Pushing patient safety takes more guts than we've seen

Getting physicians to comply with hospital hand hygiene rules has long frustrated hospital patient safety officers and quality managers.

We all know inadequate hand hygiene spreads infections. And the Joint Commission wants you to have a program to promote hand hygiene. Their Center for Transforming Healthcare has studied hand washing practices and has come up with some useful strategies for hospitals to improve compliance.

But they could do more, Dr. Bob Wachter told me. He is chief of the Division of Hospital Medicine and chief of the Medical Service at the University of California, San Francisco Medical Center. A national evangelist for patient safety and healthcare quality, Wachter believes accountability would make a big difference in hand hygiene compliance in hospitals.

"I actually believe they should have a standard," he told FierceHealthcare. He imagined a scenario where the Joint Commission would take a harder line approach to hand hygiene compliance. If "secret shopper audits" of hand hygiene reveal that people up on your floors have not been able to achieve 80 or 90 percent hand hygiene compliance, that could be a violation of Joint Commission standards, he said.

An approach that has consequences for doctors would improve hand hygiene markedly nationally, he contended, because part of the reason that hospitals have gotten doctors to comply with certain standards is that "there is skin in the game," Wachter said.

At his hospital, it is considered a violation of Medicare Conditions of Participation and Joint Commission standards if not all verbal orders are signed or doctors don't dictate operating room summaries quickly enough. Doctors risk suspension from the medical staff if they don't follow those rules.

"Everybody knows that," Wachter said. You get a couple of warnings and then you get a notice that says you can no longer take care of patients as of this Friday because you have three dictations you haven't done yet.

There is no parallel for hand hygiene. But if there were, he added, the same thing would happen. People would grouse about it for a while, but ultimately, they would just get it done.

Hand hygiene is tricky for a doctor or nurse seeing 20 to 40 patients a day. Cleaning your hands in and out of every room takes time, work and focus. "But right now, it is completely odd that I will be suspended from my medical staff if I don't do my dictations, but I can not wash my hands for the next five years and nothing will happen to me," Wachter said. "I think that has to change."

Key stakeholders, including TJC, recognize that hand hygiene is really important, that we need to support hospitals to make sure that they know what systems work because some of this was a systems problem. There weren't enough gel dispensers. There wasn't enough education. But at a certain point, Wachter said, it's an accountability problem.  

"The fact is that people know that if they don't do it, nothing bad is going to happen," he said. "After a while, you tell people, 'look you've got to do this. We're going to support you and educate you. But after that, if you don't do it, you can't practice here.'

"This takes guts and we haven't had it so far," he said. "But we need to, because we're killing patients because we have not made these courageous decisions to be tough when people don't do things that they need to do to keep patients safe." - Sandra

Editor's note: This is part two of a two-part series that looks at what can be done to get hospitals and physicians on the same page.