Here are examples of what outpatient surgical facilities around the country are doing to improve hand-hygiene compliance with hand rubs. As you'll see, it takes persistence, creativity and a willingness to nag on your part to make a difference.

1. Put dispensers everywhere
Ever notice how it seems like there's a soft drink dispenser nearly everywhere? That's because the beverage companies want you to use the machines and buy a drink whenever you feel thirsty. Use the same strategy for your hand-rub dispensers — put them everywhere. Dale Bowman, RN, CNOR, CASC, the administrator of the Roseville Surgery Center in Roseville, Calif., is always looking for a new spot to put a hand-rub dispenser. They're in the business office, on both sides of the OR doors, near the specimen handling area and even next to the time clock. "When they come to punch out for lunch, they use it," says Ms. Bowman. Employees and physicians are using the dispenser more often. "We're going through the foam," she says.

One thing to consider when adding dispensers is their proximity to sources of sparks, such as electric sockets, light switches and electrical equipment. Because of the high alcohol content, dispensers should be at least six inches away from sources of ignition in order to reduce the risk of fire, says Ms. Bowman. Check to see if your local fire code addresses the placement of dispensers.

2. Bring out the black light
With certain glow-in-the dark products, you can see where you've missed after washing your hands. At the Surgery Center of Alta Bates Summit Medical Center in Oakland, Calif., Jackie Sisto, RN, BSN, uses Glo Germ products (www.glogerm.com) to educate staff about proper hand washing and rubbing techniques. Ms. Sisto asks employees to apply a glow-in-the-dark liquid or gel as if it were hand lotion. Then the employee washes or rubs her hands normally. Afterward, Ms. Sisto shines an ultraviolet flashlight on the employee's hands.

The product's microscopic "germs" of melamine copolymer resin glow everywhere the soap missed. The same concept applies to using a hand rub. "It teaches you where to concentrate," says Ms. Sisto, who is in charge of quality standards at her facility.

Ms. Sisto also uses a similar glow-in-the-dark powder that she brushes on doorknobs and chairs. She'll then surprise employees with the flashlight and shine it on their hands to show how far microbes can travel. This helps drive home the importance of using hand rubs between hand washings.

3. Make it fun
A poster with a joke or a cartoonish animal is more likely to catch the eye and stay in the mind of a busy healthcare worker than a stern reminder. At New England Baptist Hospital in Boston, Infection Control Manager Maureen Spencer, RN, MEd, CIC, dreams up funny themes for the hospital's hand-hygiene program. Past themes include "Happy Fingers," based on the penguin movie "Happy Feet," and LUAU (Let Us Always Use Good Hand Hygiene). Once a theme is determined, Ms. Spencer checks the Oriental Trading Co.'s Web site (www.orientaltrading.com) for party favors, trinkets and stuffed animals to complement the theme. The goal behind the party favors and swag is to make an impression on staff and physicians. "We're using the same strategies as the pharmaceutical companies," says Ms. Spencer.

The fun is just one part of a two-pronged approach of positive reinforcement (funny posters, games and free pocket-sized bottles of rub) and negative reinforcement (observations and "call outs" when team members don't use the rub when required). Often it takes a combination of both to get good results, says Ms. Spencer.

A catchy poster draws attention of the staff only as long as it remains novel. After about a month, a poster becomes part of the everyday environment to passers-by. "They stop seeing things," says Ms. Spencer. So it's important to mix things up and change posters and themes often. For added surprise, change posters at irregular intervals, says Ms. Spencer.

4. Go undercover
Moles are coming to the Alaska Digestive Center in Anchorage, Alaska. This month the center is kicking off a "secret viewer" program. Each week, one employee's name will be drawn out of a hat. The chosen employee will be assigned a co-worker to monitor for one day. "It's like being a secret shopper," says Michelle Marshall, RN, the nurse manager at the center.

Before the undercover mission, each employee will get a hand-hygiene refresher course. At the end of the day, the employee will fill out a worksheet that documents what the spy saw. Spies will keep an eye on physicians as well. After a year, everyone in the center will have had a chance to monitor colleagues. Each quarter, the results of the secret monitoring will be reported during the center's quality improvement meeting and then to the board of directors. The results will be scrubbed of names so that the report is instructive rather than accusatory, says Ms. Marshall.

5. Study your progress
Monitoring compliance will help you identify areas and people that need more attention. And you might just discover that what gets measured gets done. "We did a QA study and monitored the use of hand-rub compliance in the OR and pre- and post-op areas," says Ann Twomey, MSM, the clinical director of the Boston (Mass.) Eye Surgery and Laser Center. Once everyone learned the results, behavior changed. "We shared the initial results with the staff," says Ms. Twomey. "Then we did another study, with 100 percent compliance."

6. Point out non-compliance
Don't be shy about confrontation. Encourage everyone, no matter what their job is, to ask non-compliant colleagues to use the hand rub. And ask them to do it now. This should include non-compliant physicians. It's not nitpicking, overreacting or being disrespectful. "It's called being responsible," says Ms. Marshall. "Everybody is on equal ground in this center, and the physicians are excellent and support this."

Hand hygiene is an integral part of a deadly serious issue that results in thousands of hospital-acquired infections each year. Some facilities ask patients to report whether their caregivers used a hand rub on entering and exiting a room. Other facilities go as far as asking patients to remind caregivers to use the rub when they should.

That's what happens at Kootenai Outpatient Surgery in Coeur d'Alene, Idaho. Patients receive a "movie ticket" that says, "Let someone know they're a ???star.' I saw this caregiver washing their hands:

• nurse admitting me
• anesthesia provider interviewing me
• my doctor
• OR nurse
• nurse taking care of me after surgery."

Patients are advised to circle all of the providers they see washing their hands before providing care to them, says Director Vicki Moffat, RN, CNOR. She enters tickets that patients return to discharge nurses into a quarterly drawing for a gift card.

Hand-hygiene education never ends. Bring it up at meetings, hold in-services, remind staff throughout the day and make using hand rubs a part of everyone's daily routine, advise those who make it their business to change hand-hygiene behavior in their facilities. And put these six tips into practice.