Evaluation of Barriers to Audit-and-Feedback Programs That Used Direct Observation of Hand Hygiene Compliance

Abstract

Key Points Question How have audit-and-feedback programs based on direct observations of hand hygiene compliance been implemented in real-world settings? Findings In this qualitative study of 108 hospital staff members in 10 acute care hospitals, the use of audit and feedback to improve hand hygiene compliance was problematic. Auditing by direct observation was perceived to collect inaccurate data and created tension with frontline staff, and the feedback process did not appear to encourage positive change. Meaning Strategies are needed to collect more reliable hand hygiene data and facilitate multidisciplinary collaboration toward improved hand hygiene compliance.

Unpacking the intention to action gap: a qualitative study understanding how physicians engage with audit and feedback

“…Relatedly, the perceptions of the value of QI are inconsistent from one physician to the next, ranging from the belief that it is meaningful and important to the belief that it decreases efficiency and distracts from patient care [ 20 ]. Previous work has documented responses to A&F that primarily reflect organizational perceptions of data [ 7 ], with work at the individual level revealing negative perceptions that interfere with engagement in reflexive monitoring (data is not accurate and is therefore discounted) [ 23 ]. In contrast, many physicians in our study reported that data was imperfect but still accepted it as useful for driving meaningful change in practice.…”

“The role as a champion is to not only monitor but to speak out and to educate”: the contradictory roles of hand hygiene champions

“…However, in a systematic review specific to hand hygiene, Gould and colleagues [4] found it difficult to draw conclusions on whether or not audit and feedback interventions could be sustained, largely due to the Hawthorne effect influence on performance behavior. Our own research building off of the same ethnographic study points to multiple barriers to the use of audit and feedback as a strategy for hand hygiene compliance, particularly when using direct observation as the surveillance method [40]. On the other hand, studies have also shown success with designated HCWs providing immediate hand hygiene feedback [15–17].…”

“…Schweizer et al [41] completed a systematic review and meta-analysis of hand hygiene improvement trials. Combined results from 39 quasi-experimental and six randomized trials indicated that bundles that included audit and feedback were associated with an 82% increase in hand hygiene [40]. Gould and colleagues [4] found that all 26 studies that met the criteria for inclusion reported some improvement in hand hygiene compliance; however, they were unable to draw conclusions about which interventions or combination of interventions led to clinically important improvements in compliance.…”

Out of sight, out of mind: a prospective observational study to estimate the duration of the Hawthorne effect on hand hygiene events

“…The unevenness in the HE seen in our study raises concerns regarding the accuracy of human auditing and whether it is appropriate to extrapolate audit results to longer periods and larger areas, given the apparently unpredictable differences between the electronic and human auditing compliance numbers. This flaw, in addition to the many other drawbacks of human auditing, which include the need for ongoing training,30 significant time investment yielding limited sample sizes4 31 32 and lack of standardisation,33 has contributed to a perception of inaccuracy by front-line staff 34. Notably, this perception has recently been shared by healthcare workers regarding e-monitoring systems as well, highlighting the argument that no measurement system is perfect 35…”