Evaluation of Barriers to Audit-and-Feedback Programs That Used Direct Observation of Hand Hygiene Compliance

Key Points Question How have audit-and-feedback programs based on direct observations of hand hygiene compliance been implemented in real-world settings? Findings In this qualitative study of 108 hospital staff members in 10 acute care hospitals, the use of audit and feedback to improve hand hygiene compliance was problematic. Auditing by direct observation was perceived to collect inaccurate data and created tension with frontline staff, and the feedback process did not appear to encourage positive change. Meaning Strategies are needed to collect more reliable hand hygiene data and facilitate multidisciplinary collaboration toward improved hand hygiene compliance.


eAppendix 1. Semi-Structured Interview Guide
These interviews will be conducted with the Infection Control (IC) teams at each of the five facilities at which we conduct site visits. Approximately 3 interviews will be conducted at each site, one with the Hospital Epidemiologist, one with the Infection Control Professional (ICP), and one with the MRSA/MDRA Coordinator. A modified version of this interview will be conducted over the phone with the ICP at the other five sites after the completion of the site visits. 1) What is the make-up of your IC team? 2) How long have you been in your position? Others on the team? 3) Do you know how the MRSA/MDRO position was integrated into the team after the mandate? 4) What are your current strategies for promoting hand hygiene compliance?
Probes: signs, other reminders (e.g., screen savers), educational programs, improving accessibility of hand sanitizer, audit/feedback, one-on-one coaching, use of champions, incentives or rewards, punishment, patient engagement. 5) What has worked particularly well? In what ways? 6) What have you tried that hasn't worked? What got in the way of success? 7) Overall, how would you describe hand hygiene compliance at your facility?
Examples: everyone is onboard, it is a major priority, it is abysmal, getting staff to wash their hands is the worse part of my job. 8) Do you have a written hand hygiene policy for your facility? Do you mind sharing it with me?
Which staff in the facility are aware of this policy-or pieces of it? 9) How do you measure hand hygiene compliance? 10) What is your hand hygiene compliance goal? 11) Talk with me more about how you collect your hand hygiene data. a.

. Focus Group Guide
All healthcare workers (nurses, physicians, respiratory therapists, dieticians, etc.) available on a unit at the time of the focus group will be invited to join. An invitation will be sent out to floor staff prior to the focus group so they are aware of it occurring. We will conduct 2 focus groups on different wards/units at each of five VA facilities.
1) Overall, how would you describe hand hygiene compliance at your facility? Examples: everyone is onboard, it is a major priority, it is abysmal, getting staff to wash their hands is the worse part of my job. 2) What are the current strategies for promoting hand hygiene compliance at your facility? Have you noticed: signs, other reminders (e.g., screen savers), educational programs, improved accessibility of hand sanitizer, audit/feedback, one-on-one coaching, use of champions, incentives or rewards, punishment, patient engagement? 3) What is the best hand hygiene intervention you can think of? Why was it so good? 4) What have you seen tried that hasn't worked? What got in the way of success? 5) Do you have a written hand hygiene policy for your facility? Do you know what it talks about? 6) Is hand hygiene compliance measured at your facility? 7) Do you get feedback on how you are doing? Or your unit? 8) What is your hand hygiene compliance goal? 9) Who is responsible for hand hygiene at your facility? 10) What if you were in charge of improving hand hygiene rates? What would you do? 11) Is leadership aware of hand hygiene compliance rates at your facility? Are they involved in hand hygiene interventions? Should they be? 12) What else should we know about hand hygiene here? What have we forgot to ask about? Do you have any questions for me? Epidemiologists). In-person interviews were conducted with frontline staff (e.g., clinicians).

Methods and Results
Data collection 17. Interview guide We used an interview guide, including questions and prompts. The guide was not pilot tested.