Discussion

Achieving high hand hygiene compliance continues to be a challenge in all healthcare settings. Strategies that utilize shared accountability, incentives, and direct feedback have been previously shown to be effective.^{Reference Luangasanatip, Hongsuwan and Limmathurotsakul2,Reference Talbot, Johnson and Fergus5,Reference McGuckin, Storr, Longtin, Allegranzi and Pittet6} Some hospitals have adopted electronic hand hygiene systems designed to provide real-time feedback in the form of electronic reminders via badges.^{Reference Masroor, Doll, Stevens and Bearman7,Reference Meng, Sorber, Herzog, Igel and Kugler8} These systems have demonstrated mixed results and are not currently recommended as a replacement for in-person observation.^{Reference Ward, Schweizer, Polgreen, Gupta, Reisinger and Perencevich9} Our hospital has utilized a low-technology crowdsourcing solution that encourages all HCP to provide real-time feedback to each other on hand hygiene compliance as a mechanism to reinforce good hand hygiene habits, to respectfully intervene during moments of missed compliance, and to create a culture of shared accountability to promote safety.^{Reference Sickbert-Bennett, DiBiase, Willis, Wolak, Weber and Rutala3,Reference Sickbert-Bennett, DiBiase, Schade Willis, Wolak, Weber and Rutala4}

Despite a widely adopted program across multiple hospital settings (ie, inpatient, outpatient, procedural, operating rooms), we found that feedback was not consistently delivered within and among all job classifications. In addition, feedback was much more frequently provided as reinforcing positive behavior via compliments. Although real-time interventions during moments of near-miss opportunities are critical for improving hand hygiene, promoting a program of shared accountability that encourages positive feedback can build a foundation for comfort with real-time reminders. Habits are made up of cues, routines, and rewards and hand hygiene programs that incorporate rewards in the form of real-time peer feedback can be successful for sustaining good habits.

The culture of feedback is often threatened by a real or perceived hierarchy between job categories even in a cooperative environment such as healthcare. This finding was reinforced in our results that feedback was most commonly delivered within the same job hierarchy, followed by feedback delivered down 1 job hierarchy (−1). However, outside of the hierarchical structure, we also observed that certain job classifications that are cohesive to a unit or departmental structure (ie, administrative staff who are a part of the nursing unit) may feel more empowered to speak up about patient safety issues and have an important role in behavior change. Administrative staff on the nursing units were among the most common groups to provide reminders that affected hand hygiene behavior. Job classifications were self-reported, so misclassification of job category was a possible limitation of this analysis. However, the misclassification is unlikely to have occurred more frequently for a certain job class and was likely random and nondifferential, leading to minimal misclassification that would not have affected the conclusions of this analysis.

Hand hygiene compliance metrics are fraught with concern including lack of validated metrics, observer or reporting bias, sampling bias, and the Hawthorne effect, so perhaps the time has come to reassess the goals of our metrics. A metric of feedback delivery achieved through a crowdsourcing web-based application, rather than observed compliance alone, could be a more meaningful metric for continuous improvement of hand hygiene and could simultaneously serve as an ongoing intervention strategy. Hospital epidemiologists and infection preventionists can use feedback delivery to examine the strengths and gaps of existing relationships within their organizations to continue to develop real-time feedback interventions for hand hygiene and promote a culture of safety.