All Hands on Deck: Sustaining Improved Hand Hygiene Compliance in the Operating Room

Abstract

Hand hygiene is an essential component of infection prevention in the health care setting. Despite diligent efforts, clinicians can be susceptible to hand hygiene misses in fast-paced, complex environments such as the operating room due to systemic factors such as the physical environment, workflow, and sporadic interactions with other personnel. Through the use of human factors and resilience engineering concepts, work-as-done were studied to identify barriers to hand hygiene compliance in the operating rooms of a pediatric hospital in an urban area. The saliency, effort, expectancy, value model was applied to design a multifaceted intervention that resulted in a sustained 95% hand hygiene compliance.

Keywords

perception cognitive engineering health systems workspace design environmental design

Mark Johnson is a (fictional) operating room (OR) nurse in a high-census pediatric hospital. Today, he is in the circulator role and is responsible for gathering supplies before the case starts, documentation throughout the case, managing all incoming and outgoing phone calls for the room, and gathering any supplies or equipment that are needed during the case, among other things for the team.

The operating team is on the second case of the day and Mark has been running nonstop since 6:30 a.m. The surgeon is calling for additional sutures, and as Mark goes to the in-room supply closet he realizes that they are out of the type that is needed. He ducks out of the room to grab extras from the central supply closet, then hurries back into the room to drop them onto the sterile field before heading back to his computer to catch up on the documentation he missed while he was out of the room. The case proceeds with only a slight workflow interruption due to the missing sutures, but something else has occurred during this time period – Mark inadvertently missed a moment of hand hygiene as defined by the World Health Organization (WHO) when he left the room and did not clean his hands after touching the patient environment (WHO, 2009).

Hand Hygiene and Infection Prevention

Because hand hygiene plays such a critical role in infection prevention in health care environments, a focus on compliance is essential. Health care workers’ hands are cited as the most common vehicle for transmission of health care–associated pathogens, both in the environment and to the patient’s skin (Allegranzi & Pittet, 2009; Boyce et al., 2002; Parienti et al., 2002). Pathogens can persist up to 4 months in the environment, despite the use of protective gloves (Rüden et al., 1997); without optimized hand hygiene practice, microbial colonization of surfaces is more easily established (Boyce et al., 2002). As such, hand hygiene is widely recognized as a foundational effort in the prevention of health care–associated infections (Boyce et al., 2002; Ellingson et al., 2014; Larson & Kretzer, 1995), which are the most frequent adverse events in health care and result in prolonged hospitalization, increased resistance of microorganisms, increased comorbidities, and death (WHO, 2011).

In 2005, the WHO launched a comprehensive initiative to improve hand hygiene compliance, outlining the Five Moments of Hand Hygiene and providing comprehensive guidelines for implementation (WHO, 2009). Despite this, published hand hygiene rates typically average between 30% to 50% compliance (Erasmus et al., 2010), with the OR averaging between 2% and 18% (Andersson et al., 2018; Paul et al., 2019).

What makes the or a Particular Challenge?

Mark’s story, while fictional, illustrates a common difficulty in perioperative environments across the world. ORs are particularly challenging environments when it comes to hand hygiene compliance – there exist highly complex workflows with a high concentration of equipment and multiple touchpoints between devices, equipment, and the patient throughout a procedure (Hughes & Anderson, 1999). There is also necessary compartmentalization in the OR environment – rooms are set up differently for different procedures across divisions, and so often each room looks a little different from the one next to it. The physical environment is designed to be as aseptic as possible, commonly with white or beige walls and bright fluorescent lights to allow for maximum visibility. Regulatory requirements can make hand hygiene inherently difficult – due to fire concerns, only a certain amount of hand sanitizer is allowed to be in a room at any given time, and due to high use, pumps can run out and require restocking frequently. Finally, there is a high cognitive burden on OR staff, who are exacting complex medical procedures with many job roles and teams working together in the same space (Dias et al., 2018).

Hand Hygiene in a High-Reliability Organization

At Children’s Hospital of Philadelphia, a top-ranked academic pediatric institution, hand hygiene rates are very high in comparison with published literature, with sustained performance greater than 95% over time. However, in 2017, OR hand hygiene compliance rates were approximately 20% lower than the hospital mean. Surprised by their performance, OR leadership identified several barriers to hand hygiene and assembled a project team to improve compliance, reaching out to the Human Factors team for assistance. Looking to take a holistic systems approach to this initiative, we formed a leadership team composed of stakeholders from Human Factors, Performance Improvement, the Harm Prevention Program, and Infection Prevention and Control. Our team partnered closely with clinical leadership from the OR (medical director, director of nursing, and nursing safety quality specialist) and met monthly to discuss progress, escalate barriers, and determine next steps over the course of the project. Active project work occurred over the course of 8 months and involved observations, surveys, and a pilot phase before we spread to the entirety of the OR suite. Below we describe our approach, results, and next steps.

Developing a Resilient System through Understanding “Work-as-done”

The team first sought to identify existing barriers to hand hygiene performance in the OR environment. To operationalize knowledge elicitations, concepts from resilience engineering such as “work-as-done” (WAD) and “work-as-imagined” (WAI) were employed. WAI is an idealized view of how things are done and disregards workarounds and suboptimal working conditions, whereas WAD is how work happens over time in complex systems (Braithwaite et al., 2016). To understand WAD versus WAI, we leveraged direct observations and staff surveys to gather both quantitative and qualitative data that would be used to guide our next steps (Hollnagel et al., 2015).

Our survey sought to solicit feedback from frontline staff regarding their perceptions of hand hygiene and identified barriers in the OR environment. To encourage participation, we limited the survey to three brief questions with “select all that apply” responses; staff were also given a free text option to provide any additional thoughts or feedback. Anesthesia, surgery, and nursing staff were eligible to complete the survey. The survey link was sent via email, with a 2-week completion deadline.

Survey respondents were asked the following questions:

Do you feel that you perform hand hygiene appropriately 100% of the time? (yes/no response)

What are barriers to performing appropriate hand hygiene in the OR setting? (“select all that apply” response)

What are barriers to overall workflow in the OR setting? (“select all that apply” response)

Of the 33 responses, four key barriers to both hand hygiene compliance and workflow were identified (Table 1).

Table 1.

Qualitative Survey Results

Key Barriers	Description	Sample Staff Feedback
Clinical workflow	Supplies not located where needed; e.g., hand sanitizer dispenser outside of working area	“Routine, non-emergent need to go between patient and anesthesia carts.” “It is sometimes difficult to focus on how to do complex medical care and constantly [attend] to hand hygiene.” “Unpredictable need to use computer keyboard, answer phone.”
Availability of resources	Not enough hand sanitizer dispensers	“We do not have the [hand sanitizer product] on the anesthesia workspace reliably.” “It would be helpful to have a [hand sanitizer dispenser] located on the anesthesia machine. I often move it there when caring for patients.”
Physical environment	Physical layout of the room not conducive to hand hygiene; e.g., hand sanitizer dispenser located behind door when opened	“I’d like to see pumps just outside of the rooms so I am not searching for one upon leaving.” “Having it [hand sanitizer dispenser] by the bed fits right into workflow.”
Dysfunctional equipment	Equipment does not always function as it should; e.g., automatic hand sanitizer dispenser broken and not dispensing	“Gloves boxes and pumps [are] frequently empty.”

These survey results helped us focus our naturalistic observations on variances between clinical workflow and location and availability of hand hygiene resources supply over the course of the case. Direct observations were performed by the core leadership team. We partnered with OR clinical leadership to identify an appropriate mix of cases, seeking to target different divisions and different ORs in order to gather as representative a picture as possible. Thirteen cases were observed over a 2-week period of time. The observer would arrive during room preparation and would remain in the room until case start time; this was intended to capture the majority of hand hygiene opportunities as the case and patient were being prepared. Spaghetti diagramming and link analyses were used to map clinician workflow in the room; observers also noted location of hand sanitizer dispensers and frequency of use of each dispenser.

Observations yielded critical information about key workflow junctures for staff and highlighted barriers to use of hand sanitizer. An aggregate diagram is shown in Figure 1. We identified four main nodes: around the anesthesia cart, by the computer workstation, and at the two room entrances (sterile core hallway and nonsterile core hallway). Notable observations of barriers included the following:

Hand sanitizer dispensers located in inconvenient locations (e.g., behind doors when opened, in corner of room outside of main thoroughfare)

Broken hand sanitizer dispensers

Lack of salient cues in the environment

Busy staff workflow (lots of people in and out, moving around the room, etc.)

Cognitive workload of staff

Attention

Visual search

Working memory

Competing priorities

Figure 1.

Spaghetti diagram. Arrows represent paths of motion by staff; pattern of arrow corresponds with extent of frequency (i.e., solid arrows for high-volume paths and dashed arrows for low-volume paths).

Designing the Intervention

With this context in mind, our team was able to begin developing a test of change to improve hand hygiene compliance. We selected two ORs with the lowest overall compliance to be pilot environments for a human factors–driven intervention. Given the constraints of the environment, as well as the lack of visual cues to prompt recognition of hand hygiene tasks, we employed the saliency, effort, expectancy, value (SEEV) model as a guide to design an intervention. Figure 2 shows the environment preintervention.

Figure 2.

One of the pilot operating rooms preintervention.

The SEEV model describes how humans allocate attention in dynamic environments (Wickens et al., 2009). An individual’s attention to an item or task is influenced by four key things: its saliency, or how distinct it is from the surrounding environment; the physical or mental effort required to identify it; the amount to which one expects to encounter it in its location; and its perceived value. Through our observations, we identified hand sanitizer dispensers as key areas of interest within the OR environment and so sought to increase staff’s ability to identify them using SEEV as a model.

Saliency and Effort

As previously described, the OR environment is intentionally designed with white/beige walls and bright lighting – in this environment, we noted that the white hand hygiene dispensers blended into the wall and were easily overlooked. To increase signal salience and minimize the effort required for staff to identify and utilize the hand sanitizer dispensers, our team placed bright orange stickers on every hand sanitizer dispenser in the two pilot rooms. The stickers were placed directly on the dispensers to create a direct and consistent visual cue for staff, with a color contrast that minimized the effort required in a visual scan (see Figure 3).

Figure 3.

Orange sticker on a hand sanitizer dispenser.

Expectancy

In the existing state, hand sanitizer dispensers were only located in two fixed places: by the two doors to each room. Other tabletop dispensers were not fixed and were therefore variable in their location across each room. As such, staff were unable to easily predict where they might find hand sanitizer. To address this, our team standardized the location of tabletop dispensers in each pilot room, placing one dispenser at the circulator computer station and two on the anesthesia cart at the head of the bed. We utilized a heavy duty Velcro strip to secure the dispensers to each surface. Additionally, we mounted a dispenser to the back trellis system of the second anesthesia cart by drilling into the railing and affixing the dispenser using a nut and bolt. By standardizing the location of hand sanitizer across rooms, we maximized the expectancy of locating these objects no matter the location, and therefore alleviated some of the cognitive burden that staff had when attempting to locate. Figure 4 shows a pilot room postintervention.

Figure 4.

One of the pilot rooms postintervention. Stickers are affixed to all hand sanitizer dispensers, and dispensers have been added at key junctures.

Value

The physical changes in the pilot ORs were coupled with a series of written and verbal communications and reminders regarding hand hygiene and its importance. An announcement of the pilot and its goals were sent to staff via written email, and verbal announcements were made in daily staff huddles each morning. These announcements and reminders were intended to (1) familiarize staff with the pilot process and (2) remind them of the five moments of hand hygiene and their importance in preventing infection. By leveraging these communications, our team sought to provide additional reinforcement of the value of hand hygiene compliance in staff’s workflow.

Changing and Refreezing: Spreading the Intervention

After staff were notified, our core team spent one morning installing our proposed changes in the two selected ORs before cases started for the day. We gave staff 1 week to acclimate to the changes and then returned to perform observations and to solicit feedback. These observations were performed by both core team members who were observing for workflow and barriers, as well as by hospital hand hygiene observers who were auditing for compliance. Following 2 months of observations, we reviewed our preliminary results (Table 2 and Figure 5). Room A had increased hand hygiene compliance by 25%, and Room B had increased by 19%. In addition to these quantitative results, we gathered a lot of great qualitative feedback from staff. Two representative quotes are shown below:

“Orange is an eye catcher, provides consistent visual cue, is obvious to people who work in there all the time and those who are new.”

“Great placement – having it by the bed fits right into workflow.”

Table 2.

Compliance Pre- and Postintervention

Preintervention
OR Room Number	Room Compliance (%)	Number of Observations	Number of Misses
Room A	77	36	8
Room B	81	79	15
Postintervention
OR Room Number	Room Compliance (%)	Number of Observations	Number of Misses
Room A	96	27	1
Room B	96	25	1

Note. OR = operating room.

Figure 5.

Hand hygiene compliance in pilot rooms, pre- and postintervention.

We shared these results with clinical leadership, and a decision was made to spread the intervention to the remaining ORs. Over the course of 2 months, supplies were purchased and work was done to outfit the remaining 19 ORs with a more permanent solution – this included custom orange stickers that were able to be wiped down and cleaned, additional mounted dispensers for the remaining rooms, and mounting brackets for the additional carts.

Sustaining Improvement and Lessons Learned

Following go-live across the entire OR suite, improved hand hygiene compliance was sustained, with the first month achieving 100% compliance for the first time in program history. Overall, the OR suite saw a 4% improvement in compliance in the 27 months postintervention, with only 2 months dipping below 90% compliance. Additionally, OR hand hygiene compliance saw a statistically meaningful increase following initiation of the pilot and subsequent spread, as indicated by 8 consecutive months above the centerline in a statistical process control p-chart (Figure 6).

Figure 6.

Annotated operating room (OR) hand hygiene compliance p-chart

These human factors–based interventions yielded significant improvement that appears to be sustaining over time; however, there are certainly ongoing areas of opportunity for continued work. This project and associated interventions targeted hand hygiene misses related to attention and workflow, while not specifically improving misses related to phone usage and anesthesia. Phones are a significant challenge in the OR setting, as teams rely on their devices to communicate about patient needs between and across rooms; while there is guidance around how to perform hand hygiene appropriately following phone use, this is a clear opportunity for human factors intervention to ensure that phone use is as safe and effortless as possible. Similarly, anesthesia’s role in the OR is an area that deserves individualized attention – as others have noted, there are constraints with their work area due to the equipment needed and the workflow required (Andersson et al., 2018; Paul et al., 2019), and our team has identified this as a future direction of the work. Furthermore, studying whether or not OR staff have formed new habits around hand hygiene will help glean long-term dependencies on visual cues to reinforce behavioral change.

This project has certain potential limitations that we will be interested to monitor over time – one question is around the long-term efficacy of the orange stickers. Initial impact was statistically meaningful and has been sustained in the 27 months following, but as staff become accustomed to the presence of the orange stickers, they may lose their signal salience. Our team is continuing to monitor hand hygiene compliance, and should we see a decrease, we will investigate whether this is a potential cause. Additionally, all interventions have to operate within regulatory parameters, and so we are limited in adding any additional hand sanitizer in the future due to fire risk.

Despite these limitations, this intervention was a successful example of the use of human factors to design an intervention that yields sustained results over time. This initiative occurred in a highly complex environment with persistent challenges to hand hygiene compliance and a multitude of staffing roles. By leveraging human factors and ergonomics concepts, we were able to implement relatively minor, cost-efficient environmental modifications that yielded impressive preliminary improvement, and perhaps more importantly, sustained improvement over time. This approach can be applied across any health care environment to address persistent challenges faced by health care workers and to lower barriers to providing the safest, highest quality care to patients.

Footnotes

Acknowledgements

We thank Zach Kaznica, Kimberly Wilson, and Grayson Privette for their efforts and support of this work, as well as David Cohen, Sonja Joiner Jones, and all of the OR leadership and staff at CHOP for their partnership on this initiative and their ongoing commitment to patient safety.

Orysia Bezpalko is a senior enterprise improvement advisor at the Center for Healthcare Quality and Analytics at Children’s Hospital of Philadelphia (CHOP). In her role within CHOP’s Harm Prevention Program, Orysia leads teams in redesigning processes to achieve zero harm for patients, leveraging quality improvement and human factors methodologies to create sustainable improvement in outcomes. She holds a BA from the University of Pennsylvania and an MPH from Drexel University’s Dornsife School of Public Health. ORCID iD:

Siddarth Ponnala is a human factors engineer at the Center for Healthcare Quality and Analytics at Children’s Hospital of Philadelphia (CHOP). In his role at CHOP, Siddarth works with several cross-functional teams to jointly optimize complex systems in order to improve human performance and safety. He holds a BS from the University of Illinois at Urbana–Champaign, an MS from Virginia Tech, and a PhD in human factors from the University of Wisconsin–Madison. ORCID iD:

James C. Won is the human factors program manager for the Center for Healthcare Quality and Analytics at the Children’s Hospital of Philadelphia, adjunct assistant professor for the Perelman School of Medicine and the School of Engineering at the University of Pennsylvania, and a senior fellow at the Center for Injury Research and Prevention. He holds a BS and an MS from Massachusetts Institute of Technology and a PhD in human factors from Tufts University.

References

Allegranzi

Pittet

(2009). Role of hand hygiene in healthcare-associated infection prevention. Journal of Hospital Infection, 73(4), 305–315. https://doi.org/10.1016/j.jhin.2009.04.019

Andersson

A. E.

Frodin

Dellenborg

Wallin

Hok

Gillespie

B. M.

Wikstrom

(2018). Iterative co-creation for improved hand hygiene and aseptic techniques in the operating room: Experiences from the safe hands study. BMC Health Services Research, 18, Article 2. https://doi.org/10.1186/s12913-017-2783-1

Braithwaite

Wears

R. L.

Hollnagel

(Eds.). (2016). Resilient health care, Volume 3: Reconciling work-as-imagined and work-as-done. CRC Press. https://doi.org/10.1201/9781315366838

Boyce

J. M.

Pittet

, Healthcare Infection Control Practices Advisory Committee, & HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. Morbidity and Mortality Weekly Report. Recommendations and Reports, 51(RR-16), 1–45, quiz CE1–4.

Dias

R. D.

Ngo-Howard

M. C.

Boskovski

M. T.

Zenati

M. A.

Yule

S. J.

(2018). Systematic review of measurement tools to assess surgeons’ intraoperative cognitive workload. British Journal of Surgery, 105(5), 491–501. https://doi.org/10.1002/bjs.10795

Ellingson

Haas

J. P

Aiello

A. E.

Kusek

Maragakis

L. L.

Olmsted

R. N.

Perencevich

Polgreen

P. M.

Schweizer

M. L.

Trexler

VanAmringe

Yokoe

D. S.

(2014). Strategies to prevent healthcare-associated infections through hand hygiene. Infection Control and Hospital Epidemiology, 35(8), 937–960. https://doi.org/10.1086/677145

Erasmus

Daha

T. J.

Brug

Richardus

J. H.

Behrendt

M. D.

Vos

M. C.

van Beeck

E. F.

(2010). Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infection Control and Hospital Epidemiology, 31(3), 283–294. https://doi.org/10.1086/650451

Hollnagel

Wears

R. L.

Braithwaite

(2015). From Safety-I to Safety-II: A white paper. University of Southern Denmark, University of Florida, and Macquarie University. https://www.england.nhs.uk/signuptosafety/wp-content/uploads/sites/16/2015/10/safety-1-safety-2-whte-papr.pdf

Hughes

S. P.

Anderson

F. M.

(1999). Infection in the operating room. Journal of Bone and Joint Surgery British Volume, 81-B(5), 754–755. https://doi.org/10.1302/0301-620X.81B5.10370

10.

Larson

Kretzer

E. K.

(1995). Compliance with handwashing and barrier precautions. Journal of Hospital Infection, 30(Suppl.), 80–106. https://doi.org/10.1016/0195-6701(95)90010-1

11.

Parienti

J. J.

Thibon

Heller

Le Roux

von Theobald

Bensadoun

Bouvet

Lemarchand

Le Coutour

(2002). Hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site infection rates: A randomized equivalence study. JAMA, 288(6), 722–727. https://doi.org/10.1001/jama.288.6.722

12.

Paul

E. T.

Kuszajewski

Davenport

Thompson

J. A.

Morgan

(2019). Sleep safe in clean hands: Improving hand hygiene compliance in the operating room through education and increased access to hand hygiene products. American Journal of Infection Control, 47(5), 504–508. https://doi.org/10.1016/j.ajic.2018.10.021

13.

Rüden

Gastmeier

Daschner

F. D.

Schumacher

(1997). Nosocomial and community-acquired infections in Germany. Summary of the results of the first national prevalence study (NIDEP). Infection, 25(4), 199–202. https://doi.org/10.1007/BF01713142

14.

World Health Organization. (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge clean care is safer care. https://www.ncbi.nlm.nih.gov/books/NBK144026/

15.

World Health Organization. (2011). Report on the burden of endemic health care-associated infection worldwide: A systematic review of the literature. https://apps.who.int/iris/bitstream/handle/10665/80135/9789241501507_eng.pdf;jsessionid=8D66CDD65EEA97115ECA810D1CEFC191?sequence=1

16.

Wickens

McCarley

Steelman-Allen

(2009). NT-SEEV: A model of attention capture and noticing on the Flight Deck. Human Factors and Ergonomics Society Annual Meeting Proceedings, 53(12), 769–773. https://doi.org/10.1518/107118109X12524442637426