What worked and didn't work
It was surprising what worked and what didn't work, according to Burke.

For example, peer coaching--which was expected to be one of the most effective methods--actually reduced compliance. Although counter-intuitively, bedside hand foam dispensers (as opposed to outside the room) didn't improve compliance, nor did replenishing the sanitizer canisters.

"It actually moved us in the wrong direction," Burke said, although the system isn't sure exactly why. Burke said further research would look to find out why.

As QualPro, the consulting firm that worked with Sentara, expected, a little more than half (53 percent) of the interventions made no difference in outcomes, a quarter (25 percent) helped, and more than a fifth hurt (22 percent) compliance.

What was effective were staff quizzes, initiated by leaders such as the hospital president or at any other level. For example, a nurse director would ask simple questions on a written quiz about hand hygiene, which was completed, signed and dated to make it official. It wasn't so much the paper quiz but the "power of the dialogue," Burke said. "It's not so much as getting an answer, as it is in the exchange." Leaders taking an active interest in hand hygiene builds an awareness with staff.

Similarly, nurse-initiated conversations with patients about hand hygiene, along with handwritten notes on white boards, helped reinforce the idea. They encourage patients to remind providers to wash their hands if they forget, holding them accountable.

Another intervention that worked was adding red stop signs around the hospital to remind staff to do their hygiene duty.

"Everyone is [responsible] because it requires a culture change to place safety ahead of production. And that's a job for, first of all, leaders, but execution is ultimately everybody," Burke said. "You can't confine hand hygiene to the immediate bedside staff. Every hospital president, every CEO has that responsibility in setting the tone for the facility, for the company, the entire organization; that has to start at the top."