The CDC reports hospital adherence to hand hygiene is abysmal, with observational studies finding rates of 5%–81% and an overall average of only 40%. Psychological principles are rarely explicitly utilized in studies on reducing hospital‐acquired infections. Our premise is that infection control is first and foremost a product of habit amenable to change and that unit culture will be the dominant factor that promotes and sustains improvement.
Average unit hand hygiene adherence rate was 75% in Q1 2010. The unit rate of urinary catheter‐associated infection was 4.8 per 1000 catheter‐days, and central line infection was 4.3 per 1000 line‐days. The objective of this initiative was to reduce iatrogenic infections by increasing hand hygiene rates from the baseline rate of 75% to greater than 90%.
In a participatory leadership model, the interprofessional committee implemented 4 interventions over a 9‐month period: (1) change from surreptitious auditing to real‐time feedback and immediate correction for all observed nonadherence events on the unit; (2) change from audits by a single infection control champion to random assignment of auditing responsibility to all members of the nursing staff; (3) delivery of nonadherence “tickets” and reinforcement of adherence with individually wrapped hard candy “lifesavers”; (4) follow‐up communication by unit leadership for failure to correct or repeated nonadherence by any individual, regardless of role or rank. Hand hygiene adherence progressively improved from 75% in Q1 2010 to 97.2% in Q2 2012. Iatrogenic infection dropped from 4.8 per 1000 urinary catheter‐days to zero. Bloodstream infections fell from 4.3 per 1000 central line‐days to zero.
Hand hygiene occurs at the intersection of habit and culture. Improvement required bringing awareness of nonadherence to the level of the individual. Direct and immediate feedback propels it from unconscious to conscious behavior. The medical literature rarely discusses employing operant conditioning on medical staff using small sweet rewards, but this initiative demonstrates how this can be done to facilitate new habit development. Staff assignment to perform observations may alter hand hygiene behavior, even on days not designated to perform audits. Application of social psychological principles including the peer pressure of conforming social norms sustains behavior change. Fostering a culture of patient safety requires participatory leadership and level hierarchies within a sustainable model of culture change. Changes to hand hygiene auditing and response processes demonstrate the ability to improve adherence rates within a clinical microsystem.
To cite this abstract:Cumbler E, Castillo L, Satorie L, Ford D, Hagman J, Hodge T, Price L, Wald H. Culture Change in Infection Control: Applying Psychological Principles to Improve Hand Hygiene. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 529. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/culture-change-in-infection-control-applying-psychological-principles-to-improve-hand-hygiene/. Accessed July 21, 2019.