Hand Hygiene Is a Team Effort

Creativity, conversation and data can boost clean-hands compliance.

“Clean in, clean out” is the mantra that acute care teams use to keep staff hands clean and patients safe from transmissible infection. Of course, busy surgical team members know hand hygiene is not that simple in hectic perioperative suites, where staff, vendors and patients’ loved ones move in and out of patient-occupied spaces.

Nicole Nomides, MT(ASCP), MS, CIC, FAPIC, witnessed this firsthand in 2015 as an infection prevention manager for Michigan Medicine in Ann Arbor. She was leading a systemwide push to improve hand hygiene compliance across the system, yet the compliance numbers in perioperative care persistently hovered around 20%. “Hand hygiene isn’t rocket science, but in perioperative care it is unique,” she acknowledges.

Collaborating with OR leaders and perioperative staff to investigate why compliance was so low, she identified several barriers and periop-specific factors that required closer attention. After a diligent two-year effort to address those challenges, hand hygiene compliance in periop areas at University of Michigan Medical Center increased from 20% to more than 80%.

Make hand hygiene easy to get right

To help ASC leaders improve hand hygiene compliance in their own busy centers, Ms. Nomides says creative, data-driven collaboration is key, not only between infection preventionists and OR leaders, but also directly with the frontline staff and patients. She offers the following low-cost, high-impact suggestions to tweak perioperative hand hygiene habits for long-term success.

1 Ramp up compliance observations. When Ms. Nomides launched her hand hygiene improvement work, she hired a team of college students and trained them as covert hand hygiene compliance observers. By tracking when staff practiced appropriate hygiene coming in and out of patient care areas, their strategic observations provided extensive compliance data that uncovered far more nuanced activities than previous observations completed by infection preventionists and others.

The undercover compliance observers found staff were not always practicing hand hygiene when going in and out of a patient-occupied OR suite. “Often staff were moving supplies and their hands were frequently full,” says Ms. Nomides. “We also saw a need for more hand hygiene stations placed within common pathways for OR, preoperative and postoperative care staff.”

After discussing these observations with OR leaders, Ms. Nomides found that perioperative staff had different attitudes about hand hygiene because so much of what OR nurses handle is in a sterile space, and they may not recognize that routine hand hygiene expectations go beyond the surgical hand scrub.

2 Refine workflow and rules. Together these OR leaders and Ms. Nomides re-established some rules for periop hand hygiene practices, such as not requiring washing when transporting a patient or in an emergency situation, and counting a surgical scrub as a hand hygiene event. “We wanted to simplify hand hygiene expectations so there were no questions as to when it was required,” says Ms. Nomides. As definitions were standardized for compliance, her covert observers collected data and shared it with OR team leads to address remaining compliance gaps and to target education and training.

HELPING HANDS Strategically placed, visually engaging materials about best practices and processes, like this pink paper reminder from Hunterdon Center for Surgery, can boost hand-hygiene compliance.

3 Determine ideal locations for hand hygiene stations. New locations for hand hygiene stations included the entrance/exit of every preoperative, OR and PACU care area and near every anesthesia cart. “Convenience is important,” says Ms. Nomides. “If you need to walk across a room to a hand hygiene station outside of your typical workflow, it makes it more of a challenge.” She cautions that fire safety standards must be met when placing alcohol-based sanitizer dispensers. For example, the CDC spells out fire safety standards for alcohol-based hand sanitizer, such as not exceeding 95% alcohol content by volume and placing dispensers at a specified distance from ignition sources including wall outlets, thermostats and appliances.

4 Choose preferred products. Make sure the team has access to a gel, foam or alcohol-based hand sanitizer. Given that the average nurse sanitizes their hands 15 times per hour during a shift, leaders should survey their team for product preference. Gels and foams work equally well, so Ms. Nomides suggests asking team members which they prefer. “You don’t want to ask staff to use a product that makes their hands sticky and yucky or smells displeasing,” she says. “If they like an alcohol-based sanitizer, they will be more inclined to use it.”

5 Designate a champion. Find a frontline staff member who is respected by staff and will collaborate well with an infection preventionist to strategize hand hygiene improvements that are tailored to your facility. “This can be especially helpful in a small center where a dedicated infection preventionist might not be part of your full-time staff,” says Ms. Nomides. The champion should reinforce best practices and coordinate compliance observations. Ms. Nomides’ perioperative hand hygiene champion re-evaluated hand hygiene station locations, stocked stations with adequate alcohol-based sanitizer and collaborated directly with frontline providers on re-education sessions. A 2024 study highlighting success strategies of hand hygiene champions reflects similar approaches. That study found champions successfully engaged staff by setting clear goals, helping develop good habits, engaging teams in comprehensive training, offering adequate resources and creating a positive culture of communication.

6 Instill a “compliance culture.” Hand hygiene reminders shouldn’t feel punitive. They can even be fun. Ms. Nomides gamified compliance through friendly competitions with T-shirts, prizes and an ongoing rewards program. The teams with the highest compliance numbers were recognized. The fun vibe made staff members feel safe to remind colleagues — and be reminded themselves — to wash their hands at appropriate times. The mantra “Clean. Remind. Thank.” was repeated daily by leaders to set a culture of psychological safety. They engaged in regular conversations and modeling to normalize hand hygiene reminders.

7 Collect and share compliance data. Establishing a culture of hand hygiene requires robust data collection. In her experience now as director of infection prevention and control in the Office of Clinical Quality & Safety at Henry Ford Health in Michigan, the covert observers Ms. Nomides previously used produced amazing data that made a difference, but “detailed compliance data can be gathered with resources at hand if observations are collected and shared in a standardized, consistent way,” she says.

One helpful tool she and her colleagues use is an app that any hand hygiene observer can use to collect data in the moment and share easily.

“As soon as you turn away from an intense and consistent focus on hand hygiene, compliance will slip,” warns Ms. Nomides. “It’s just the nature of working in a very fast-paced care environment. However, when you track compliance data and follow up with conversation and reeducation, you will see high hand hygiene compliance numbers stay high.” OSM