Increasing hand hygiene compliance rate

Increasing hand hygiene compliance rate among healthcare workers, patients and visitors through the use of electronic monitoring technology


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Anna K. Banguket BSc ,PGC Clinical Drug Development



School of Health and Social Work



Department of Adult Nursing








First and foremost, I thank God for all his love and mercies. I will also like to say thank you to my supervisor, Mrs Irene Anderson for all her help and support during the process of writing this dissertation. I will also like to thank all my lecturers at the University of Hertfordshire for all they have taught me about nursing. Lastly I will like to thank my husband and family for their continued love and support.
























Table of Contents

Acknowledgement. 2


1.0 Introduction. 1

1.1 Background of the proposed innovation. 2

1.2 Rationale. 3

1.3 Aim.. 4

1.4 Objectives. 4


2.0 Literature review.. 5

2.1 Inclusion criteria. 5

2.2 Exclusion criteria. 5

Table 1: Summary of reviewed papers. 6

2.3 Key themes. 8


3.0 Implementation plan. 17

3.1 Phase one. 18

3.2 Phase 2. 18

3.3 Phase 3. 19

3.4 Phase 4. 20


4.0 Change theory. 22

4.1 Lewin’s Unfreezing stage. 23

Table 2:  Driving and restraining forces. 25

4.2 Lewin`s moving stage. 27

4.3 Lewin’s refreezing stage. 28


5.0 Evaluation. 30

5.1 Process. 31

5.2 Impact. 31

5.3 Outcome. 32


6.0 Conclusion. 34






























1.0 Introduction

The purpose of this innovation is to increase hand hygiene (HH) compliance by healthcare workers (HCWs), patients and visitors through the use of technology, in order to reduce the incidence of healthcare associated infections (HCAI). HCAI is a serious problem worldwide being a burden to all healthcare systems financially and in human terms (WHO, 2011). WHO (2009) estimates that HCAI affect about 10% of hospitalised patients yearly. In the United States, it is estimated that HCAI add a cost of $96-$147 billion yearly to the healthcare system, and affects 1 in 20 hospital patients (Marchetti & Rossiter, 2013). In the UK, approximately 300,000 patients are affected yearly, at a cost of about £1 billion to the National Health Service (NHS), £56 million of which is incurred after patients are discharged from the hospital (National Audit Office, 2009). HCAI must be treated with antibiotics, resulting in an increase in antibiotic-resistant organisms, lengthened hospital stays, additional surgical procedures, inefficiency in hospital systems, disability and sometimes death (Boscart et al., 2012). HH, which involves either using alcohol-based hand rub (ABHR) or water and soap, is the single most important strategy in preventing the transmission of HCAI (WHO, 2009).  This is because effective hand decontamination will result reduction in the number of pathogens on the hand, and therefore logically decrease the incidence of HCAI, leading to a reduction on morbidity and mortality (WHO, 2009). It is therefore shocking that for something as simple as hand hygiene, compliance rates remain low-about 50% for HCWs and 20% for the public (Marra and Edmond, 2014). Reducing the incidence of HCAI in a bid to treat and care for people in a safe environment and protect them from avoidable harm is one of the priorities of Department of Health(DOH) as listed in the NHS Outcomes Framework (DOH, 2014). Doing this will also prevent patients form dying prematurely and enable them to have a positive experience of care (DOH, 2014).

1.1 Background of the proposed innovation

Despite international, national and local campaigns (WHO Save lives: clean your hands (2009); National Patient Safety Agency’s “Clean your hands campaign” (2004)) to improve HH practices, over all compliance remains low (Erasmus et al., 2010). Strategies which target organisations and behaviours, such as introduction of HH products, strategic placement of sinks and HH products, education programmes, reminders, posters, prompts and a focus on organisation safety have been recommended by national and international bodies (NICE (2014); WHO (2009)) with little success in improving overall compliance (WHO, 2013)

The WHO’s “five moments for HH” recommends that HH is indicated before and after touching a patient and after touching patient’s surroundings (Sax et al., 2007). If patients are not in single rooms, then the ward entrance is synonymous to the patients’ room, as it will therefore be the last doorway passed through before touching patient and the first through after touching a patient. 

Contrary to popular accepted view, resistant strains of organism might be spreading from the community into the healthcare system instead of the other way round, hence patients and visitors (carers and family members) need to be included in interventions to promote HH adherence (Birnbach et al., 2012) The National Institute for Healthcare and Clinical Excellence (NICE) quality standard on infection prevention and control (2014) advocates that patients, their families and carers should be included in infection prevention and control, as well as decision making about their treatment and care.

A multimodal approach to increase HH compliance among HCWs which includes patients and carers asking HCWs to perform HH, has shown no effect on reducing HCAI, as many patients do not feel empowered to challenge HCWs especially doctors (Longtin et al., 2009). This project will be trying a different approach where everyone is reminded by an automated message, sparing patients and visitors the need to do so.

The national Audit Office (NAO) (2009) identified systemic issues to be tackled in a bid to reduce infection rates, among which was a culture of continuous improvement, and a whole system approach with clear structures, roles and responsibilities. Thus interventions aimed at reducing HCAI should include everyone in the system-HCWs, patients, visitors (carers and families).

In trying to improve HH compliance in the healthcare setting electronic technologies are being introduced to assist with training, supervising and gathering data (McGuckin, 2015). The use of external cues such as voice prompts has also been supported in triggering behavioural change (Dieckmann et al., 2006). The proposed innovation will use both of these.

It is very important to note that no one intervention works on its own to improve HH compliance, but a multimodal approach is recommended (Watson, 2016).

1.2 Rationale

  • HH is the most important strategy to prevent HCAI but overall compliance is low (Erasmus et al., 2010)
  • On estimation, HCAI cost the NHS approximately £1 billion yearly (NAO, 2009) and has negative effects on patient safety, patient quality of life and patient satisfaction (NICE 2014)

1.3 Aim

To increase HH compliance rates to 75% among HCWs, patients and visitors through the use of an electronic monitoring system in a 10-month period.

1.4 Objectives

  • To create awareness on the importance of HH among HCWs, patients and visitors
  • To increase the rate of HH compliance, thereby reducing the risk of harm caused by HCAI to HCWs, patients and visitors.
  • To reduce the cost of HCAI to the NHS in a cost-effective manner













2.0 Literature review

The keywords used to search for literature included: “hand hygiene”, “hand wash*”, “comply*”, “electronic reminder”, “automated reminder”, “healthcare worker” and “patient”. These search terms were used to search for articles from specialist’s databases including CINAHL plus, PubMed, and the Cochrane Library using Boolean operators. Articles from 2011 to present were considered for selection, so as to ensure the evidence is current. Any papers not in English was excluded, as well as research carried outside a hospital, as the proposed innovation is in a hospital ward.

2.1 Inclusion criteria

  • Articles published in the English Language
  • Articles published after 2011
  • Peer-reviewed literature
  • Ward-based research studies
  • Studies that included patients and visitors

2.2 Exclusion criteria

  • Articles not in English
  • Articles published prior to 2011
  • Articles with community-based studies

Of the articles which included research on healthcare workers and adult patients, 5 studies were chosen for this literature review. Each selected study passed the Critical Appraisal Skills Programme (CASP) for quantitative, qualitative studies and cohort studies.

The table below gives a summary of the reviewed papers. 

Table 1: Summary of reviewed papers

Authors/Date Aim Methodology Findings
Ellison et al. (2015) To assess whether HH activities among HCWs could be increased using an electronic HH monitoring and reminder system Prospective control cohort study over 25 weeks. Electronic hand hygiene monitoring system (Door entry/exit chimes in combination with real-time compliance feedback) is reported to be able to increase healthcare worker hand hygiene performance by 24% in an ICU setting.
Moller-Sorensen et al. (2015) To use simple audio visual reminder to improve HH performance of HCWs, patients and visitors after restroom visit

Prospective intervention trial


HCW HH compliance rate increased from 66% to 91 % and patient and visitors HH compliance rate increased from 28% to 70%. 
Fakhry et al. (2012) To test the effectiveness of an audible reminder on hand hygiene adherence at a hospital ward entrance during an 8-month period. Quantitative pre interventional and post interventional study. The electronic motion sensor-triggered audible reminder was effective in increasing HH adherence overall from 7.6% to 49.9%.
Birnbach et al. (2012) To assess the use of ABHR by visitors for HH in a hospital lobby. Observational controlled study A combination of sign and freestanding ABHR dispenser improved HH compliance among visitors by 11.6% 
Ardizzone et al. (2013) To assess hand hygiene practices in surgical patients. Mixed study design involving a qualitative part and a quasiexperimental pre-test/post-test part. 55% of patients reported not being offered handwashing by nursing staff prior to an education intervention, after which there was an increase from 17.3% to 44.6% in nursing staff offering patients assistance with HH.


2.3 Key themes

The key themes to be discussed during this literature review include

  • Electronic HH reminder systems
  • HH education
  • Multimodal HH intervention strategy

The study by Ellison et al. (2015) focused on using an electronic hand hygiene reminder system to improve hand hygiene compliance among healthcare workers in two medical Intensive Care Units (ICUs). The study had four phases- baseline phase which lasted 6 weeks, the door entry/exit chimes phase which lasted 5 weeks, another 5 weeks with both door entry/exit chime and continuous real-time display of the most recent hand hygiene compliance and finally a 4-week washout period with no reminder. 

Ellison at al. (2015) reported a 24% increase in the mean number of healthcare worker HH events per day when a combination of the room entry/exit chimes and real-time computer monitor feedback was used, with little decay in HH activity over this phase. Also reported was a 40% increase in Hand Hygiene Entry/Exit Ratio (HHEE) compared to baseline levels with a combination of both interventions. This result was statistically significant with P < 0.001.  The number of HH events returned to baseline levels during the washout phase. There was no significant change in HH events in the control ICU throughout the trial. The authors concluded that a reminder system which provided real time feedback significantly increased HH compliance in an ICU.

The inclusion of a control is an asset to this study as it helps minimise reporting bias, which Srigley et al. (2015) criticised as a methodology fault of most trials involving HH monitoring technology. The use of electronic monitoring implies HH compliance can be recorded round the clock, which is a challenge is studies using human observers, where data collection takes place at specific times of the day and is costly and time consuming (Ward et al., 2014). The provision of feedback is another strength of this study as feedback acts as a motivation to do better (Mitchell, 2013). The trial also has several shortcomings, such as there is a chance that HCW HH activity was underreported as other staff and visitors were not aware of the trial so they may not have been very responsive to the reminder system but their entry/exits was recorded. This view is supported in a study by Birnbach et al. (2012) where visitors failed to use ABHR because they may not have known what it was for. Another possible reason for under reporting is the fact that technology is not infallible so glitches could cause errors in data collection (McGuckin & Govednik, 2015). The study takes place in an ICU where patients have individual rooms. It might not be very feasible in an open ward where there is only a ward entrance. Another issue is the use of chimes, which might cause disturbance to resting patients. Furthermore, this electronic system could not be used to measure the 5 moments of HH as per WHO recommendation. Lastly, it could be argued that the 5-week duration of the dual intervention phase was not long enough to exclude alarm monitor fatigue where HCWs get desensitised to the continuous alarm sound, and do not respond when it rings (Cvach, 2012), and the hawthorne effect where people modify or improve their behaviours when they are aware of being observed (Hagel et al., 2015).

A major problem with this study is the fact that HH compliance rates returned to baseline levels post intervention. This is most likely due to the lack of a multimodal strategy which involves HCW education HH to give them knowledge on the importance of good hand hygiene. Such strategies have been reported to be successful in maintaining improved HH compliance rate (Watson, 2016)

Moller-Sorensen et al. (2016) conducted their trial using eight restrooms in 2 university teaching hospitals. At each centre, two of the restrooms were for patient and visitors’ access and two for HCW access only. The patient’s/visitor restrooms had soap dispenser and the HCW restroom had both soap and alcohol hand rub (AHR) dispensers. The dispensers were equipped with a sound wave sensors, an electronic processor and a speaker and illuminating system. The system was programmed so that it could produce an audio-visual signal in response to sound waves. So a high-pitched sound was produced after flushing, which continued until soap dispensing occurred, in the absence of which the sound went on for sixty seconds. Where AHR dispensing system was included, a blue pulsing light turned on 10 seconds after soap dispensing to make the restroom user aware of alcohol dispensing.  Compliance was monitored using a hidden sound recorder which counted toilet flushing sounds together with electronic logging of soap and AHR dispensing. An observation period of three months’ pre-intervention was used to establish baseline and a further three months after the intervention for follow up. A statistically significant increase from 66% at baseline to 91% HH compliance post intervention for HCWs and from 46% to 76% for patients/visitors was reported.

A strength of this research is the inclusion of patients and visitors, who have been recorded to have much lower compliance to HH than HCW (Ardizzone et al., 2013). The study successfully used a time-framed counting device which Srigley at al. (2015) reported to be a difficulty in research that uses electronic technology to evaluate HH compliance.

A shortcoming of this research is the absence of a patient outcome as the main purpose of the research was improving HCWs hand hygiene. Also the assumption that HH is performed when dispensing is performed is faulty as HH quality has been shown to vary when quantified electronically from when observed physically (Srigley et al., 2015). The trial has some technology limitations, as not all restroom users will flush, and some will only flush after HH so will not be counted. Finally, it could also be argued that the study was not long enough to study the effect of alarm fatigue (Cvach, 2012).

The 91% compliance rate reported post intervention is quite impressive, but there is no way of knowing if such rates are sustainable, as that result may have been due to the hawthorne effect, which 3 months might not be long enough to quantify. Also the lack of a multimodal approach with an educational component is a concern, as it is the best recommended strategy to ensure sustained improved compliance (Midturi et al., 2015)

Fakhry et al. (2012) conducted a study involving a 2 month pre intervention phase to get baseline HH compliance rates and a 6months post intervention find out the effect of the intervention on HH compliance rates. The intervention involved fitting a motion sensor-activating audible reminder in the ceiling in the corridor outside the ward entrances. The reminder broadcasted the message “Please clean your hands with hand rub dispensers when entering or exiting any clinical ward”. Compliance was recorded as any attempt at using the ABHR provided at the ward entrances. Observations were completed over three fifteen minute periods during the day by researchers who disguised it by pretending that they were waiting for a lift. Data was collected to compare HH adherence between the pre and post intervention phases as well as between the pre intervention and later part of the post intervention phase to compare sustained improvement in HH compliance.

An increase in compliance rate from7.6 % to 49.9 % including an increase from 10.6% to 63.7 % for visitors was reported. These results correlate with those from previous trials where a red sign at surgical ward entrance improved HH compliance from 24% to 62% (Davis, 2010).

This study is advantageous in that the audible reminder system needs neither education nor training, is rapidly deployable, immediately effective and relatively inexpensive (£500). However, the message being only in English is limiting factor for non-English speakers. Another advantage is that it includes visitors, a group that has been reported to have very low HH compliance rates (Birnbach, 2012). The post intervention period of 6 months was long enough to quantify alarm fatigue but the use of human observers is a short coming as adherence is only measured at certain times of the day thus only a snapshot of HH compliance is obtained (Boyce, 2008).

All three trials involving the use of technology reported an increase in HH compliance by both patients/ visitors and HCW during the intervention phase (Ellison et al., 2015; Moller-Sorensen et al., 2016 & Fakhry et al., 2012). However, only 2 of the trials (Moller-Sorensen et al., 2015; Fakhry et al., 2012) reported sustained increase in compliance rate.  It could be argued that this positive sustained HH compliance was because the said trials were not long enough to study the problem of alarm fatigue and a dwindling impact of the Hawthorne effect (Srigley et al., 2014).  Also only one of the trials had a control group. This is a general problem with electronic monitoring systems hence the systematic review of such systems by Srigley et al. (2015) recommended that future studies involving such systems should include a control arm so as to ascertain the efficacy of the HH monitoring system.

Another problem with hand hygiene monitoring systems HHMS is cost (Marra & Edmond, 2012). Only one of the studies reviewed stated the cost of the system (Fakhry et al., 2012). Given the limited infection prevention and control budgets of most hospitals Ward et al. (2014) recommend that cost- effectiveness analysis be performed to show that these systems are worthwhile, if they are to be widely adopted.

The efficacy of the electronic systems is called into question as none of the trials provided details on the effect of the electronic HH monitoring systems on rates of healthcare acquired infection (HCAI) which is the main goal of all HH improvements interventions (WHO, 2009).

Birnbach et al. (2012) conducted an observational controlled study at the entrance of 560-bed tertiary care university hospital where visitor’s use of ABHR at the lobby security desk was observed during 3 phases: one involving an 8.5×11-inch sign placed at the security desk warning visitors to clean their hands; two involving a freestanding commercially available ABHR dispenser placed in front of the security desk; three a sign placed on top of the freestanding automatic dispenser and a sign placed on the security desk. The control arm of the study was a wall mounted ABHR dispenser mounted on a wall adjacent to the security desk. Baseline compliance data was collected before any intervention. Observations were conducted twice a day on each day of the week (10-11:30 am and 4-5:30 pm) as these are the busiest periods for visitors. There was no fixed observation period for each phase but 150 patients were considered to be the sample size based on a previous pilot study.

Baseline compliance was 0.52%, and that of phase one, two and three were 0.67%,9.33% and 11.67 % comparison with baseline, phases 2 and 3 which involved a new location for the ABHR dispenser showed statistically significant increase in HH compliance rate at P<0.01. 

Despite the cues, HH compliance rate among visitors increased, but was still sub optimal (about 10%). The study results highlight the importance of placement of HH products, and also the fact that even with appropriate sign, visitors might not be aware of the intended use of HH products, so a targeted educational approach is recommended. The use of human observers is a shortcoming.

The qualitative quasi-experimental study by Ardizzone et al. (2013) involved interviewing 72 patients and 42 nurses in a surgical unit to examine their views and knowledge about patient hand hygiene. Concurrently, these staff and patients were observed by a volunteer team of trained observers and the primary investigator for assistance with hand hygiene during four 3-hour sessions. A 30-minute presentation on HCAI, hand washing, and results of the observations were given to the nurses 2 months later. A month after this educational intervention, the same group of nurses and a new patient cohort were observed for assistance with patient and washing for 6 weeks during four 2-hour sessions. Inclusion criteria included being a surgical patient, 28 years or older and being willing to participate. 

41 patients (55%) reported that they were not offered hand washing by staff. 19% disagreed with the opinion that nurses view patient hand hygiene as important. 21% reported being unsure of nurses’ view on patient hand hygiene and 35 % reported staff rarely or never encouraging them to wash their hands. Posting signs, putting posters in bathroom, increasing reminder to staff, providing personal hand sanitizer to each patient, and a video loop on the hospital television reminding patients and visitors to clean their hands were the most common recommendations from patients on ways to improve patient HH.

In contrast to the patient report, 25 nurses (60%) reported that they offered patients assistance with HH, most commonly with ABHR. 90% reported that patient HH was important in preventing HCAI, and improved signage, more verbal reminders from staff and patient access to hand sanitizer were the most recommended intervention to improve patient HH.

Before the educational intervention, out of 81 observations, staff assisted patients with HH 14 times (17.3%). Post intervention, out of 83 opportunities, patients were assisted 37 times (44.6%). This increase was statistically significant (P=0.003). This increase in assistance seems to suggest that educating staff about the importance of hand hygiene could be an effective behaviour change strategy which will also increase staff awareness about the need to assist patients with HH.

The reviewed literature stresses the need for better methods to measure and monitor HH compliance, while minimising observational and reporting bias. It is also evident that both HCWs, patients and visitors have to be involved in HH interventions. A multimodal approach with an educational and feedback component is the best reported strategy for obtaining and sustaining improved compliance rates. The proposed innovation will seek to encompass all these.













3.0 Implementation plan

This chapter will outline the plan for using an electronic monitoring system to improve HH compliance among HCWs, patients and visitors at the entrance of a hospital ward. The project will be carried out in four phases, and will cover a 10-month period. Though this may seem like a long time, previous studies have been criticised for not being long enough so as to make sure that the data collected was free of the hawthorne effect, and so that alarm fatigue could be accounted for (Srigley, 2015; Ellison et al. 2015). ABHR consumption will also be used as a measure of success and for this to happen, studies have to run for long duration (Haubitz et al., 2016) The electronic monitoring system (EMS) to be used has 3 components

  • A data collection component which collects data on HH compliance using door opening versus use of wall mounted alcohol-based hand rub (ABHR) and moisturiser dispensers
  • An audio system with motion-sensor which gives out and automated message reminding people to perform HH when the sensor senses someone is 3m from the door
  • A screen component which gives daily feedback on HH compliance rate—ward entry/exit against number of HH events performed. This feedback is given along with a health promotion message on the importance of HH.

This system is installed by Technical initiatives UK Ltd, and cost $500.

3.1 Phase one

This phase will involve 2 wards- the ward of interest, and another ward which is identical in structure, staff and patient number, to minimise any bias (Srigley et al., 2015). The second ward will be the control ward. During this phase the hospital board will be approached to gain consent for this project. After this, the data collection component of the EMS will be installed at the entry to both the intervention and control wards. The dispensers will be fitted with counters which work in conjunction with door opening and closing. So upon opening, HH will be considered as compliant if the ABHR system dispenses within 10s following door opening. The 10 seconds time frame was chosen because it had been used and reported as sufficient time for HCW to think about performing HH on ward entry (Armellino et al., 2012).

Data on HH compliance will be collected for 3 months. This will be the baseline data. During this time, no one (HCW, patients, visitors) will be aware of this data collection. This is so as to avoid the Hawthorne effect where people change their behaviour when they know they are being watched (Hagel et al., 2015). 3 months was chosen because it will be enough time to get a true picture of the HH compliance rate of the wards (Moller-Sorensen et al., 2015)

3.2 Phase 2

During this phase HH champions will be recruited, as they are motivated, passionate and persistent in their effort to implement change (Hendy and Barlow,2012). The champions will include both lay people and HCWs from the wards. The hospital infection control team’s help will be sought to train these champions on HH and its importance in preventing HCAI, due to their expertise (NICE, 2011). Volunteer opportunities to be a lay champion could also be advertised around the hospital using posters. In total 6 champions will be needed-3 from the ward and 3 lay volunteers. This is so that they can cover both staff and patients/visitors in both wards.

The champions will carry out short informal interviews with HCWs, patients/visitors in both wards, to find out their point of view on HH, its importance in preventing HCAI, if and why HH is not performed. Answers will be anonymised to protect people’s identity, as some people might not be open and forthcoming with their views for fear of repercussion (Ahmad et al., 2016)

HCWs on both wards will also be given Foresight training by the champions to help them manage barriers to HH such as forgetfulness and heavy work load (Norris, 2012). The training consists of both paper-based and video-based scenarios relevant to staff based in acute and mental health settings. Patients/ visitors will be given education on HH by the champions. Leaflets on HH could be given to re-inforce the education sessions (Birnbach et al., 2012) A good time to do this will be during visiting hours as relatives/visitors will be present with patients. Champions will also organise short education sessions on HH for HCWs, who will be able to attend in groups of 3, to make sure that patient safety on the ward is not compromised.

This phase will last for one month

3.3 Phase 3

This phase will involve installation of the motion-sensor part of the EMS which gives the voice prompt at the entrance of the intervention ward. An automated voice prompt stating “Please Clean your hands using alcohol and moisturiser to help prevent infection and protect yourself, our patients and your families at home”.  Message strategy here is very important, so the automated message has to be worded in such a way as to have both a rational and emotional component of why HH is important (Taylor, 2015).

Feedback will also be given weekly on a computer screen at the nurse’s station, which is visible to all entering the ward. Giving feedback will enable everyone see how they are doing, and could act as a motivation to do better (Watson, 2016)

This phase will last for 3 months, as this will be considered long enough time to collect data with diminished Hawthorne effect and also enough time for alarm fatigue to set in (Srigley et al., 2015)

3.4 Phase 4

In this phase, the second and third parts of the EMS will be taken away and HH compliance will be recorded for another 3 months. This is so as to assess the HH compliance rate post intervention (Srigley et al., 2015). 

All data will be collected using the EMS and analysed by the hospital data collection team.

Results will be compared with baseline data to see the long term effect of the intervention on HH compliance.

Even though the innovation is aimed at using EMS, a multimodal approach is the best approach recommended for HH compliance interventions, hence the educational, training and feedback components of the innovation (WHO, 2009; Watson, 2016)

One of the shortcomings of this project is the use of an audible prompt, which may disturb patients especially those whose beds are closer to the door (Boscart et al., 2008). Also this study is only able to promote HH compliance for only 2 out of the 5 ‘WHO my 5 moments of HH’- before and after contact with the patient. Another weakness in the use of electronic system is to do with data collection. Technology is not infallible and glitches may lead to the system not recording HH events, or in cases where several people go through the door during one open/close, it will be impossible to reflect that in the data. The language of the automated system will be English, so patients/visitors who are not English speaking may not understand the message, thus not perform HH. This could be remedied by the champions using leaflets in different languages.















4.0 Change theory

In this chapter, the change management theory for this innovation will be discussed. Lewin`s theory of planned change will be used, and it consists of 3 stages namely; unfreezing, moving and refreezing (Mitchell, 2013)

 This model was chosen because it contains the concept of force field analysis (FFA), which gives an idea of how to design detailed action plans and decision matrices for the proposed change (Shirey, 2013). FFA enables the change implementer to identify the driving and restraining forces pertaining to the proposed change. Lewin’s model has been reported to be best suitable in highly stable environments such as hospitals where there is enough time to plan and implement small scale changes (Suc et al., 2009). The proposed innovation is at the entrance of a hospital ward. Another reason for this choice is the fact that this change model is practical, easy to use, and offers sufficient adaptability (Shirey, 2013). Also because of its age (it was invented in 1951), there is a lot of experience using this framework to drive change in the social sciences (Bozak, 2003; Lehman, 2008; Cathro, 2011).

Critics of this model have pointed out that it is only suitable for small change projects and it ignores the powers of organisations and their politics (Burnes, 2004).  Another issue is that it is top to bottom driven and assumes that organisations operate in stable states (Burnes, 2004). This is important because some desirable changes may need to be from bottom-up in order to be accepted and internalised (Shirey, 2013). Its simplicity has also been put forward as another criticism (Burnes, 2004). Another downside of the model is the fact that change is most often unpredictable and complex, it may not be always possible to move from an unfreezing to a moving to a refreezing stage as Lewin suggested (Shirey, 2013). Choosing this model for this change project was due to its simplicity and ease of use. Also the planned change is small pertaining only to a hospital ward. A democratic leadership style (Tomey, 2009) will be adopted during this as multimodal approaches to improve HH adherence focus on co-operation and a joint team effort from both hospital administration, HCWs, patients and visitors (Midturi et al., 2015). Therefore, the notion that the model is top to bottom driven does not apply to this project.

4.1 Lewin’s Unfreezing stage

This is the first stage, and it involves getting ready for the change. It involves recognising a problem, identifying the need for change, and getting HCWs, patients and visitors to see the need for that change (Mitchell, 2013). The NHS Outcomes Framework 2015/2016 stresses the need for treating and caring for people in a safe environment and protecting them from avoidable harm (DOH, 2014). HCAI continue to be a challenge and its cost creates a burden to healthcare systems both in human and financial terms (WHO, 2011). HH compliance is considered to be the most effective strategy in preventing HCAI (Erasmus et al., 2010; Azim and McLaws, 2014). These findings have been proven and reported time and time again, but still HH compliance rates are below optimal, with reported average compliance at 40% (Erasmus et al., 2010).

Having identified the problem and the need for change, the next step will be to convince everyone else-HCW, patients and visitors on why it is important to increase compliance with HH practices. Communication will be a very important aspect to consider when doing this. This is because effective communication will enable HCWs, patients and visitors to understand about infection risks and the ways to prevent them (NICE, 2011). Also good communication will be needed to understand if the strategies employed are working, and if not what can be done as a team to make it better (Mitchell,2013). 

A good place to start will be to obtain support from the hospital’s management board, including directors. A detailed plan and draft guideline of the innovation should be given to them, which will include the aims and objectives of the proposed innovation (Mitchell, 2013). This will provide the backup needed for the success of the innovation, as well as commitment from senior management to the improve HH compliance so as to reduce the incidence of HCAIs. Engaged leaders with a focus on team effort in HH compliance interventions have been reported to increase compliance rates (Barley and Chapman., 2013)

For HCWs, patients and visitors to see the reason for the change, perceived hindrances to HH compliance and electronic systems to promote HH compliance will have to be addressed (Boscart et al., 2012).  This is where Lewin’s FFA comes into play (Shirey,2013). This framework illustrates that any change will be met with driving forces which support the change and restraining forces which are against the change, and can be countered only by increasing the driving forces (Mitchell, 2013). So for this innovation to succeed, perceived barriers and facilitators will need to be identified and dealt with for all those concerned (Mitchell, 2013). In this way, the innovation will be seen as a team effort where everyone has the same goals, thus increasing the likelihood of success (Murphy, 2006).

An efficient way of doing this is through key informant interviews with HCWs, patients and visitors to find out their knowledge of HH, its importance and why they do/don not perform HH (Boscart et al., 2012).

The table below lists some of the driving and restraining forces for this proposed change.

Table 2:  Driving and restraining forces

Facilitators (Driving forces) Barriers from HCW Barriers from patients/ visitors

Suboptimal HH compliance rates

Cost and burden of HCAIs to patients and the healthcare system



Lack of time

Workload pressures

Lack or resources

Lack of knowledge

Poor role modelling

Lack of organisational support


Lack of knowledge

The assumption that infection control was not their responsibility

Fear of/ discomfort in challenging healthcare professionals


Source: (Gluyas, 2015)

A study by McLaughlin et al. (2013) in which HCW answered a questionnaire about their knowledge on HH practices, reported an average score of 26.55 out of 35 questions. These results are very surprising given the focus on HH in recent years, and the assumption that HCW are familiar with the best HH practices and know when to carry them out (Gluyas, 2015). Education programmes containing messages of ‘when, how and why’ with regards to HH must continue, as this has been reported by Watson (2016) to increase HCW HH compliance. This education will be provided by drafting the services of champions whom research has reported are very effective in motivating others and contributing to processes and practices such as education, with passion and persistence (Hendy and Barlow, 2012). The champions will be recruited through poster advertisement around the hospital. The champions will include 3 trained HCWs and 3 trained lay volunteers. The champions will also promote the innovation because they act as role models, are committed, and act as go-between top management and HCW.  They have been reported to even go beyond their normally prescribed roles, in a bid to promote change, and in so doing act as encouragement to others (Hendy and Barlow, 2012).

Tiredness, heavy workload and multiple distractions have been associated with healthcare workers making mistakes (Gluyas and Morrison, 2013). One strategy which can be used to manage this is Foresight Training (Norris, 2012). The hospital management will have to be approached with regards to letting staff have these trainings, which will result in staff being able to better manage their workload, and in so doing ensure patient safety (NPSA, 2008), in this case by complying with HH to reduce HCAI.

Lack of knowledge about the use of HH products was reported by Birnbach et al. (2012) as one of the reasons for poor HH compliance by hospital visitors, who even with appropriate signage did not use the ABHR at the hospital lobby. A targeted approach using posters around the hospital as well as leaflets will be used to enable visitors join the fight against infections (Birnbach et al., 2012). 

Patient education could be done in the form of patient empowerment (WHO, 2009), as this will give patients the knowledge, skills and attitudes they need to make choices about their care (WHO, 1998). Barriers to patient empowerment such as cultural and behavioural factors will have to be addressed during these educational sessions to both HCWs and patients by the HH champions (Pan et al., 2013). The proposed innovation will spare patients these feelings as the reminder to everyone will be an automated message, which patients have reported preference for (Michaelsen et al., 2013). 

An important issue to consider will be the cost of the innovation, as healthcare organisations have to meet challenges of rising demands using limited resources (Hendy and Barlow, 2012). Costs which will be involved in the proposed innovation will include costs for training HCWs, patients and visitors, the cost of the EMS, and the cost of personnel to collect and analyse the collected data. A cost analysis will be carried out to ensure cost effectiveness of the intervention in relation to cost of treating HCAI

4.2 Lewin`s moving stage

This phase is the intervention phase, and necessitates creating a detailed plan which is presented to the hospital management to seek permission for the study (Shirey, 2013). A difficulty during this phase is the fear associated with change, and this can be overcome by using Champions (Hendy and Barlow, 2012). Due to the nature of the electronic system (Loud automated message), and the place of the intervention (ward entrance), randomisation of participants is not possible. The study will be a quantitative multimodal study.

This stage will involve phases one, two and three of the implementation plan (as seen in chapter three).

Feedback will be given weekly for both wards. The feedback will include compliance data for the previous day, and a health promotion message on the importance of HH in reducing hospital stays. The system will be programmed to relate 3 health promotion messages alternately, as message strategy has been reported to be motivation to improve HH compliance (Taylor, 2015). The 3 messages will be

  • A sensory message stating: Sanitizer with moisturizer relieves hand dryness
  • A social message which states: Washing my hands protects me, my patients and my family
  • A message that appeals to rational thinking which states: Handwashing reduces infection and helps prevent illness.

The last phase of the intervention will be a 3 months’ data collection, after the automated voice prompt and feedback screen are removed. This will be to collect data on HH compliance after the intervention phase, so as to assess long term sustainability.

4.3 Lewin’s refreezing stage

This stage will involve stabilizing the change so that it is embedded in practice (Shirey, 2013) which in this case is increase HH compliance. In the past interventions to improve HH compliance in hospitals using electronic monitoring systems have reported successes (McGuckin & Govednik, 2015), but the difficulty has always been in maintaining this increase level of compliance post intervention (Ellison et al., 2015).

A solution to this will be to adopt a multimodal approach (Pinock et al., 2012). An approach which will address education, culture and environment was tried with success by Carboneau et al. (2010) in Belgian hospitals. It will be worth trying such an approach here in the UK, as HCAI is a problem in every part of the world. Also, goal setting and reward incentives are some strategies that can be used to promote long term sustainability to increase HH adherence (Luangasnatip et al., 2015). These could be implemented in the ward to ensure long term sustainability of the improved compliance rates which is expected to result from this project.

It has to be acknowledged that making a change is very difficult, as most individuals prefer to work within known practices rather than identifying and accepting new innovative methods (De Bono et al., 2014). But by identifying barriers and addressing them, it is possible to make change that will be embedded within practice.

A success of this innovation will be increased HH compliance rate to 75% for both HCWs, patients and visitors, which will lead to a fall in HCAIs, and therefore reduction in cost to the NHS, reduction in length of hospital stays, reduction in resistance to antibiotics used to treat infection and improvement in patient satisfaction.














5.0 Evaluation

This chapter will discuss the evaluation of the change project. Evaluation is important to know if this project is beneficial 

  • to the ward, in terms of increase HH compliance and reducing HCAI incidence 
  • to HCW, patients and visitors, in terms of increasing their knowledge and awareness on HH in preventing HCAI. 
  • To the hospital in terms of reducing the burden of cost incurred from treating HCAI.

Evaluation will enable me to know if standards have improved in terms of HH compliance (Mitchell, 2013). The success of this project will be measured through audits.

NHSI (2005) defines evaluation as the systematic assessment of implementation and impact of an initiative, programme or project, as part of a recognised processes of judging its effectiveness and efficacy. Evaluation will enable all those involved in this project (HCW, patient, visitors, hospital administration) to gather information, learn, and make informed decisions about infection control compliance and its role in preventing HCAI. (Naidoo and Wills (2009) report that the main purpose of evaluation is so that activities can be assessed in relation to their proposed goals, so that outcomes can inform decision-making for the future. Evaluating this project will use the process, impact outcome model.



5.1 Process

This assesses how the project works once it has started and if it is being delivered effectively (Laverack, 2014). This type of evaluation measures skills, knowledge, participation and organisation (Laverack, 2014). With regards to the project, the training of champions, training materials, interview sessions, and feedback will be evaluated for efficacy.

Identifying motivated champions has been shown to increase the likelihood of success of hand hygiene interventions (Hendy and Barlow, 2012). This is because of their positive attitude, motivation, passion and commitment makes them role model. Education is also an imperative part in any HH multi modal intervention as it improves knowledge on the importance of HH in HCAI prevention. The use of leaflets and posters is also well documented to be important in HH intervention, to highlight educational messages (WHO, 2009). Language is an important barrier when communication is concerned because recipients might not get the message if it is in a language they don’t understand. So during the educational phase of the project, it is important that leaflets are printed in different languages spoken by patients locally (Birnbach et al., 2012). Using short interviews is an effective way to get HCW, patients and visitors’ opinion on HH (Boscart et al., 2012).

5.2 Impact

Impact evaluation assesses the objectives, or short term progress in the project implementation (Laverack, 2014). It measures intermediate health outcomes, which in this case is increase compliance with HH. This can be done through an audit.

Covert direct observation by a trained observer is considered the gold standard for monitoring HH compliance (Haubitz et al., 2016). This method is however time-consuming, costly, provides only a snap shot of compliance, and subject to observation and reporting bias (Ward et al., 2014). The impact of this project will be evaluated using data collected from the EMS which is cheaper, gives a more accurate report as it is collected continuously over time. HH compliance rate will be evaluated by comparing the pre-intervention compliance rate to that observed during the intervention phase and post intervention phase.

Another method of evaluation could be by comparing ABHR consumption during the different stages of the project. This because ABHR consumption can be used as a measure of compliance (Haubitz et al., 2016). It must be stressed that this assumption can only be made for longer studies, as studies lasting ≤20 weeks showed no correlation between ABHR consumption and HH compliance.

5.3 Outcome

Outcome evaluation is concerned with long term effect of the intervention (Laverack, 2014). As HCAI is an ongoing problem, it will be important to maintain this increased rate of adherence that is expected to result from the project.

Multifaceted interventions to promote HH compliance often succeed, but the main problem usually is sustaining that increase in compliance post intervention. In relation to the objectives of this project, the long term outcome will be to maintain sustained increased rates in HH compliance in the intervention ward. This could be evaluated by comparing data on the incidence of HCAI on the ward pre and post intervention.

One way that can be suggested to maintain long term compliance is to set goals, and have reward incentives for staff if those goals are met (Luangasanatip et al., 2015). Rewards could be in the form of vouchers, trophies, etc. These rewards act as positive recognition and boost staff morale (Midturi et al., 2015). Sporadic HH campaigns by champions, providing education, and enforcement using posters, leaflets, etc. to both HCWs, patients and visitors is another way that can be used to sustain increased HH compliance (Wetzker et al., 2016).



















6.0 Conclusion

This chapter concludes the innovation and highlights it strengths and weaknesses. HCAI is a serious burden worldwide, imposing a heavy burden on health care systems, both in financial and human terms. In the UK, the NHS spend about £1 billion yearly to treat HCAI which affects about 300000 people yearly. HH (using either ABHR or water and soap) is the single most important strategy in preventing the spread of HCAIs. Though HH is a simple task, reported compliance levels in both HCWs, patients and visitors are continuously low. Electronic HH monitoring technologies are coming into the market in a bid to improve HH compliance rates in hospitals. This innovation was aimed at using one of such technologies to increase compliance rates among HCW, patients and visitors. It should be stressed that no one intervention on its own can produce sustained increase HH compliance rate, but a multimodal intervention including education is recommended.

The proposed innovation is to use the electronic monitoring system (EMS), which has an audible automated reminder message as well as a feedback component inside the ward, to encourage people to perform HH upon entry into the ward and at exit as well. Data on compliance and ABHR use was collected by the electronic system. An education component of the study involves the use of 6 highly motivated champions to organise teaching interviews and teaching sessions on the importance of HH in preventing HCAI to both HCWs, patients and visitors.

A strength of this study is the inclusion of HCWs, patients and visitors, as improved HH is the responsibility of everyone, not just HCWs. Also the electronic system measures compliance continuously, eliminating the use of human observers, which is costly, time- consuming and open to observation and reporting bias. Cost is another benefit as s system like the one used in the trial cost just $500, which is cheap in comparison to the cost of treating HCAIs. Finally, the intervention period was long enough to minimise the hawthorne effect, and account for alarm fatigue. The educational component was also beneficial in imparting knowledge too HCWs, patients and visitors on the importance of HH compliance.

A major shortcoming of this intervention is that it did not have any measure of the incidence of HCAI, which is the ultimate goal for HH promotion.

I will recommend that future projects of this nature be designed in such a way as to be able to collect data so that the incidence of HCAI could be measured before and after the intervention.












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