Health care workers forget
Visual reminders—including posters on walls in units, on elevators and by dispensers, and stickers on
dispensers—were used to some extent by all the hospitals. Signage needs to be switched now and then
to keep the images and message fresh. “We had to change signage frequently,” said Susan Kulik, nurse
manager, Nelson 8, Johns Hopkins Hospital. “People get used to looking at signage.” She added, “A huge
factor is making staff more aware. Using visual reminders is one of the most effective methods of raising
Johns Hopkins Hospital also used red lines at the thresholds to all patient rooms to serve as a reminder
to “wash or don’t cross,” said Kulik. At Memorial Hermann The Woodlands, the door thresholds in the
ICUs have red tape that goes up the side of the door with an arrow pointing to where the hand sanitizer
is located. That area is marked “patient zone” to remind health care personnel and all visitors that they
are crossing this threshold and should clean their hands. “We know hand hygiene has become a habit
when a serious situation develops in the ICU and we see health care providers pause in the doorway to
get hand sanitizer,” said Parks. “It is the last point at which a health care worker can get it right and
prevent infection,” observed Rob Morehead, RN, infection control practitioner. “If we wash hands, we
can still get it right,” he added.
A couple of hospitals involved patients and visitors in monitoring hand hygiene and reminding health
care providers to wash their hands. According to nurse manager Rivera, “When Pam [unit manager] and
I do our rounding, we ask the patient, ‘Did you notice your nurse sanitizing before coming in here?’ One
hundred percent of patients say, ‘Yes, nurses and therapists are washing their hands all the time.’ ”
Rivera added, “We would always encourage the patient to ask the provider [to wash hands]”. Blaha
added that nurses and therapists can serve as role models. “Family members mimic staff,” she said.
Cedars‐Sinai also has placed kiosks across the hospital, so visitors know how important hand hygiene is,
said Mark Noah, MD, medical director, graduate and continuing medical education at Cedars‐Sinai.
At the Johns Hopkins NCCU, patients’ families were also invited to participate in the effort. “We
provided hand hygiene score cards to families so they could score our compliance,” said Feurer. The
patient representative in charge of the unit’s visitors’ lounge would give families the score card and
basic information and ask if they would be willing to score. They targeted families who had been on the
unit for more than 24 hours and did not have a family member in crisis. About half of the families did
help, said Feurer. She stressed that the data collected from families was not used as part of their
measurement data but primarily to make health care personnel aware that families are watching. If a
family member mentions the name of a team member that was compliant, Feurer, the unit’s assistant
nurse manager, highlights it on the staff bulletin board to recognize and thank that person.
Visual cues and reminders also can help health care personnel who become distracted. Along with their
name badge, employees at Memorial Hermann wear a badge with a hand that says “Clean In and Clean
Out.” Individuals are taught to flash the badge to coworkers as a reminder. “We also try to give positive
feedback to staff with leaders giving out cards that say, ‘You Got Caught Cleaning Your Hands,’” said
Kingdon. “If someone did not wash their hands, the leaders provide this feedback as well and ask the
individual why. This provides just‐in‐time coaching and potentially identifies an issue that needs to be
resolved,” she added.
WFUBMC found its top root cause for failure to wash hands was distractions, which included staff having
hands full, handling several requests at one time and being busy. “Distractions are a matter of changing
your mind set,” said Martin, physician group member on the project.