Be prepared for increased scrutiny and more stringent scoring of hand hygiene compliance during your next TJC survey. Effective January 1, 2018, if a surveyor observes an individual staff person failing to perform hand hygiene during direct patient care, this single observation will be cited as a deficiency resulting in a Requirement for Improvement under the Infection Prevention and Control chapter. This applies across all accreditation programs. This scoring is different from the past approach which focused more on the organization-wide hand hygiene improvement program; specifically, whether the program was consistently implemented and if progress was being made. Observations of individual failure to perform hand hygiene were not cited as deficiencies if there was otherwise a progressive program of increased compliance. TJC indicated that they moved to the more stringent approach because organizations have had since 2004 to implement successful hand hygiene programs. In addition, it has long been proven that hand hygiene is the most effective method for preventing health care associated infections.

Surveyors will continue to evaluate the organization-wide hand hygiene compliance program and compliance with the requirements of National Patient Safety Goal .07.01.01 which requires data collection, goal setting, and progress toward those established goals.

We have seen several organizations (both psychiatric hospitals and behavioral healthcare organizations) that don’t prioritize their hand hygiene compliance program, thinking that this requirement is intended primarily for med/surg hospitals. While there may be much more hands-on patient care in those settings, there are various types of hands-on care provided in psychiatric hospitals and some behavioral healthcare organizations. This would include, for example, physical exams, taking vital signs, medication administration, and collection of specimens. In addition, there are psychiatric hospitals that do wound care and procedures such as urinary catheterization. The following examples of recent survey findings provide some insight into surveyors’ expectations on this topic:

“Due to the lack of systematic collection of valid data, the evaluation of the hand hygiene compliance program was ineffective.  There was no collection of data for the behavioral programs.  Staff do serve food, administer medication, and assist with medical treatment and/or ADL’s necessitating the collection of hand hygiene compliance data.”

“There was no collection of hand hygiene compliance sampling in the Partial Program.  Staff do take vital signs and serve food.”

“The collection of hand hygiene compliance samples was not done in a consistent, systematic way to determine rate of compliance. The only sampling done was for some RN’s doing med pass and glucometer cleanings.”

“The organization had begun to collect data on hand hygiene compliance, but did not have an organized plan to include all categories of staff for which collection would be necessary or the number of observations that would be necessary for effective analysis to be done.”

So, when designing your hand hygiene monitoring program, incorporate the following “best practice” approaches:

• Identify the specific types of hands-on care that you will monitor for hand hygiene compliance.
• Identify the different categories of staff that will be observed.
• Utilize trained observers (can be “secret shoppers”) to collect the data.
• Focus your monitoring on peak times and locations for hands-on care.
• Consider using the Targeted Solutions Tool available through the Joint Commission Center for Transforming Healthcare.

For an interesting example of how two inpatient behavioral health units of a medical center implemented their hand hygiene compliance program, see the article “5 Moments for Hand Hygiene in the Behavioral Health Setting: Can it be Accomplished?”