Watchful eyes make for clean hands

Greater Baltimore Medical Center used signed pledges and volunteer auditors to dramatically improve hand hygiene rates.

Where: Greater Baltimore Medical Center

The issue: Creating and maintaining a successful, multi-faceted hand hygiene initiative that engages employees at every level.


In early 2007, the Greater Baltimore Medical Center's (GBMC) infection control department commissioned a group of nurses to conduct a one-day point prevalence study of compliance with the hospital's hand hygiene policy.

“The results were not pretty,” said Stephanie A. Mayoryk, RN, BSN, infection control practitioner. “The national average for hand washing is about 40% compliance, and our data for that one day showed that we were a little below that. Obviously, we had a lot of work to do.”

How it works

GBMC established Team Hand Hygiene, a group of nurses, secretaries and other non-physician personnel who agreed to serve as on-site hand hygiene auditors in their units.

Beginning in spring 2007, each auditor was asked to perform 80 observations per month (since reduced to 50). “Auditors were required to provide on-the-spot education,” Ms. Mayoryk said. “When they saw someone neglect an opportunity to clean their hands, they approached that person in a friendly manner and reminded them that this is important for patient safety.” Concurrently, the hospital launched a mass installation of alcohol-based hand sanitizer dispensers, which are now available both inside and outside every patient's room.

With auditors and dispensers in place, the compliance rate began to climb, reaching about 73% by the end of 2007. “Availability of the dispensers was a key component of our early improvement, but we also realized that we needed to keep the hand hygiene effort visible and make it personal for every employee,” said John R. Saunders, MD, a surgeon who is chief of staff at GBMC.

In 2008, the hospital launched a new campaign called “Because” and mailed out pledge cards to all employees and staff. “The card read, ‘I wash my hands because…,’ followed by several blank lines. About 2,000 of our 3,000 employees listed their own reasons and signed the pledge card. Then we posted all 2,000 cards on walls throughout the hospital,” said Dr. Saunders.

In addition to the pledges, hundreds of photographs were posted showing GBMC's top officers and managers, as well as other hospital staff, using the hand hygiene dispensers. “Patients, visitors, everyone could see them,” said Fred T. Chan, ACP Member, medical director of inpatient services and director of the hospitalist program at GBMC. “The signed pledges and photos created a conversation. You could just walk down the hall and see how serious everyone was about this initiative. That really created a global awareness of its importance.”

Another key component of the program was ongoing communication of results, Dr. Saunders said. “We track hand hygiene compliance by unit on a monthly basis, and also break it down by discipline. My role is to use the bully pulpit to communicate about the importance of the campaign and to let our 1,200 physicians know how they're doing. It took us a couple of years, but now physicians have the highest compliance as a group, and we advertise that widely.”

The 24 hospitalists at GBMC are particularly engaged, Dr. Chan said. “We have seen and recognize the potential complications that can develop from hospital-acquired infections. We're an important part of any of these quality control initiatives because if we adapt our process, 50% of medical patients will be affected by our efforts.” The hospitalist group manages about 50% of all medical admissions at GBMC, he said.


“The challenge with hand hygiene in any health care facility is that people don't take it seriously,” said Dr. Saunders. “No one would ever think of contaminating the sterile surgical field in the operating room for no reason, and yet people will go into patients' rooms without washing their hands.”

Dr. Chan added, “New staff coming on board, not just physicians, but patient transport, dietary, everyone who comes to GBMC, has a learning curve if they come from an institution that doesn't emphasize hand hygiene.”


Hand hygiene compliance rates reached 87% by the end of 2008 and remained above 90% throughout 2009, Ms. Mayoryk said. Suspecting that auditor bias—the fact that the auditors are well known in their units—might be skewing the results, the in- fection control department used a student volunteer to observe and record compliance anonymously for two weeks.

“We did find discrepancies when we compared her results with those of our regular auditors,” Ms. Mayoryk admitted. “She observed a wide range of compliance among the units observed. Some units returned to around the national benchmark level of 40%, while others were only slightly below their ‘auditor’ reported rates of 90%. We still see great room for improvement.”

Lessons learned

“A hand hygiene campaign has to be very visible, and you have to keep communicating the results as you go forward,” said Dr. Saunders. “You also have to make it easy to do. If you have to walk down the hallway to clean your hands, then it won't get done.”

How patients benefit

Ms. Mayoryk reported that from fiscal year 2008 through fiscal year 2009, the hospital's rate of health care-associated Clostridium difficile infections decreased 54% and the rate of health care-associated MRSA infections decreased 29%. “This happened at the same time that some other institutions in our area have reported outbreaks of C. difficile infections, so clearly the GBMC hand hygiene effort has helped us to better manage our patients,” said Dr. Chan.

Next steps

GBMC has joined the Maryland Patient Safety Center Hand Hygiene Collaborative, a statewide initiative launched in late 2009.

“This initiative requires that secret shoppers collect the data, so we're taking a year-long break from our previous approach. Our auditors will no longer work in the unit they're observing, but will rather be people like social workers, who have a reason to be there but are not there all the time,” explained Ms. Mayoryk. “They'll carry smart phones that allow them to report the data as it's collected, and we will be able to benchmark ourselves against other Maryland hospitals.”

In the meantime, a multidisciplinary task force will continue to brainstorm creative ways to maintain hand hygiene awareness and communicate results, she added.

Words of wisdom

“Hand hygiene is the number one way we can prevent infections, so we can never give up on the battle,” said Ms. Mayoryk. “We always have to find ways to reinvent ourselves. We need to continue to strive to do better and assume that each hospital-acquired infection is potentially preventable.”