Hand hygiene.pdf

2. HAND HYGIENE AS A QUALITY INDICATOR FOR PATIENT
SAFETY
Patient safety has become the touchstone of contemporary medical care. Medical errors
and adverse events occur with distressing frequency, as outlined persuasively in the United
States Institute of Medicine’s To err is human 700 . HCAIs are second only to medication
errors as a cause of adverse events in hospitalized patients. Hospital infection control
provides a mature template for patient safety with a long track record of research, evidencebased
practice standards, and practice improvement efforts. Moreover, infection control
professionals and hospital epidemiologists have pioneered real-time methods to detect the
occurrence of HCAI and monitor compliance with infection control standards. Nonetheless,
as documented in this report, compliance with hand hygiene – the pillar of infection control
– remains woeful in the vast majority of health-care institutions. The current emphasis
on hand hygiene by the WHO World Alliance for Patient Safety and many regulatory and
accrediting agencies reflects the slow progress of the health professions in meeting even
modest performance standards.
Donabedian’s quality paradigm of structure, process and outcome 701,702 provides a useful
framework for considering efforts to improve hand hygiene compliance. Clearly, if sinks
and alcohol dispensers are not readily accessible (faulty structure) and hand hygiene is not
performed (inadequate process), the risk of infection and its attendant morbidity, mortality
and cost (outcomes) will increase. Quality indicators can be developed according to
Donabedian’s framework.
Hazard analysis critical control point is another valuable method to examine the system
of patient care as it relates to hand hygiene. Originally developed to provide astronauts with
pathogen-free food, hazard analysis critical control point is now widely employed in good
manufacturing practice, food and drug safety, and blood banking. In brief, the method identifies
error-prone aspects of systems (critical control points), evaluates the risk they pose, and
designs them out. Critical control points are scored according to their probability of occurrence,
probability of avoiding detection, and severity of downstream impact. Failure mode
and effects analysis is closely related to hazard analysis critical control point and is being
exploited increasingly in patient safety. A desirable feature of both hazard analysis critical
control point and failure mode and effects analysis is their emphasis on systems’ errors and
their consequences. An empty alcohol dispenser, failure to educate staff in proper hand
hygiene technique, and failure to practise hand hygiene after glove removal are serious
failures at key points in the patient-care system. When multidisciplinary care teams map
their institution’s system for hand hygiene, they not only identify error-prone critical control
points and barriers to compliance, but also identify which aspects of the system are most
critical to improve and monitor. This collaborative approach to identifying key quality indicators
vastly improves these indicators’ local credibility and relevance and provides a guide
to ongoing improvement and auditing efforts.
Failures at critical control points in the hand hygiene system can be seen as problems in
the reliability of the system. The concept of reliability is the bedrock of modern manufacturing
(for example, it transformed the quality of automobile production) but has been applied
to health care only recently. Reliability looks at the defect or failure rate in key aspects of
production (i.e. patient care). Industry often seeks to achieve defect rates of one per million
or less (a component of so-called six-sigma reliability). While such a high degree of reliability
seems impossible in many aspects of health care, it is worth noting that most institutions
have hand hygiene defect rates of six per ten opportunities or greater. Moreover, these rates