Hand Hygiene Enforcement Done Right

Workplace Culture Infection Prevention

By: Jared Bilski | Managing Editor

Published: 5/23/2022

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Designated auditors, frequent and formal evaluations and a top-down culture of compliance are the keys to success.


Every time Lauren Bryan, RN, notices an OR team member following her facility’s robust hand hygiene protocols, she makes it a point to verbally acknowledge the compliance she just witnessed. It’s positive recognition, sure. But there’s a more subtle reason for the shout out, as well. “It lets staff know we’re always watching and paying attention,” says Ms. Bryan, infection prevention program manager at UCHealth Yampa Valley Medical Center in Steamboat Springs, Colo.

This example encapsulates the challenges surgical facility leaders face when it comes to hand hygiene compliance. This crucial but often overlooked area of infection prevention requires leaders to walk a delicate balance between positive reinforcement and gentle corrective action — with an emphasis on the “gentle” aspect of rectifying compliance mishaps. “When it comes to hand hygiene, we’re not punitive, but we are very conscientious,” says Crystal Corfman, BSN, RN, CNOR, clinical director at PSB Surgery Center in Falls Church, Va.

Both Ms. Bryan and Ms. Corfman boast sterling hand hygiene adherence rates and credit their success to a combination of tools and tactics that foster a culture of compliance. 

• Dedicated enforcement staff. If you’re serious about hand hygiene, you need to task someone or, ideally, multiple people with enforcing your protocols. For instance, Ms. Bryan has a formal training program in place where auditors on the unit are trained on how to evaluate staff’s hand hygiene practices. “You have to teach the auditors what to look for,” she says. “Are you following WHO standards? The CDC’s? Spell out exactly what they should be monitoring.” Like all protocols, retraining is occasionally necessary to make sure everyone is on the same page, and Ms. Bryan used the pandemic — a time when infection prevention was top of mind for everyone — to retrain auditors on what proper hand hygiene was and what to look for during the audits.

Ms. Corfman’s facility also assigns a staff member in pre-op to audit both hand hygiene practices and on-time case starts. “They monitor whether staff foam in and foam out before and after seeing the patient, whether the correct techniques are in place and whether their nails are compliant and don’t have any chips in them,” she says.

If non-compliance is observed, it’s noted on the standardized form the facility uses to document staff performance and real-time coaching or correction is provided (always away from the patient). That generally does the trick, but if a lack of compliance occurs more than twice, the situation gets escalated, and Ms. Corfman will have a conversation with the offending staff member. “If the issue continues beyond the one-on-one conversation, I could escalate it further,” she says. “But I haven’t had to because staff are very receptive.” So receptive, in fact, that PSB’s hand hygiene compliance rate consistently hovers between 98% and 100%.

• Formal and frequent audits. Once you have your designated compliance checker or team in place, you need to formalize the process, audit regularly and use the information you uncover to improve your processes. At Yampa Valley Medical Center, formal hand hygiene evaluations are part of a constant multitiered process that begin as soon as current audits conclude because, as Ms. Bryan puts it, “hand hygiene never stops.”

After UCHealth’s hand hygiene auditors submit their findings to infection prevention, Ms. Bryan’s department analyzes the information and sends it back to the leader of the surgical unit. From there, the leader of the unit reports directly to senior leadership on the compliance findings. To fine-tune the process, the facility performs gap analyses to address current or looming issues, provides regular refresher training — emphasizing the “why” behind the facility’s protocols — and reaches out to the staff being audited for feedback. “We have interview sheets where we ask people, ‘What are the barriers to compliance? What types of hand hygiene products do you like or dislike?’” says Ms. Bryan.

• Top-down modeling. A culture of compliance is reinforced by staff seeing and doing what their peers do. The most effective way to do this is from the top down. There’s a significant amount of research showing that if physicians and other OR leaders model and practice proper hand hygiene, residents and direct reports will do the same, says Ms. Bryan. “There’s a strong correlation between leaders and team members, and it’s important to leverage the human effect in a way that’s not too punitive,” she says. This can be challenging — especially when surgeons come in from different departments or areas of your health system or community. However, once the culture is in place, you might be surprised at how comfortable your entire staff will be about speaking up if they see something. “We have dedicated nurses who’ve created such a safe environment where all of us feel comfortable stopping anybody and saying, ‘Hey, you forgot to foam in,’” says Ms. Corfman. 

• Emphasis on convenience. With myriad tasks and processes OR staff carry out for each case, you need to make hand hygiene as simple and convenient as possible. To that end, PSB has strategically placed sanitizer dispensers in every nook and cranny of the facility. “With that type of placement, it’s convenient for staff to practice proper hand hygiene,” says Ms. Corfman.

When it comes to hand hygiene, we’re not punitive, but we are very conscientious.
— Crystal Corfman, BSN, RN, CNOR

At UCHealth Yampa Valley, Ms. Bryan is constantly looking for ways to make it easier for staff to seamlessly fit hand hygiene into their workflow. As surgical leaders are aware, anything that adds another step or a couple extra seconds is easily left by the wayside when push comes to shove.

“Staff want to do the right thing, but if you don’t make it convenient for them and don’t use a product they like, it’s that much harder to get them to comply,” says Ms. Bryan, who gives the example of placing a urinary catheter to illustrate her point. “If staff are holding the patient up to place the catheter, they’re not going to walk away and rescrub their hands,” she says.

For this very scenario, her facility has catheter kits that include hand sanitizer, so staff don’t need to walk away from the patient. In fact, they don’t even need to turn away to rescrub. “Whenever something takes you away from the bedside, it decreases the chances that you’re going to do it,” she says.

Proper hand hygiene is one of many crucial steps providers must adhere to in order to provide patients with the best protection from infection. To do it well, you must ingrain this simple practice in the fabric of your facility’s culture. Designated auditors and point people, formal audits, top-down modeling and convenient processes make it much easier for compliance to become second nature with your staff. And second nature is what you’re aiming for because as Ms. Bryan puts it, “Hand hygiene is a muscle memory thing.” OSM

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