission monograph designed to help institutions monitor hand hygiene adherence is available at http://www.jointcommission.org/assets/1/18/hh_monograph.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
A list of the The Joint Commission's 2008 National Patient Safety Goals is available at http://www.patientsafety.gov/TIPS/Docs/TIPS_JanFeb08.pdf.
Getting Started with This Innovation
- Secure leadership buy-in: Share data with administrative and physician leaders on the magnitude of the problem of health care–associated infections, the role of proper hand hygiene in reducing such infections (and their associated costs), and Joint Commission requirements related to hand hygiene. Leadership support can be crucial in overcoming initial resistance and skepticism among clinicians and frontline staff.
- Work with existing resources: As noted, copies of a patient survey, the card, and an implementation checklist are publicly available; these tools can be adapted for use by would-be adopters.
- Pilot test program to demonstrate its potential: Conduct a small pilot test in one or more clinics where staff and physicians show a willingness to innovate. Success from this test can be used to encourage other clinics to adopt the program.
- Support clinic staff: Provide frontline clinic staff with support (including suggested scripts) to help in recruiting patients to serve as observers.
Sustaining This Innovation
- Offer regular feedback on performance, celebrate successes: Providing feedback on performance and recognizing strong performers help to encourage continued attention to proper hand hygiene, both among providers and the frontline staff who hand out the cards.
- Support poor performers: Periodic education and training by infection control and quality improvement specialists can help poor performing clinics to improve adherence to appropriate hand hygiene.
- Tap into technology to reduce costs: As noted, Johns Hopkins is implementing a scanning system that will automatically tabulate results, thus reducing the labor resources required for data collection and analysis.
Additional Considerations and Lessons
- Consider encouraging patients to speak up: As noted, more than half of surveyed patients indicated a willingness to speak up to their providers if they did not follow appropriate hand hygiene. Patient feedback can be a powerful motivator for providers, and use of such an approach would be consistent with The Joint Commission's Speak-Up campaign.
- Consider provider-specific feedback: Although Johns Hopkins presently does not collect the names of individual providers, program leaders might alter the data collection card to do so in the future, thus allowing the creation of provider-specific performance reports.
Use By Other Organizations
- As noted, Tripler Army Medical Center in Honolulu, HI, uses a similar approach.
McGuckin M, Waterman R, Govednik J. Hand hygiene compliance in the United States: a one-year multicenter collaborative using product volume usage measurement and feedback. Am J Med Qual. 2009;24:205-13. [PubMed]
3 Dobson MR. Disease: the extraordinary stories behind history's deadliest killers. London: Quercus; 2007.
Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of hospital-wide programmme to improve compliance with hand hygiene. Infection Control Programme. Lancet. 2000;356:1307-12. [PubMed]
Benton C. Hand hygiene-meeting the JCAHO safety goal: can compliance with CDC hand hygiene guidelines be improved by a surveillance and educational program? Plast Surg Nurs. 2007;27(1):40-4. [PubMed]
Bittle MJ, LaMarche S. Engaging the patient as observer to promote hand hygiene compliance in ambulatory care. Jt Comm J Qual Patient Saf. 2009;35(10):519-25; AP1-AP3. Online version with appendix. [PubMed]
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Service Delivery Innovation Profile
Original publication: March 17, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: May 22, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: April 09, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.