Hand Hygiene

Frustrated Getting Healthcare Workers to Clean their Hands? Perhaps Try a Different Approach

Michael Gardam


By Michael Gardam, MSc, MD, CM, CIC, FRCPC

Director of Infection Prevention and Control at the University Health Network

Infection prevention can be a very challenging job. We see patients in our facilities becoming sick or even dying from infections they did not need to have.  We spend many hours providing education sessions and in-service sessions to staff who frankly, often don’t seem to care very much. We are passionate and often may even feel personally responsible for some of the infections we see. Perhaps, if we had educated more or put up more reminders, staff would have changed their behavior.

Paradoxically, our passion for patient safety may be part of the reason why we aren’t making the progress we think we should. When we in infection prevention own the problem, should we be surprised when others don’t seem to care? Why should they since it isn’t their issue?

The first half of my career I owned all the infections in our hospital, yet felt powerless to make improvements. As the expert, I would provide frontline staff with lots of evidence-based guidelines and tools, but adoption was usually abysmal. I would often get push back about how whatever I provided wasn’t relevant or wouldn’t work in that setting. I truthfully got to the point where I considered changing careers.

A Change in Perspective
My attitude began to change several years ago when I was introduced to the field of complexity science and began to realize that my approach was actually a big part of the problem. Although they appear simple, many of the challenges we face in infection prevention are highly complex, meaning there often is no right answer on how to tackle the problem and no obvious route to take to ensure success.

My former self was stuck in the expert model, where I had all the answers. Learning about complexity made me realize that in order for a group to change its practice and behavior, the members of the group need to be the ones leading the change. My role began to shift from being the expert to being a facilitator whose job it is to help the team achieve its goals. I started to listen more and ask questions rather than assuming that concerns about a particular course of action meant that someone didn’t care. I also learned that while some standardization is necessary, spending time to determine which interventions needed to be standardized and which could be left up to local variation became very important.

Over time, the approach we developed became termed, “front-line ownership,” namely empowering those you want to change to lead the process.1 We have successfully used this approach for several different patient safety challenges including staff hand hygiene, preventing patient falls, pressure ulcers and infections, and others for very little cost.

Impact on Hand Hygiene
When working on hand hygiene, we determined early on that certain factors needed to be standardized for a given institution, for example: how auditing is performed, the hand hygiene product that is used and if that product is available at point of care, etc. In addition, others should be allowed to vary between different areas as they all have different cultures. Thus, the use of reminders, where the hand hygiene product is located at point of care (at the end of the bed, on the wall, etc.), rewards, etc. all emerged out of engagement with front-line staff. In effect, we allow each ward to “rebuild the wheel” to determine what will work for them. While this sounds inefficient, we have found it leads to true ownership and sustained change. 

If you are frustrated in your role, honestly ask yourself if you might be contributing to your own frustration.2 I’ve been there, and honestly, both my patients and I are in a better state now that I have learned to engage others in safety. 

Dr. Gardam will discuss this topic at the GOJO Interactive Breakfast Symposium at this year's APIC Conference in Nashville, Tenn. The Symposium will take place on Sat., June 27th from 5:30 a.m. to 7:30 a.m. Register today.

[1] Zimmerman et. al. Front Line Ownership: Generating a cure mindset for patient safety. Healthcare Papers. 2013;13(1):6-23.
[2] Gardam and Gitterman. If you don’t succeed the first 20 times, please try something different. Qmentum Quarterly. 2013. Available at: https://www.accreditation.ca/sites/default/files/qq-fall-2013.pdf

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