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Joint Commission’s focus on hand washing puts pressure on healthcare facilities

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April 1, 2018

For once, Marge McFarlane, PhD, MT(ASCP), CHSP, CHFM, HEM, MEP, CHEP, was a visitor when she arrived in the middle of one night in 2010 at the emergency room of a hospital with which she was affiliated. Her husband was there for a non-life-threatening medical emergency, which is why McFarlane, who has worked as an independent safety consultant since 2005, was sitting in the corner when a caregiver walked in, spotted her, and made a beeline toward a sink.

“He saw me, and he said, ‘Oh, Marge. Good to see you. See, I’m washing my hands because I know you’re on the hand washing team,’” McFarlane recently recalled.

The playful comment was also a startling admission that the doctor might not have remembered to wash his hands had he not known McFarlane was in the room.

“They knew something was up because Marge was on the floor, so then they all behaved themselves,” she says. “If I’m on the floor and people see me, you better believe they are going to follow all the protocols related to their job, including proper hand washing. So I would observe 100% [compliance]. But if I sent a ‘secret shopper’? Not so much.”

Healthcare workers should also know they need to be on their best behavior when a surveyor from The Joint Commission (TJC) rolls through their healthcare facility. But now, after a significant rule change went into effect in 2018, all it takes is one hand hygiene slipup for a TJC surveyor to slap your organization with a citation.

“If you are busy doing patient care and not watching the regulatory history and the raising of the bar to make this happen, it may come to you as a total shock,” said McFarlane, principal of Superior Performance in Eau Claire, Wisconsin. “But it’s the right thing to do for patient care no matter what, so we should all be behind it.”

Late last year, TJC announced that effective January 1, if a surveyor witnesses an individual who directly cares for patients fail to perform required hand hygiene, the person’s healthcare organization will receive a citation under TJC’s Infection Prevention and Control (IC) standard IC.02.01.01, element of performance 2, which requires organizations to use precautions such as hand hygiene to reduce infection risk.

Additionally, healthcare facilities must meet National Patient Safety Goal (NPSG) 07.01.01, which requires them to implement and maintain a hand hygiene program.

In 2004, TJC first required all healthcare organizations to implement a hand hygiene program and keep track of individual performance within that plan. McFarlane expresses skepticism, though, about the accuracy of such self-monitoring.

“[Organizations] have designed compliance monitoring [plans] that may or may not reflect reality depending on who’s doing the observations, the number of observations, and the consistency of the observations,” McFarlane says. “That’s my opinion.”

Previously, healthcare organizations were not penalized by TJC for an individual failure to perform proper hand hygiene if that organization had an otherwise compliant hand hygiene program. McFarlane says it typically took three observations for an inspector to mark the organization down as “non-compliant” and issue a citation.

But now, a TJC surveyor spotting a single violation will cite the organization for a deficiency, resulting in a Requirement for Improvement. And when the citations — for a hand hygiene failure or anything else — pile up, it can put an organization’s TJC accreditation in jeopardy, along with the ability to accept Medicare and Medicaid patients.

McFarlane notes that last year CMS took the approach of citing each slipup that inspectors saw: whether it was one unlatched door, one uncalibrated gauge, or one unwashed pair of hands. It didn’t take long for TJC to fall in line behind them.

“In the CMS world, [where they] are the federal payers who have the biggest stick of all, [CMS has] been forcing, encouraging, requiring that accrediting agencies — The Joint Commission, DNV, HFAP, CHIQ, AAAHC, the list goes on — to cross every ‘t’ and dot every ‘i,’ ” McFarlane says. “Since CMS has adopted a one-and-done policy, they have now upped the ante for hand washing to one and done.”

Peggy Luebbert, MS, CIC, CHSP, CBSPD, an infection preventionist at OrthoNebraska in Omaha, Nebraska, says that while there was no formal warning from the accrediting agency that this change was coming, recent collaboration with CMS suggested that “they are taking [hand hygiene] seriously and they expect us to take it seriously.”

Might the recent change create needed accountability on an individual level, making the medical environment safer for both patients and caregivers?

“Oh yes. Oh yes,” Luebbert says. “It just takes Joint Commission to see one lapse for us to have to respond accordingly and to reinforce with employees the importance of doing the little things such as hand hygiene to break the chain of infection.”

According to CDC, one in every 25 hospital patients acquires a healthcare-associated infection on any given day. The hands of healthcare workers are “the most common vehicle for transmission,” a 2009 study in the Journal of Hospital Infection concluded.

Yet, only about 40% of hospital workers complied with hand hygiene standards, according to a 2010 study published in Infection Control & Hospital Epidemiology, the medical journal published by the Society for Healthcare Epidemiology of America.

Stubborn caregivers say they are too busy to lather up every single time they deal with a patient. Some may be so overwhelmed, especially in emergency settings, that they do actually forget to stop at the sink. Others argue that repeated washing is hard on their skin. Or, despite all the data demonstrating the risk, some workers may still not fully comprehend the danger in not washing their hands.

“I mean, it’s the key,” Luebbert says of proper hand washing. “When hand hygiene numbers fail, when employees stop washing their hands as much as they need to, infection rates go up — not only for our patients, but also for our employees.”

So what can be done to nudge caregivers toward compliance? Linda Gylland, MLS (ASCP), QLS, a lab safety officer for Sanford Health in Fargo, N.D., who says most departments at Sanford typically report compliance rates above 95%, has some suggestions.

1. Educate your staff. Gylland says when Sanford first started its hand hygiene program, all employees were required to sign a hand hygiene pledge and a hand hygiene poster. Staff were also required to complete an online course so they were aware of the importance of washing their hands and the increased risks they open themselves up to by skipping the sink. “Making this data known to staff is imperative in enforcing the importance of continuing good hand hygiene,” she adds. 

2. Monitor them, too. While Gylland expresses skepticism about the effectiveness of electronic hand washing monitoring systems, she agrees it is important to keep an eye on employees. She says Sanford relies on secret observers to make sure folks wash their hands and “provide reinforcement when it was observed and remind staff of missed opportunities.” The primary purpose is not to punish employees, but to gain an understanding of what prevented them from washing their hands and then share that with the hand hygiene committee, notes Gylland.

3. Make hand hygiene easy. Healthcare workers are usually juggling multiple tasks, so they may forget to wash their hands or decide they don’t have time for it in a particular instance. That’s why facilities should place everything caregivers need to get their hands clean in locations that are easy to see and access. “It is very easy to install wall dispensers with hand sanitizer, preferably in sight of patients,” Gylland says. “We have them in the hallways, in patient rooms, in our labs, everywhere. It is an easy fix.”

4. Reinforce through reward. The need to let employees know when they fail to wash their hands is obvious. But how about some love when they are at or near 100% compliance? Gylland says that at Sanford, when any department achieves at least 95% compliance for three consecutive months, they get recognized. Some even reward their staff with a pizza party or morning muffins. “Letting staff know their work is appreciated will result in increased compliance,” she says.




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