June 2010 Vol. 10, No. 6 StrategiesThe recession, which officially started in December 2007, has affected the job market. Picture the current state of the nursing shortage as a tsunami

Combating the nurse shortage

Market-savvy healthcare organizations have imple-

mented workforce development strategies to address the

existing and projected labor shortages. This helps organi-

zations determine where their strategic priorities lie. The

recent economic downturn will have lasting effects.

The recession, which officially started in December

2007, has affected the job market. Picture the current

state of the nursing shortage as a tsunami. The first thing

that happens in a tsunami is that the water on the beach

rushes away from the shore.

Nurses are filling current vacant positions en masse.

Nurses who had planned to retire, work only part-time,

or reduce their hours find they have had to change

their plans. They are staying and taking on full-time,

rather than part-time, positions (Buerhaus, 2009).

“As RN spouses lost their jobs (70% of RNs are mar-

ried) or wor-

ried that they

might be laid off,

many non-work-

ing RNs rejoined

the workforce”

(Buerhaus).

With RN va-

cancies being filled at an exceptional rate, organizations

might have an urge to ease their recruitment and reten-

tion efforts. This is exactly the wrong strategy to take.

As the economy begins to adjust, the tidal wave will

hit. The impact of the tsunami wave depends on how

quickly the economy recovers.

Organizations can’t

afford to simply react to

the workforce shortage.

Instead, they must take

steps to reduce the effects

of the shortage on their

organization.

> continued on p. 2

IN THIS ISSUE

p. 3 Best practiceExamine missed opportunities for rapid response by looking at one facility’s story of improving its rapid response team process.

p. 5 Patient safetyDiscover how interpreters can help overcome linguistic and cultural barriers.

p. 7 Transformational leadershipUnderstand how a blog can help strengthen the communication between CNOs and their staff.

p. 9 Hand hygieneLearn from two facilities that share their approach to improving hand hygiene compliance through spies, marketing, and monetary incentives, raising rates as high as 98%.

p. 12 Tip of the monthDevelop realistic goals while promoting performance excellence.

S t r a t e g i e sJune 2010 Vol. 10, No. 6

After reading this article, you will be able to:

➤ Discuss ways organizations can combat the RN

shortage

We’re seeking experts for books, audio conferences, and seminars

Writing books and articles for publication or speaking

on audio conferences, Webcasts, and at seminars are great

ways to share your industry knowledge with peers.

With the guidance of a solid publishing company, you’ll

see your thoughts and tips become beacons to others in

your field.

We’re always looking for new authors, speakers, and re-

viewers. For more than 20 years, HCPro has been a leading

provider of integrated healthcare information, education,

training, and consulting products.

Contact me at [email protected] and let me know your

areas of expertise and interests in nursing.

—Sincerely,

Sarah Kearns

Editorial Assistant

Page 2 www.StrategiesforNurseManagers.com June 2010

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Nurse shortage < continued from p. 1

If the economy recovers quickly, jobs will be rapid-

ly added back to the market. Many nurses who had to

come back to work or work more hours to supplement

the family income will leave the job market (Buerhaus).

Nurses who postponed retirement may stay in the mar-

ket a little longer than anticipated to rebuild their retire-

ment incomes, but they will also leave (Buerhaus).

What about the new graduates coming out of nursing

school? In a down economic climate, employers are able

to be more selective when posting positions.

When employers were faced with a lack of experi-

enced nurses applying for jobs in specialty areas (e.g.,

emergency room or neonatal ICUs), they had no choice

but to take on new graduate nurses (Clavreul, 2009).

If the economy recovers at a slower pace, nurses will

not leave the workforce. This means that new graduates

will continue to have difficulty finding jobs unless they

are willing to be flexible and work in a more generalist

role. Whether the economic recovery is fast or slow, it will

have long-lasting effects on healthcare organizations.

Organizations cannot afford to simply react to the

workforce shortage. Instead, they must take steps to re-

duce the effects of the shortage on their organization and

take an aggressive stance on recruitment and retention

strategies. The financial viability of an organization de-

pends on it.

Case in point: The cost to fill an RN position due to

turnover is between $82,000 and $88,000 (Jones, 2008).

RN vacancy rates have an even greater financial effect

on organizations. Costly approaches to filling the void in-

clude using agency/traveler temporary nurses, manda-

tory/voluntary overtime, closing patient units, and/or

diverting patients to other facilities (Jones). n

Editor’s note: This article is based on information found in

the book Nursing Orientation Program Builder: Tools for

a Successful New Hire Program. For more information, visit

www.hcmarketplace.com.

ReferencesBuerhaus, P.I. (2009). “The shape of recovery: Economic im-plications for the nursing workforce.” Nursing Economic$ 27(5): 338–336.

Clavreul, G.M. (2009). “Why nursing school grads have trouble finding jobs.” WorkingNurse.com. Retrieved No-vember 3, 2009, from www.workingnurse.com/articles/Why-Nursing-School-Grads-Have-Trouble-Finding-Jobs.

Jones, C.B. (2008). “Revisiting nurse turnover costs: Adjusting for inflation.” Journal of Nursing Administration 38(1): 11–18.

Editorial Advisory Board Strategies for Nurse Managers

Group Publisher: Emily Sheahan

Editorial Assistant: Sarah Kearns, [email protected]

Shelley Cohen, RN, MSN, CENPresidentHealth Resources Unlimited Hohenwald, TN

Marie Gagnon, DM RN, B-C, MS, CADAC, LISAC, CISMDirectorBaptist Health System School of Nursing Abrazo Health Systems Phoenix, AZ

June Marshall, RN, MS ANCC Magnet Recognition Program® Project DirectorMedical City Hospital Medical City Children’s Hospital Dallas, TX

David Moon, RN, MSDirector of Recruitment Summa Health System Akron, OH

Bob Nelson, PhDPresidentNelson Motivation, Inc. San Diego, CA

Tim Porter-O’Grady, DM, EdD, APRN, FAAN Senior PartnerTim Porter-O’Grady Associates, Inc. Atlanta, GA

Dennis Sherrod, EdD, RN Forsyth Medical Center Distinguished Chair of Recruitment and Retention Winston-Salem State University Winston-Salem, NC

Strategies for Nurse Managers (ISSN: 1937-7673) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $99 per year. • Copyright © 2010 HCPro, Inc. All rights reserved. Except where specifically encour-aged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. For renewal or subscription information, call cus-tomer service at 800/650-6787, fax 800/639-8511, or e-mail [email protected]. • Visit our Web site at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessar-ily those of Strategies for Nurse Managers. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. MAGNET™, MAGNET RECOGNITION PROGRAM®, and ANCC MAGNET RECOGNITION® are trademarks of the American Nurses Creden-tialing Center (ANCC). The products and services of HCPro, Inc., and The Greeley Company are neither sponsored nor endorsed by the ANCC. The acronym MRP is not a trademark of HCPro or its parent company.

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Bourg teamed up with two colleagues, Julie Benz,

RN, MS, clinical nurse specialist, and Melissa Richey,

RN, BS, clinical nurse for trauma services, to educate

the staff at SACH to be more knowledgeable about when

to call the RRT and more comfortable in doing so.

Working with the Wells Center in Colorado, a facility

that provides state-of-the-art patient simulation tools,

Bourg, Benz, and Richey rented a simulation-training

dummy.

“Wells Center supplied us with the simulation man-

nequins, along with the nurse driver,” says Bourg. “But

we were able to use our own nurse educators and ad-

vance practice nurses to help facilitate the groups.”

The nurse driver helped run the simulation, but

SACH staff wrote the script for the missed opportunity

scenarios. During the simulation training, a nurse per-

formed an assessment of a patient. Then, based on what

the nurse observed, he or she called an RRT.

“The purpose of the simulation training is to help the

nurses recognize the signs and symptoms, identify the

patients at greater risk, and then distinguish if they need

to call an activation of the RRT,” says Bourg.

The staff members at SACH first participated in the

simulation training in July 2008. Between August and

December 2008, the women analyzed missed opportu-

nities that took place after the simulation training and

saw a drop in the number.

Results not typical from simulation training

or education

Bourg’s team discovered that when the nurses ap-

propriately identified a patient in need of an RRT, there

were acute changes in the patient’s condition. But

when the changes to the patient were not as acute and

more subtle, the nurses did not notice them quite as

readily.

Over the past five years, rapid response teams (RRT)

have been brought to the forefront of American hospitals.

In 2004, the Institute for Healthcare Improvement (IHI)

launched its 100,000 Lives Campaign, of which RRTs were

a focal point, and in 2008, The Joint Commission added a

National Patient Safety Goal requiring hospitals to have a

process to recognize and respond to patients who are dete-

riorating. Those requirements are now located in standards

PC.02.01.19, HR.01.05.03, and PI.01.01.01.

Both of these initiatives sparked interest in RRTs

among hospitals, especially at St. Anthony Central Hos-

pital (SACH) in Denver, which began to develop its own

RRT in conjunction with the IHI initiative.

However, in 2008, SACH officials began to notice a

trend of patients who were meeting the criteria for RRT,

but for a variety of reasons, the team was not called.

A subgroup of 17 missed opportunities (including

deaths) was identified in the first half of 2008. With the

help of simulation training and debriefing interviews,

SACH was able to lower that number to nine for the sec-

ond half of 2008 out of 2,400 trauma-related admissions

for the year. That number was cut again for 23 total missed

opportunities and no resulting patient deaths out of about

2,400 trauma-related admissions in 2009.

Education and simulation training

In 2008, Pamela Bourg, RN, MS, ANP, CNS, direc-

tor of trauma services, first noticed a trend developing

across the trauma patients at SACH. There were particu-

lar instances where patients met the criteria for an RRT,

but nurses were not calling a team to follow through.

Best practice

Colorado hospital evaluates ‘missed opportunities’ in rapid response teams

> continued on p. 4


➤ Identify the training techniques used by SACH to

educate staff on rapid response teams



on missed opportunities. It is also helpful to take opportu-

nities to encourage staff members and let them know that

by calling the RRT, they did the “right thing.”

For example, one facility Duncan worked with had a

trophy that rotated between units based on which unit had

the most calls for an RRT and the least amount of codes.

“Staff members may work for three months and nev-

er call a team, but if they see a graph showing the calls

other units have made, or see fellow staff members get-

ting gift cards to coffee shops for calling the most RRT,

it reminds them that the rapid response system is still in

place and rescuing patients,” says Duncan.

Even if it is not clear what is wrong with the patient,

but there are some subtle changes, it’s important to com-

municate to staff that it is always good to have another

set of eyes on the patient, says Duncan.

“If the RRT comes in and assesses the patient occa-

sionally, additional information can be gathered or there

can be a quick consult or discussion of opportunities to

help the patient,” says Duncan.

This tactic is also beneficial because if for some rea-

son the nurse calls the RRT again, the team will know

the patient has had previous issues and may work more

quickly to assess and intervene.

Looking to the future of missed opportunities

Bourg says SACH will now use simulation training

with staff every quarter, as opposed to once per year.

“The simulation training has provided the most bang

for the buck,” says Bourg. “It has shown staff members

to no longer consider the least-case scenario, but to in-

stead look into the worst-case scenario.”

Even though SACH saw a reduction in missed oppor-

tunities in 2009, the number was still too high, she says.

“In 2010, we look to better our number and eventually

get down to zero.” n

Source Adapted from Patient Safety Monitor (Briefings on Patient Safety), April 2010, HCPro, Inc.

Even though the number of missed opportunities de-

creased toward the end of 2008, as 2009 began, Bourg

watched the numbers increase, despite staff members

having gone through simulation training. “We sat down

and knew there were other issues we needed to identify

because the numbers were increasing,” she says.

At first, Bourg thought it might have something to do

with new graduates working at SACH. But after looking

at things more closely, she discovered that other factors

contributed to the missed opportunities.

“In addition to the huge changeover we saw at SACH,

staff members who had been with us for over two years

were failing to activate an RRT,” says Bourg.

In hopes of improving the number of missed opportu-

nities, Bourg and her colleagues went back and began in-

terviewing staff members who failed to activate an RRT.

They developed a debriefing tool using a variety of nurs-

ing literature to help understand why nurses were failing

to activate the RRT.

“We try to make sure that when a missed opportuni-

ty presents itself, we contact the nurse within 24 to 48

hours to ask them more about the situation,” says Bourg.

When a nurse has a missed RRT opportunity, an ad-

vance practice nurse conducts a debriefing interview,

not the manager.

During the interview, the nurse is asked questions

about what was going on at the time of the missed op-

portunity, what kind of patient report he or she received

from the previous nurse, whether there were competing

priorities, and so on.

“We are not trying to assign any blame,” says Bourg.

“We are trying to create a culture of safety so people are

willing to come forward and give us the information to

help make our practice better.” In addition, staff went

through simulation training again in July 2009.

More ways to encourage the activation of RRT

IHI faculty member Kathy Duncan says the education

SACH provides for nurses is a good way of cutting down

Rapid response < continued from p. 3



supervisor of Community House Calls/Interpreter Services

at Harborview Medical Center in Seattle.

Harborview has used its Community Health Calls

program to help bridge linguistic and cultural barriers

for 16 years.

Originally established to serve the county’s East Af-

rican and Cambodian refugees, the program has since

expanded to provide services to patients that speak

Spanish, Vietnamese, and Somali.

Harborview employs 50 state-certified medical in-

terpreters that speak 26 languages and serve a patient

population that

speaks 80 lan-

guages. Harbor-

view had more

than 100,000 in-

terpreter encoun-

ters in 2009.

When Harbor-

view has a patient that speaks a language that is not in

its medical interpreters’ repertoire, it gets help from an

outside interpreter service agency. Facilities that do not

have interpreters on staff should at the very least have

access to a strong telephone interpreter service, says

Bogomolov. Facilities should never rely on a patient’s

family members or a bilingual staff member in another

department to provide interpretive services. “There are

issues of bias, performance, patient safety, and confiden-

tiality,” she says.

The National Standards on Culturally and Linguistical-

ly Appropriate Services (CLAS) do not allow a patient’s

family members to interpret medical instructions unless

the patient specifically requests that they be allowed to

do so.

For more information on the CLAS standards, visit the

U.S. Department of Health and Human Services’ Web

site at http://hcpro.com/url/1230.

Nearly half of U.S. physicians say language and cul-

tural barriers are at least minor obstacles to providing

high-quality patient care, according to a study released

by the Center for Studying Health System Change, a

nonpartisan policy research organization located in

Washington, DC.

The study highlights the need for healthcare providers

to address non-English-speaking patients, especially as

the percentage of non-English speakers rises.

The latest U.S. census data, collected in 2000, says

47 million residents over the age of five (18% of the to-

tal population) speak a language other than English at

home. In 1990, 31.8 million residents (14%) reported

they did not speak English at home, and in 1980, 23.1

million residents (11%) did the same.

Considering communication is at the heart of what

staff members do, staff leaders should treat solving

the problem of language and cultural barriers as a top

priority.

Such obstacles “can lead to wrong clinical paths and

poor outcomes, even disastrous outcomes,” says Barbara

Bogomolov, RN, MS, BSN, manager of refugee health

and interpreter services at Barnes-Jewish Hospital, a mem-

ber of BJC HealthCare,in St. Louis.

Use interpreters to bridge communication gaps

Patients rely on staff—such as nurses and case manag-

ers—to explain forms such as the Important Message from

Medicare, provide instruction on performing post-dis-

charge tasks, and ensure their concerns are met. However,

many facilities lack resources to address non-English-

speaking patients, says Bria Chakofsky-Lewy, RN,

Patient safety

Interpreters help overcome linguistic and cultural barriers

> continued on p. 6


➤ Develop a process that addresses non-English speakers

➤ Choose a qualified interpreter

The latest U.S. census data,

collected in 2000, says 47

million residents over the

age of five (18% of the

total population) speak a

language other than English

at home.



to advance effective communication and cultural

competence.

The Joint Commission plans to release those stan-

dards this year for use in 2011. In the meantime, it has

created a crosswalk between the CLAS standards and

existing Joint Commission standards, which is available

at http://hcpro.com/url/1229.

During its regular accreditation, The Joint Commis-

sion will review the medical record to evaluate a facil-

ity’s ability to facilitate non-English speakers.

Facilities should develop a process to make sure that

they properly document encounters with non-English

speakers, Bogomolov says.

When patients are registered or admitted to Barnes-

Jewish, they are asked what race and ethnicity they

identify with and what language they prefer to use for

communicating with healthcare providers.

Staff enter these data into patients’ permanent records,

so the questions are asked only once, and information

flows down to the inpatient charts.

Based on the data, staff can determine whether inter-

pretive services are required to bridge cultural or linguis-

tic barriers.

“There should never be a situation where you cannot

communicate with a patient,” Bogomolov says. n

Source Adapted from Case Management Monthly, April 2010, HCPro, Inc.

Facilities can also take advantage of interpreters as

a source of cultural information. “It’s not all about lan-

guage. We are used to Western-educated patients un-

derstanding their rights and obligations to make choices

for themselves, but many [patients] come from cultures

where that is not normal or appropriate,” Bogomolov says.

Tip: Staff should have a pre-conference with inter-

preters before they interact with patients. During that

time, interpreters will learn what the expectations are

for the medical encounter, and they can alert health-

care providers of any cultural barriers that may obstruct

those expectations.

Choose an interpreter

Interpreters should have credentials or some other

means of displaying competence in both languages. Keep

in mind good interpreters don’t necessarily provide word-

for-word translations. Sometimes medical terms have no

direct translation.

“There is no word in Somali for MRI,” Chakofsky-

Lewy says.

Although they do not need to possess a strong clinical

competence, interpreters should have enough familiarity

with medical terminology to be able to create word pic-

tures that the patient can understand.

To make sure that patients comprehend the informa-

tion, it is best to ask them to explain what they have

been told in their own words, Chakofsky-Lewy says.

Document encounters with non-English speakers

The Joint Commission (formerly JCAHO) is de-

veloping hospital accreditation standards that aim

Interpreters < continued from p. 5

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The hope was to use the blog as a direct communica-

tion tool. But the first post received only 19 responses.

“We needed to increase awareness the blog existed,”

says Latty. “So we focused our efforts on communication.”

Posts were also used to educate as well as thank

staff members. For example, one post talked about the

daunting task of implementing the electronic medical

record (EMR).

“We recently implemented the EMR, and the last blog

talked about that, discussing how there might be bumps

in the road and thanking everyone for doing their part,”

says Latty.

Technological requirements

Setting up the blog was simple. St.Vincent had the

blog up and running in less than one day with the help

of the organization’s IT department.

It was so convenient, in fact, that it led to one of the

first lessons of creating a blog: Have a communication

plan in place.

“One thing we realized—and it’s still a pretty new

blog—is that if you don’t keep the posts current, people

stop going to the site,” says Latty.

And given how busy every CNO is, finding time to

write blog posts on a regular basis can be tough. Although

they may not take much time, they do require a good deal

of thought.

“In hindsight, because the idea surfaced quickly and

there was so much excitement, we didn’t spend much

time planning what the process would be, what the

purpose would be for the blog,” says Latty.

She suggests spending some time with all the parties

involved in conceiving and maintaining the blog to cre-

ate a plan and goal before implementing it.

“Do that up front,” says Latty. “Two questions we en-

countered later were: Do people know about it? And

what is our plan for keeping it current?”

There are a number of methods organizations can

use to help demonstrate visibility of their CNO, and with

readily available, user-friendly technology all around us,

something as simple as blogging can turn into a road of

communication between the CNO and the staff. St.Vincent

Indianapolis Hospital, for example, turned to the nursing

portal on its intranet.

“This is our one-stop shop for nurses,” says Sallie

Latty, MA, BSN, RN, MRP coordinator at St.Vincent.

“We were looking at ways to meet the needs of a young-

er generation.” That younger generation would be more

tech-savvy and more likely to look for updates through

electronic means, such as a blog.

It’s not a small task to reach all of the organization’s

nurses, either—there are 2,300 nurses at St.Vincent,

1,500 of those at the bedside.

Although talking leadership into adopting new or

different technology options can be a challenge in

healthcare settings, this was not the case at St.Vincent.

It didn’t take any convincing to get the CNO to partici-

pate in a blog.

“Our CNO loved it the minute the idea popped up,”

says Latty. “There was no need for encouragement—

she was really excited about it.”

Choosing content

The blog’s content started directly.

“The very first blog posted was meant to gain feed-

back on how the nursing staff wanted our CNO to be

visible in the organization,” says Latty. “Did they want

[her] to have public forums, tours of their units, shadow

nurses—what were their thoughts?”

Transformational leadership

To blog or not to blog: CNO connects with staff nurses

> continued on p. 8


➤ Develop a blog in order to communicate with your

CNO



The shadowing experiences eventually became part

of the blog.

“[The CNO] schedules four-hour blocks of time to

work alongside a nurse—it allows her to come into con-

tact with physicians and ancillary staff as well as all of

the situations that nurse encounters,” says Craig.

This sort of shadowing gives the CNO an opportunity

to see the nurse’s perceptions of the organization, the pa-

tient’s perceptions of the nursing staff, and a chance to

evaluate the processes being used, Craig says.

The blog is only one example of the CNO’s methods

for improving visibility to the staff. “[Our CNO] has a

routine article in our Nursing at a Higher Level newslet-

ter,” says Latty.

A presence in every meeting

The CNO attends every meeting she is requested to at-

tend, when possible. “Whether a unit has asked her to

be at a staff meeting or other opportunities to encounter

staff, she is always willing to change her schedule to do

so,” says Latty. Because of shared decision-making, staff

nurse participation on many committees has increased,

giving staff further opportunity to interact with the CNO

and other nursing leaders.

“Our CNO also conducts periodic nursing forums.

They’re usually planned around a topic or communica-

tion item she wants to get the message out about,” says

Craig.

Finally, sometimes visibility can be as simple as being

out among the staff.

“Sometimes it’s a small thing that helps with expo-

sure,” says Latty. “Going to the cafeteria might seem

like a little thing, but when you do that along with all

these other pieces, it helps associates feel like they know

who the CNO is, especially in a large organization like

St.Vincent.” n

Source Adapted from HCPro’s Advisor to the ANCC Magnet Recognition Program®, April 2010, HCPro, Inc.

Staff reaction

The blog had the potential to reach those staff mem-

bers who can be the most difficult for CNOs to find.

“We felt the blog would be a good way to communi-

cate with staff that might be on the night shift, or week-

ends only,” says Pat Craig, MSN, MBA, RN, FACHE,

an MRP coordinator at St.Vincent. “These are times

when leadership isn’t always personally available.”

The CNO also started to receive direct e-mails from

staff who did not want to post feedback publicly. However,

those who do leave public comments can do so anony-

mously. “Staff have the option of leaving their name or

not,” says Latty.

Concerning public posts, two unexpected develop-

ments occurred:

➤ Those who left comments were more often than not

middle-aged nurses, not the younger generation

St.Vincent expected to see when the blog was first

conceived

➤ Non-nurses discovered the blog and were able to

comment as well—and they did

“It’s interesting to have non-nurses responding,” says

Latty. In fact, the blog received one suggestion from a

member of the security staff on how to improve collabo-

ration between nursing and security that turned out to

be worth exploring.

Increased visibility

The CNO traveled the floors, encouraging staff mem-

bers throughout the implementation process. The blog

provided a way for the CNO to reach out to staff to con-

vey her experiences and thank them for their efforts. It

also gave the CNO a chance to discuss her experiences

and observations after shadowing a nurse.

“One of the things a hospital [on the journey to ex-

cellence] has to do is show evidence of visibility of nurse

leaders,” says Latty. “You have to demonstrate and de-

scribe how you do that at an excellent level.”

To blog or not to blog < continued from p. 7



Using hand hygiene spies

A common method to track hand hygiene com-

pliance and improve rates is the use of hand hygiene

“spies” or “secret shoppers.” Both Texas Children’s and

Abington Memorial have used spies to kick-start their

programs.

When she first started, Collette Hendler, MS, RN,

CIC, infection preventionist at Abington Memorial,

said she used hospital volunteers and physicians wait-

ing for residency

as hand hygiene

spies, but soon

found she needed

more observations

than they could

provide.

Roughly two

years ago, Hendler formed a team of hospital employees

whose “regular work flow allows them to be in all areas

of the hospital so they are not noticed.”

These spies remain anonymous so employees aren’t

aware of when they are being watched or who is watch-

ing them.

At first, employees were not happy with the thought

of colleagues spying on them, and even refuted the col-

lected information when it came back unfavorable. Ini-

tially, compliance rates were around 34%.

“But if a nurse manager would say to me he didn’t be-

lieve my data, I would tell him to do it himself and see

how his data compared to ours,” Hendler says.

“In the one particular case, he came down halfway

through the day and said he couldn’t take it anymore and

believed our numbers were what they were,” says Hendler.

Jeffrey Starke, MD, director of infection control at

Texas Children’s, took a similar approach four years ago,

The perennial problem in healthcare facilities around

the country usually comes back to a very simple 30-sec-

ond procedure.

Ask any infection preventionist (IP) about his or her

major focus on hand hygiene compliance and you’ll

likely hear a number of strategies, obstacles, or frustra-

tions with getting staff members to comply with hand

hygiene best practices. Hand hygiene compliance rates

vary from facility to facility, and even from unit to unit.

There are three main methods for measuring hand

hygiene compliance, according to The Joint Commis-

sion’s (formerly JCAHO) monograph Measuring Hand

Hygiene Adherence: Overcoming the Challenges:

➤ Direct observation

➤ Measuring product use

➤ Conducting surveys

However, measuring compliance is just half the battle

for IPs. Improving compliance is another challenge. Part

of the Joint Commission’s National Patient Safety Goal

NPSG.07.01.01 requires facilities to set goals for improv-

ing hand hygiene rates, and it’s a continued focus of Joint

Commission surveyors (see the December 2009 Briefings

on Infection Control for more info).

Texas Children’s Hospital in Houston and Abington

(PA) Memorial Hospital have both improved their com-

pliance rates through a variety of successful strategies,

from marketing to monetary compensation.

Hand hygiene

Improving hand hygiene compliance rates with marketing, accountability, and incentives

> continued on p. 10


➤ Identify proven methods to improve hand hygiene

compliance

➤ Explain how monetary incentives improved rates at

Texas Children’s Hospital

“ We try and do things that

are funny, things that are

serious, just try to shake

it up so people look at the

screen savers and there is

some message going on.”

—Collette Hendler, MS, RN, CIC



Texas Children’s took a similar approach two years

ago, focusing on marketing its hand hygiene campaign

rather than just educating employees.

The marketing team brought in an outside consul-

tant who helped develop a campaign called “Hy-Five”

aimed at patients and families as well as physicians and

employees.

The campaign increased compliance to approxi-

mately 80%, and as a result, Texas Children’s won the

Child Health Corporation of America’s National Qual-

ity Award.

“Executives love marketing, and so they know that

these data are looked at by outside agencies that are

looking at us and are doing rankings, and so they know

that they can look people in the eye and say, ‘We real-

ly believe in quality; here is the data and the awards to

back it up,’ ” Starke says.

Relying on incentives and accountability

Starke says even though Texas Children’s reached

80%, getting over that last hurdle to the 90th percentile

took additional facilitywide motivation.

“We said we needed to do a little better, and I’m a big

believer in incentives,” Starke says. “I think we are all in-

fluenced by the same things as other people.”

Texas Children’s has an employee bonus program

called P3. Previously, all incentives were based on finan-

cial numbers and volume, but Starke went to his admin-

istration and talked it into making hand hygiene part of

the bonus program for employees. Then he took it one

step further and made it part of the administrators’ bo-

nus program as well.

“I know this sounds trite, but we convinced them

that it was the right thing to do,” Starke says.

“We said, ‘What’s good for the goose is good for the

gander,’ and once you agree to do this for the employees,

how can you possibly exempt yourselves? [We were] sort

of trying to create a ‘just culture,’ and I think this is a very

important part of ‘just culture,’ that administrators be just

but with one exception: He hired outside infection control

professionals to come in as hospital employees and anon-

ymously observe hand hygiene. These spies found that

Texas Children’s hand hygiene rate was around 50%.

“These are folks that are totally unknown to the people

in the institution,” Starke says. “This is also completely un-

known to hospital administration. People think adminis-

tration messes with this, but it’s entirely controlled by IC.”

Creating a buzz

Obviously, these rates were not good enough for

each respective facility. Now that the spies had been

dispersed to collect data, the message needed to be

clear and consistent.

Both facilities turned to their marketing teams to cre-

ate more buzz around hand hygiene compliance and of-

fer daily reminders to staff members.

“I actually probably have something that a lot of other

hospitals don’t have, and that’s that I have my own PR

person who is assigned to the hand hygiene project and

I work very closely with him and he comes up with a lot

of creative ideas,” Hendler says.

One of those ideas included screen savers with hu-

morous or provoking messages. One included a picture

of a young patient that read, “You could kill him with

your bare hands.” Another was a spoof of the “Sham-

wow” infomercial that read “Hand-wow.” These ap-

proaches raised compliance rates to 88%.

“We try and do things that are funny, things that are

serious, just try to shake it up so people look at the screen

savers and there is some message going on,” Hendler says.

Hand hygiene < continued from p. 9

Contact Editorial Assistant Sarah Kearns

Telephone 781/639-1872, Ext. 3298

E-mail [email protected]

Questions? Comments? Ideas?



[infection prevention] falls down, is not making execu-

tives responsible.”

Abington Memorial is also in the process of imple-

menting an additional accountability program because

compliance rates have begun to plateau at 80%.

Although it isn’t fully implemented, this new program

will continue tracking compliance with spies, but manag-

ers will hand out index cards.

If an employee has practiced good hand hygiene, the

index card will enter that person in a prize raffle.

Employees who are observed not washing their hands

will receive an infraction. After three infractions, those

employees will receive a letter warning them about their

noncompliance.

Hendler made it clear that contrary to an article in

Philadelphia Inquirer, employees would not lose their jobs

for noncompliance, but they would be held accountable.

Abington Memorial also took an approach that has

been used in many other healthcare facilities in an at-

tempt to personalize the infections that result from im-

proper hand hygiene.

In one staff meeting, the hospital’s chief of staff, John

J. Kelly, told a story about Catherine “Pat” Zakrzewski,

a patient that underwent an amputation and ultimately

died from a MRSA infection that could have been pre-

vented through hand washing.

“[She] was one of our physicians’ mothers, and it

really got personal and hit home with a lot of people,”

says Hendler. n

Source Adapted from Briefings on Infection Control, April 2010, HCPro, Inc.

as responsible for these things as the frontline employ-

ees are.”

The incentive was not an all-or-nothing approach;

the facility had to meet a 95% compliance rate for em-

ployees and administrators to get that portion of their

bonus, while other factors contributed to other portions

of their bonus.

“I mean, what does CMS do?” says Starke, referring to

the CMS never events. “CMS is setting a financial incen-

tive, so I don’t see how this is any different than that, ex-

cept we are controlling it.”

Since implementing this incentive, compliance rates

at Texas Children’s have stayed between 95% and 99%,

Starke says. Simultaneously, bloodstream infection rates

have plummeted.

Although Starke admits there are other factors to ac-

count for this reduction, it has helped set the culture and

emphasize infection prevention.

“It’s not like there are administrators browbeating

people,” Starke says. “It’s not like people are up there go-

ing, ‘If you don’t do this, we can’t vacation this year.’ It’s

creating the same culture and expectations at every level

of the organization, and I think that’s sometimes where

Upcoming WebcastJune 17, 2010—Horizontal Hostility in Nursing: Proven

Organizational Strategies for Effective Communication

and Collaboration (SKU061710)

For more information, call HCPro’s customer service

representatives at 800/650-6787 or visit

www.hcmarketplace.com.

Establishing healthy competition

Focusing on the culture of hand hygiene at Texas Chil-

dren’s Hospital in Houston has resulted in some tangible

results, says Jeffrey Starke, MD, the facility’s director of

infection control.

The hospital now tracks days without bloodstream infec-

tions on every floor to give employees a goal to work to-

ward. In this case, the goal is to continue the number of

days without a bloodstream infection. Hand hygiene is part

of the central line bundle to prevent bloodstream infections.

The facility’s pediatric ICU just went 291 days without

a bloodstream infection before recently recording one.

Even the neonatal ICU, which is notoriously difficult to

keep infection-free, has gone 40 days without a blood-

stream infection. “It’s a question of engaging people,

making it part of their professional pride, and rewarding

them for a good job,” Starke says.



ReferenceNational Institute of Standards and Technology (n.d.) “Baldrige in Health Care: Performance Excellence Delivers World-Class Results.” U.S. Department of Commerce. www.baldridge.nist.gov.

Source Shelley Cohen, RN, MSN, CEN, Health Resources Unlimited, www.hru.net. Adapted with permission.

As managers and leaders, we all want to improve our

patient outcomes while balancing staff satisfaction. This

is something that we strive for, even though it is not an

easy task and many obstacles surround us.

When trying to improve quality as well as productivity,

keep in mind the Baldrige Quality Program that offers cri-

teria you can follow as you work toward achieving your

goals of excellence. The Baldrige Quality Program offers

staff and leader progress surveys to use within your organi-

zation, which will help provide a dose of reality for all.

Misperceptions can quickly defuse any energy gained

in your progress for achieving excellence. Use the follow-

ing survey criteria to guide the evaluation of your status

as well as assist in developing some realistic goals:

➤ Achieve superior healthcare outcomes and service

delivery outcomes

➤ Attain positive patient-/customer-focused outcomes

➤ Achieve significant gains in financial and market

outcomes

➤ Know your strongest assets

➤ Demonstrate your ability to operate as a leader

through organizational effectiveness outcomes

➤ Realize leadership and social responsibility outcomes

through your role modeling

➤ Cultivate a results-driven environment n

Tip of the month

Promoting performance excellence

Web site spotlight

Do you know a fellow nurse that goes beyond the call of duty

or a nurse manager who had a positive effect on your experience as a nurse? Do

you want to show your appreciation, but don’t know how? Now you can, by nominating them for

HCPro’s 2010 Nursing Image Awards! The award honors nurses whose leadership,

teamwork, or clinical expertise embodies an image of nursing excellence and contributes to improving patient

care, quality outcomes, nurse satisfaction, and the healthcare environment.

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June 2010 Vol. 10, No. 6 StrategiesThe recession, which officially started in December 2007, has affected the job market. Picture the current state of the nursing shortage as a tsunami