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3 ways to break cultural IP barriers

Publish Date: 8/28/2013

Three years ago, hospital-wide hand hygiene compliance at Johns Hopkins Bayview Medical Center in Baltimore was in the 40-percent range. At this time, when hospital employees were questioned about not practicing appropriate hand hygiene the response was often anger, frustration and denial.

Today, hospital-wide hand hygiene compliance is sustained at above 85%. When Infection Prevention Practitioner Kerri Huber, MSN, RN, CIC, does observe and mention non-compliance with hand hygiene, the embarrassed employee apologizes and immediately goes to a hand hygiene station.

In the OR, a project focused on compliance with terminal cleaning of high touch objects is yielding a similar culture shift.

“It’s exciting to witness this amazing transformation,” Huber acknowledges. “Seeing the power of positive reinforcement has empowered us to reward the good as a way to change the bad in all areas of infection prevention compliance.”

Instilling a “clean culture”
“We recognized that the root of our non-compliance with infection prevention was tied to behavior and culture,” Huber notes. To tackle this needed culture shift, both positive reinforcement and more punitive, peer-pressure methods were tested.

She explains, very simple positive reinforcement, things like rewarding good hand hygiene by handing out a Life Saver® candy and a thanks for being a “live saver,” led to a two-fold increase in hand hygiene compliance. Whereas, negative methods, such as asking care providers to call out colleagues when they witnessed non-compliant hand hygiene was “a complete flop.”

Today, a positive reinforcement approach is serving to sustain compliance with infection prevention across the board, Huber says. She adds, “Among all hospital employees, from frontline nurses to pharmacy techs and dietary assistants, we are witnessing a culture shift toward infection prevention compliance.”
The other key ingredient for this success is enlisting frontline care providers to address problems and develop solutions together.

Here are the key approaches Huber says are helping build a clean culture at Johns Hopkins Bayview Medical Center:

1. Call out good behavior for ALL to see
Building off of our Life Saver campaign for hand hygiene compliance, we implemented a reward system for good hand hygiene behavior, with individual and unit-based recognition. Unit-recognition for a month of the highest hand hygiene compliance rates includes a trophy, a write-up in the facility newsletter (this public recognition is key) and entry into a raffle to win a unit pizza party or ice cream social.

Individual chances at raffle prizes are awarded to any hospital employee who is observed practicing correct hand hygiene, including any member of the perioperative team.

By rewarding positive behavior, we have made infection prevention compliance a cultural expectation and a competition. This approach is now mirrored in every infection prevention campaign we initiate, including initiatives specific to the perioperative setting.

2. ALWAYS work with the frontline to tackle IP barriers
Any performance improvement project has to start at the ground level. It’s a cultural norm at Johns Hopkins Bayview to address change from the bottom up. To do this, it’s critical to listen to frontline team members for identifying problems, developing solutions and measuring success to see what works and what needs to be adjusted.

For example, with the recently implemented study on terminal cleaning in the OR we sat down with environmental services techs and perioperative nurses to ask what needs to change for improved cleaning compliance. Then we vetted these changes up to OR and infection prevention leadership. With the changes implemented, we are feeding compliance data back to frontline techs.

We’ve found frontline stakeholders to be very receptive IF they see an outcome. The key is asking for frontline input because you legitimately value their opinion. Any idea is much more readily adopted if it comes from the people who are responsible for the work and accountable to the outcomes.


3. Share infection rates with ALL hospital employees
All infection rates from every area of the hospital are posted on our hospital intranet for any employee to access. There was some initial pushback to provide such open access to these data, but it is now well received. Sharing infection rates has proven successful in supporting accountability because everyone can see the effects of the care they provide. We are seeing less corners being cut, because the effects of those cut corners are posted for all to see.

Additional Resources

Want to learn more about these positive reinforcement campaigns?

Read a poster abstract on the hand hygiene study led by Kerri Huber (published as Kerri Adams) in the June 2013 supplement in AJIC.

Look for study findings on the OR terminal cleaning campaign next summer.

Need a framework for implementing change? 

Huber suggests accessing information on using a Comprehensive Unit-Based Safety Program (CUSP).

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