Compliance Strategies Include Making It Easy for Healthcare Workers to Do the Right Thing

Mandeep Rai, MD (left) and Kristen Korte, RN, CIC, demonstrate good hand hygiene at Banner Thunderbird Medical Center in Glendale, Ariz. Photo by Dolly Ahles/VIRGO

By Kelly M. Pyrek

Kristen Korte, RN, CIC, senior infection preventionist, and Mandeep Rai, MD, medical director of infection prevention and control, at Banner Thunderbird Medical Center in Glendale, Ariz. share their thoughts about the challenges related to healthcare workers' compliance with evidence-based practices.

ICT: What are some common barriers to compliance with infection prevention and control practices and what can infection preventionists do to overcome them?

Korte: I think infection preventionists must be visible and available to healthcare workers as much as possible. At our hospital we have approximately 2,800 employees, so I understand the challenge in this endeavor. Infection preventionists must think of different ways to get the word out as much as they can in this busy day and age. For example, for the last five years we have had a multidisciplinary hand hygiene team that addresses compliance issues and gets other people besides infection prevention involved. The team is able to put strategies in place that help boost compliance. When it comes to healthcare workers' compliance with wearing personal protective equipment (PPE) we have started doing audits of transmission-based precautions, where we watch people working in isolation rooms. If we identify non-compliance with isolation precautions, then we talk to the healthcare worker (in addition to completing an audit form), explaining why the precautions are necessary. Sometimes they have simply forgotten and they need this reminder.

Rai: Addressing non-compliance with infection prevention practices has to be a team effort. I think strong leadership and a significant presence by the infection preventionists  is essential because it reminds our medical staff and other services to be compliant --  because it's always the right thing to do for patient safety.

Korte: We have the advantage of Dr. Rai being on the infection prevention team -- all of the physicians know her and she is an advocate for our program. She can speak directly to her peers in order to improve compliance and reduce risk.

Rai: I think it is extremely important to have physician engagement. We are lucky in that we have very strong support from the administration and the medical community. I think feedback is essential, both positive and negative, for behavior modification.

ICT: So it sounds as though seizing upon those teachable moments when they present themselves is very important?

Korte:  Definitely. I once heard an infectious disease physician say "you cannot do infection prevention from an office" and as challenging as it can be to get out there and stay visible because we serve so many different teams and areas of the hospital, our presence can have an important impact.

ICT: How do you approach those teachable moments to ensure they are appropriate?

Korte: It depends on the situation but what you don't want to do is have this conversation in public in front of other people and make it punitive. You should take the individual aside and be able to talk healthcare worker to healthcare worker -- explain to him or her that you want them to be safe and you want our patients to be safe. Maybe they just don't understand why it is so important to wear a gown or gloves, or to ensure they put that respirator on correctly. If you detect non-compliance repeatedly from the same individual it might need to be reported, but otherwise you seize upon that teachable moment and have a one-on-one discussion  so that staff understand the principles behind the practice.

ICT: When it comes to instruction in infection prevention, what works best -- individual teaching or a group in-service approach?

Korte: We take both approaches and I think each type of instruction is very important. To be able to reach out to more people you might want to present to a group, and many people are more comfortable hearing a targeted message in a group dynamic. When you are out on the floor and observing healthcare workers' practices, you usually  discuss things on an individual basis. 

ICT: Healthcare workers have varied levels of comprehension, language skills and learning aptitudes, so how can infection preventionists reach everyone with their message?

Korte: It is definitely a challenge. It makes me think of both the environmental services department and the food services department, for example, because they are  such  varied groups with many different nationalities. What you must do is present to the level of the group and in a way they understand. We presented at our environmental services department very recently because we are preparing for our accreditation survey soon and we were reviewing infection prevention information with them. The director was also there -- we like management to be present when we educate so they can continue to support the learning and compliance anyway the group was very quiet so the director grabbed some candy bars to create a little competition and encourage people  to speak up and answer questions, and it really helped. I usually take alcohol-based hand sanitizer samples to pass out, but food does work well as a reward too!

Rai: Make the message as simple as possible, and make the signs in patient rooms as simple as possible in addition to saying what kind of precautions the patient is in, say and show exactly what the healthcare worker needs to do -- wash your hands, or gown, glove and wash your hands -- the simpler it is, the better the compliance.

ICT: In addition to a reward-based approach to learning, what other approaches are effective?

Korte: I think both the reward-based approach and classroom learning can each be successful. You have to make it fun, too, depending on the setting and the department to which you are addressing your message. A fair type of educational event can work as well. For example, we participate in  a safety fair every year, and we also hold various events during Infection Prevention and Control Week -- to spotlight various education.  Last year we organized  a flash mob that took place outside one of the hospital entrances, and the song highlighted the importance of hand hygiene.  Besides getting the word out to employees and the medical staff this way, the media carried our message out to the community too!  I think you have to seize upon every possible opportunity you have because adult learners need to experience the message often -- I believe a person has to hear a message at least seven times before it really sticks and the knowledge is retained.

ICT: Infection prevention-related topics can be difficult subject matter, so is that an obstacle to learning and to compliance?

Korte: It can be, but it can be overcome. For example, new employee orientation is something that all staff members experience, so even though there is  a wide variety of people with various levels of experience and understanding, it's a good opportunity to present information about infection prevention and control. Beyond that we go to individual units and do in-services on topics that are appropriate to individual departments. For instance, we conducted a pertussis in-service for the emergency department recently because we are seeing an increase in pertussis patients coming in. So for the most part, the information we provide is information that healthcare workers understand  is important to them and their job performance.

ICT: When lapses in infection prevention occur among healthcare workers, is it a knowledge gap or an implementation gap?

Korte: I think it's both. For instance in the case of pertussis, we have been pushing that vaccine for adults for about five years now and we have shared critical information with staff.  Not everyone thinks that it is important or that it applies to them, so  when an exposure occurs it gives us another opportunity to bring the information to the people who need to know about it most.

ICT: How do you begin to create behavior modification that impacts compliance with infection prevention?

Rai:  No. 1 is consistent education and No. 2 is making it easy for healthcare workers to be compliant.  For example, when the nursing staff may be going in and out of a patient's room five to seven times an hour, it is time-consuming and not practical for them to be washing their hands every time.  It's easier for them to be compliant with hand hygiene if there are hand sanitizer dispensers conveniently positioned so that nurses and other staff members can gel in and gel out of a  patient room. So it's very important to make it convenient for staff to have the dispensers accessible, and especially for C. diff patients, to have sinks accessible for staff so they can wash their hands.  Have PPE easily available -- especially PPE that is easy to don and dispose of.  I think these are critical factors in healthcare worker compliance with infection prevention. Being visible and letting healthcare workers know we are there to help is critical to behavior modification. It goes both ways -- we want to make sure they are doing the right thing but we also want to give them the tools they need to be successful in their compliance efforts.

ICT: Do you perform audits to track compliance?

Korte: We perform audits on healthcare workers' practices and also monitor our infection rates, and we report this data to the people who can make a difference and improve  things

Rai: These audits are not punitive, they are more educational in nature. It's very collaborative. When we see the rates of some of the infections actually go down, it's extremely heartening and they can be used to  reinforce positive behavior. Taking that information back to the nursing staff and other providers can provide very strong positive feedback and will reinforce the message we are driving home about the importance of infection prevention.