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Study: Hand Hygiene Greatly Improves When Auditors Are Present

July 11, 2014
Health care workers are three times more likely to wash their hands when auditors are around – at least in one Toronto acute-care hospital.

Health care workers are three times more likely to wash their hands when auditors are around – at least in one Toronto acute-care hospital.

The study examined the Hawthorne effect, also known as observation bias – the tendency of people to change their behavior when they’re aware of an observer – by electronically monitoring hand hygiene at two inpatient units in the University Health Network. Ultrasound “tags” on soap dispensers transmitted a signal to a nearby receiver each time the levers were pushed, and a time-stamped hand-hygiene wash was recorded in a central database.

Sixty health care workers volunteered to participate in the study. A real-time electronic system measured their hand-hygiene dispenses while auditors were visible, and monitored their hand-hygiene behavior prior to the arrival of the auditors and at a different dispensing station not visible to the auditors.

Auditors typically did not go into patient rooms, so separate hand-washing rates were determined for dispensers inside patient rooms and those in hallways. The study included 12 audits between November 2012 and March 2013.

Although the health care workers were aware that data would be used in a variety of studies, they were “blind” to the questions asked in the studies. Auditors did not announce their presence during audits but wore white lab coats.

The study, conducted by Dr. Jocelyn Srigley and Dr. Michael Gardam, found that there was an approximately three-fold increase in the rate of hallway hand washes per hour among health care staff when an auditor was visible (3.75 per hour), compared with a location where the auditor was not visible (1.48 per hour) and to the previous weeks (1.07 per hour).

Hand-washing rates with the auditors present were compared with separate groups at different time periods and locations to ensure that the differences found were not due to hand-hygiene patterns that could be attributable to time of day or location.

In each instance, the hand-washing rates were significantly higher when the auditors were present, with the increase occurring after the auditors’ arrival, suggesting that the arrival of the auditor triggered the increase in hand hygiene.

“The difference in hand-hygiene rates – when an auditor is present compared with those times when one is not – is huge in this study, and we showed this effect to be very consistent,” says Gardam, who is the director of infection prevention and control at the University Health Network and Women’s College Hospital.

The study appears online in the BMJ Quality & Safety Journal.

Srigley, who conducted the study as part of her master’s thesis as a clinical fellow in infection prevention and control at the University Health Network and the University of Toronto, says that although the researchers were “surprised at the tripling effect” of having an auditor present, there still might be some value in conducting audits as there could be opportunities for in-the-moment education with health care staff.

Gardam suggests that a “front-line staff ownership” approach that engages rather than “nags” staff is a good option. Gardam brought the approach to the University Health Network about six years ago, and front-line staff have developed their own reminders to influence workers to wash their hands, including pancake breakfasts, public-unit reporting, pledges, posters and holding each other accountable.

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