by A decade ago direct observation of Health Care Workers (HCW’s) by their peers became the “Gold Standard” in the health care community to benchmark hand hygiene compliance. Although the spread of Nosocomial Infections or commonly called Health-Care Associated Infections (HAI’s) is a complex problem, it is widely accepted that up to 50% of HAI’s are transmitted through sub-standard hand hygiene compliance by HCW’s.
The question arises, “What are the drawbacks to this age-old industry standard?
THE METHODOLOGY IS EXPENSIVE.
Direct observation is typically done by skilled nursing personnel that have gone through specific training programs for data collection methodology. The observation data is logged either manually onto a form and then input into a database which is a time and labor extensive process or into smart device applications that have been introduced to streamline this process but cannot eliminate the hours of labor entailed in the observation method.
THE STATISTICAL VALIDITY IS POOR.
According to Boyce (2011) less than 1% to 3% of all hand hygiene opportunities are captured using the observation method. This couples with the subjective viewpoint of the observer in “awarding” a compliant event to whether the data captured is accurate. Are there methodologies that can capture up to 99% of hand hygiene events to give a better representation of compliance?
POOR STANDARDIZATION WILL LIMIT SCALABILITY AND COMPARISONS.
In an effort to support the observation methodology the World Health Organization (WHO) has published reference materials for training observers and collection methodologies. The challenge begins when this universal process is not used or modified. How valid can any comparisons between facilities be when they are not utilizing the same tools to derive data. The problem only compounds itself when observation data collection increases when an industry standard is not in place.
OBSERVER COMPETENCE
The premise of assigning an observer who can consistently and accurately ascertain a hand hygiene event is flawed. If you were to assign four observers to record the same events over a period of time, how likely are their notes to match? To further dilute confidence in data accuracy is the fact that every individual that steps into this roles comes from unique backgrounds, both educationally and culturally. There is no cookie cutter solution for this.
CRITERIA FOR COMPLIANCE
Even though there are published methodologies to provide consistent, accurate data, there is no mandate to use a standard criteria for compliance. Once again the subjective, semi-standardized nature of the observation method begs to question the accuracy of the observations. One institution might use 20 seconds as the benchmark for a compliant hand wash event while another will use 30 seconds.
COMPLIANCE INCREASES WHEN HCW’S KNOW THEY ARE BEING OBSERVED (THE HAWTHORNE EFFECT).
There has been significant support in the concept of the fact that HCW’s will increase their compliance when they know they are being observed. How secretive can an observer be when capturing data if they are hidden from view of the HCW? Most patient rooms do not have full visual access from the hallway which questions how observations are being made unnoticed by their peers.
OBSERVATION TIMEFRAMES CAN INFLUENCE COMPLIANCE
The timeframe of the observation period can also have an impact on the accuracy of the data. Specifically, were the observations made on all shifts, or only during weekdays. The numbers of hand hygiene opportunities taken and missed can vary dramatically during a 24 hour period. Is the reported data reflecting this aspect of peaks and valleys of activity by the unit or the greater picture of an entire facility?
Questioning common theory brings new innovation to old solutions. The question becomes, is observation a relic of the past and what new solutions are on the horizon?
