Data Validation of Hand Hygiene Compliance

ISSUE: In compliance with JCAHO Safety Goal # 7 following the Centers for Disease Control (CDC) standards on hand hygiene (HH), the Department of Veterans Affairs New Jersey Healthcare System (VANJHCS) Infection Control program in 2004 initiated the monitoring of HH practices by training intra-raters (unit-based observers). The compliance of East Orange campus was below 90% despite aggressive campaign, medical center-wide display of hand washing posters and “hand-glow” demonstrations. The Infection Control Practitioners also met with non-compliant departments where data was graphically presented and proper product use and HH techniques were re-emphasized. In an effort to validate HH data, a high school volunteer was utilized as the inter-rater in the summer of 2005 to conduct observational reliability monitoring of HH practices in four (4) patient care, namely Emergency Room, Medical and Surgical Intensive Care Units and Same Day Surgery. PROJECT: The monitoring initiative started with orientation of intra-raters to the process, which required observations of ten (10) healthcare providers per month performing HH practices before and after patient contact. The volunteer, a non-employee who maintain confidentilaity and reduce bias was trained as inter-rater and given the exact orientation as the intra-raters. The inter-rater monitored the healthcare providers in the designated areas for two (2) months. RESULTS: The inter-rater had 239 observations and the uint-based observers monitored 80 healthcare providers for that period. The inter-raterʹs rate of compliance to HH practices was lower than the intra-raters. LESSONS LEARNED: The inter-rater an external observer captured the actual HH practices of the healthcare providers. The data of the unit-based observers should be validated for reliability and be use for process improvement.