Discussion

This survey provides insights into barriers to achieving high HCW hand hygiene compliance from the perspective of hand hygiene auditors. The results also provide data that will inform future interventions aimed at improving HCW hand hygiene compliance. This survey builds on the results of prior studies and identifies auditor comfort providing feedback to HCWs and staff reactions to receiving feedback as two potential targets for interventions to improve hand hygiene compliance. ^{Reference Goedken, Livorsi and Sauder4,Reference Jain, Edgar and Bothe5}

Some studies suggest that immediate feedback during observations does not significantly improve hand hygiene compliance and the updated SHEA/IDSA/APIC guidance advises against using direct overt observation for compliance rates outside specific contexts. Despite this, monitoring hand hygiene and providing feedback remains an important metric assessed by regulatory and watchdog organizations such as The Leapfrog Group. ^{Reference Glowicz, Landon and Sickbert-Bennett1,Reference Livshiz-Riven, Azulay and Koyfman6,7} The Leapfrog hand hygiene standards require hospitals to collect data on a prespecified number of hygiene opportunities per patient care unit each month, provide feedback to staff, and use an electronic monitoring system or direct observation methods to monitor HCW hand hygiene complaince. ⁷ To accomplish this, BUH employes a combination of both direct overt and direct covert observations is used to monitor hand hygiene compliance and provide HCWs feedback.

We found most BUH auditors were comfortable providing feedback to staff regarding their hand hygiene practices; however, comfort levels varied significantly by occupation of the staff member receiving feedback. Furthermore, most auditors reported staff have positive or neutral reactions to receiving feedback on hand hygiene practices; however, approximately a quarter of auditors reported staff have mostly negative reactions to feedback or that they do not provide feedback to staff at all. The auditors’ responses suggest there may be factors that deter them from providing consistent feedback which may affect the quality and frequency of feedback provided. These results build on prior studies showing hierarchical dynamics and factors related to the institutional culture may influence auditors’ comfort in providing feedback to certain staff. ^{Reference Goedken, Livorsi and Sauder4,Reference Jain, Edgar and Bothe5,Reference Livorsi, Goedken, Sauder, Vander Weg, Perencevich and Reisinger8} This highlights the necessity for interventions that foster effective communication and feedback strategies, that empower auditors to confidently and consistently provide feedback across all occupations, and that address the perceived value of feedback among staff. ^{Reference Glowicz, Landon and Sickbert-Bennett1,Reference Livorsi, Goedken, Sauder, Vander Weg, Perencevich and Reisinger8,Reference Pittet, Allegranzi and Boyce9}

This survey was subject to several limitations including a relatively small sample size of and a relatively low response rate. Further, this survey was not comprehensive and only included eight multiple choice questions and one-short answer question. Finally, the results of this survey may have limited generalizability as it was conducted at a single healthcare system.

These survey results highlight the necessity of a multi-pronged approach that combines accountability, education, infrastructure needs, cultural change, and innovative feedback methods when developing interventions focused on improving HCW hand hygiene compliance. Initiatives aimed at improving hand hygiene in healthcare settings should focus on fostering a culture of safety and accountability, encouraging openness to feedback, and engaging leadership to champion hand hygiene interventions. ^{Reference Glowicz, Landon and Sickbert-Bennett1,Reference Livorsi, Goedken, Sauder, Vander Weg, Perencevich and Reisinger8–Reference McInnes, Phillips, Middleton and Gould10}