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Invited Commentary
Health Policy
October 12, 2018

Time to Implement Immediate Personalized Feedback and Individualized Action Planning for Hand Hygiene

Author Affiliations
  • 1Royal Free Campus, University College London Medical School, University College London, Hampstead, United Kingdom
JAMA Netw Open. 2018;1(6):e183422. doi:10.1001/jamanetworkopen.2018.3422

Improving hand hygiene is difficult and improvements are hard to sustain. Is there anything else to say that does not cause health care workers’ eyes to glaze over and induce dèjà vu in infection control teams? The study by Livorsi and colleagues1 of the practice and perceptions of audit and feedback of hand hygiene bucks that trend. Ally their findings to the randomized controlled trial (RCT) evidence for what makes audit and feedback effective and one comes a step nearer to a unified approach that, if adopted within hospitals’ clinical governance frameworks, may produce the modest increase2 in hand hygiene required to lower the spread of infection. That approach is immediate personalized feedback coupled to individualized action planning (IPF-IAP).

Audit and feedback is recommended by the Centers for Disease Control and Prevention and the World Health Organization and nearly all Veterans Affairs centers comply with this. The authors claim these organizations provide no specific guidance. This prompted them to investigate how audit and feedback is done and perceived in a geographically diverse sample of 10 Veterans Affairs hospitals. In fact, the World Health Organization provides detailed guidance on audit, stressing, as do experts,3 the value of immediate personalized feedback to health care workers’ in its technical manual4 underpinning its globally adopted hand hygiene intervention. However, let us place their findings against what we know makes audit and feedback effective in general and in hand hygiene.

They report 4 barriers to audit and feedback: lack of time and personnel, skepticism about accuracy of hand hygiene data, tension between staff, and feedback results not reaching health care workers. They conclude that greater incorporation of evidence-based interventions into audit and feedback activities for hand hygiene is required. So what is that evidence base?

The evidence comes from a Cochrane review of 49 RCTs that evaluated the effectiveness of audit and feedback on health care workers’ compliance with evidence-based guidelines.5 The overall effect size was small (median increase in compliance, 4.3%; interquartile range, 0.5%-16%) but increased to nearly 9% to 11% if feedback was delivered at least monthly, was verbal and written, or was accompanied by action planning and increased to 16.5% if delivered by a supervisor or senior colleague. The Cochrane authors counseled cautious interpretation of results, but there are remarkable echoes of these findings from subsequent RCTs of hand hygiene interventions.

The Feedback Intervention Trial (FIT)6 was a 3-year stepped-wedge cluster RCT in 16 hospitals on 60 wards (16 intensive therapy units [ITUs] and 44 acute elderly wards). The trial followed the Medical Research Council framework for evaluating complex interventions and used a behavioral theory framework to study implementation difficulties.7 The FIT intervention was designed using goal-setting and control theories. These conceptualize behavior as goal driven and feedback controlled, with goal setting and action planning augmenting feedback’s effects. The intervention was carried out by an allocated ward coordinator and consisted of a repeating 4-week cycle (20 minutes/week) of hand hygiene observation followed by IPF to health care workers, accompanied by IAP. In weeks 1 and 2 an individual health care worker was observed. Weeks 3 and 4 focused on group compliance. Observations, feedback, and action plans were documented by ward coordinators.

Despite implementation difficulties (3 quarters of ITUs but only half of the elderly wards implemented it) the intention-to-treat analysis showed a significant 7% to 9% increase in observed compliance (primary outcome) and a 30% increase in soap procurement (secondary outcome) for ITUs. The per-protocol analysis in implementing wards showed a 10% to 13% increase on elderly wards and a 13% to 18% increase in ITUs, where soap procurement also increased by 30%. The effects were sustained for 16 months. On ITUs there were strong fidelity to intervention effects. The more frequently the intervention was done, the higher the compliance, ie, effectiveness was related to implementation. Investigation of implementation suggested it would improve if the intervention were an intrinsic part of a hospital’s clinical governance framework, with designated time for it to be carried out by senior colleagues with established appraisal and feedback roles.

Further indirect evidence for the effectiveness of IPF-IAP comes from a 3-year single center RCT on 67 wards in Geneva, Switzerland.8 The overall conclusion was that there was a sustained 8% to 11% increase in hand hygiene compliance in a hospital where two-thirds of the wards received audit, immediate personalized feedback of directly audited hand hygiene behavior (verbal and sometimes written) allied to individualized action plans. There is striking similarity between the size effects of these 2 trials and that of the Cochrane review when audit and feedback was written and verbal, included action planning, or delivered by senior supervisors. Modeling2 suggests that such size effects would, in most ward settings, be sufficient to lower transmission of infection

Livorsi and colleagues1 have shown that when processes that increase the effectiveness of audit and feedback programs are absent, such programs face multiple barriers, which they summarized under 4 themes, all of which are addressed by IPF-IAP. Theme 1 (finding time and personnel) is addressed by use of senior ward staff for a short time each week as part of their role within the hospital’s clinical governance and audit program. This is consistent with the National Institute for Health and Care Excellence guidance that behavioral change should target both institution and individual.9 Theme 2 (accuracy of hand hygiene data) and theme 4 (feedback not reaching health care workers) are addressed by direct observation and an IPF component. Theme 3 (tension between staff) is addressed by the use of senior ward staff with preexisting roles in staff appraisal and performance review.

Livorsi and colleagues1 are right that greater incorporation of evidence-based interventions into audit and feedback activities is required but not that there is a major knowledge gap. The Cochrane review of audit and feedback,5 subsequent hand hygiene trials,6,8 and Cochrane review showing the effectiveness of IAP10 have given us a clear steer, and the principles of effective feedback and action planning are well known and behaviorally grounded.3,6 The Cochrane review5 notes that the 75th percentile effect size is large (16%, like that achieved by delivery through senior colleagues) and that audit and feedback used in the right way can play an important role. The evidence base and behavioral theory behind IPF-IAP are much stronger than the single-center nonrandomized study originally underpinning the successful World Health Organization intervention that has been adopted worldwide. Rather than develop new strategies as Livorsi and colleagues suggest, why not implement what looks likely to work? It takes several years to develop a new hand hygiene intervention. We cannot afford to wait, not with the global priority of combating the spread of antimicrobial resistance.

The IPF-IAF has been evaluated in multiple RCTs, including hand hygiene trials, in systematic reviews, and in an implementation study7 whose conclusions echo the findings of the systematic reviews. We now know enough about what it should look like. Perhaps the study by Livorsi and colleagues1 indicates that for the Veterans Affairs hospitals to improve what they already do. The time to implement IPF-IAP has come.

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Article Information

Published: October 12, 2018. doi:10.1001/jamanetworkopen.2018.3422

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Stone SP. JAMA Network Open.

Corresponding Author: Sheldon Paul Stone, BSc, MD, FRCP, Royal Free Campus, University College London Medical School, University College London, Rowland Hill Street, Hampstead, London NW3 2PF, United Kingdom (sheldon.stone@ucl.ac.uk).

Conflict of Interest Disclosures: None reported.

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