A System-Wide Approach: Hand Hygiene Observations Performed by Parent Observers in Pediatric Ambulatory Care Settings

Background: The “healthcare worker (HCW) as hand hygiene (HH) observer” model, created by the Joint Commission Center for Transforming Healthcare, works well in inpatient settings but presents challenges in ambulatory care settings. This model, using the targeted solutions tool (TST) for HH, evaluates compliance based on the World Health Organization’s (WHO) moments of HH: before and after contact with a patient and their surroundings. HH observations performed by HCWs in ambulatory care settings interrupt patient care and do not maintain anonymity of the observer. HH observations performed by HCWs showed a compliance of ≥ 95%; however, parent feedback and leader rounding observations suggested lower compliance. This resulted in concerns with the reliability of HCW HH compliance data and a need to evaluate other methodologies. Although adult studies show that patient observations are a valid method for determining HCW HH compliance, there is limited research on parent HCW HH observations in pediatric ambulatory care settings.
Aim: This quality improvement (QI) project aimed to implement HCW HH compliance using parent observations in pediatric ambulatory care settings by September 30, 2023.
Methods: A benchmark survey was conducted through the American Academy of Ambulatory Care Nursing to assess HCW HH observation practices in ambulatory care settings. In March 2023, the Associates in Process Improvement’s model for improvement framework was used to identify goals and measures of change. HCW HH compliance was measured utilizing direct parent observation during their scheduled visit in ambulatory care services across the system. The QI project defined HCW HH compliance as correct HH performed before and after contact with the patient or their surroundings. The ambulatory care quality workgroup created the parent observation process by obtaining HCW feedback regarding the current process, created a parent survey and QR code, and established a communication plan for stakeholders. A QR code linked to an organization approved survey software captured data. After implementation in April 2023, a member of the ambulatory care quality workgroup analyzed data bimonthly to ensure metric compliance. The ambulatory care quality practice council, representing over 100 clinics, met to analyze the data and disperse findings to their respective areas.
Results: In April 2023, the pediatric ambulatory care clinics successfully implemented a system-wide parent observation process for HCW HH compliance. Prior to implementation, HCW HH scores averaged 99.2% but contradicted parent feedback and leader rounding observations. Although, post-implementation HCW HH scores decreased to 90.3%, the team met the organization standard of ≥ 90% HCW HH compliance. However, post-implementation of PDSA cycle number 3 reflected an increase in HCW HH compliance to 96.4%.
Conclusion: Healthcare systems rely on HCW HH compliance data to drive infection prevention practices. Due to workflows in ambulatory care settings, HCW observations can affect data reliability. This QI project implemented a system-wide parent observation process in pediatric ambulatory care settings and achieved HH compliance ≥ 90%. Project limitations included setting goals for the target number of parent observations, data surrounding HCW feedback, and parent participation in the planning phase. Future QI initiatives should focus on parent engagement, empowerment, education, and survey submission targets.