Public Reporting of Hospital Hand Hygiene Compliance—Helpful or Harmful?

Public reporting of hospital performance has been proposed as a means of improving quality of care while ensuring both transparency and accountability.¹ Organizations feel pressure to perform well, deriving from their desire to protect market share and defend reputations. This pressure, if effectively harnessed, can lead to an increase in quality improvement activities and better patient outcomes, although the evidence supporting the latter claim is mixed.¹

In 2002, it was estimated that approximately 1.7 million hospital-acquired infections (HAIs) and 99 000 HAI-related deaths occurred in the United States each year.² Hand hygiene is considered the most important strategy to prevent HAIs.³ Since 2002, an increasing number of US states have mandated public reporting of quality indicators related to HAI prevention; to date, none have included reports of hand hygiene compliance in their mandates. This Commentary suggests the need for caution by states considering publicly reporting hand hygiene compliance as a mechanism to reduce HAI.

Public reporting creates an incentive to maximize performance but does not specify the manner in which this is achieved. Broadly speaking, 2 approaches are possible. Hospitals can adopt evidence-based strategies designed to improve patient outcomes that will also improve the publicly reportable indicator, or they can adopt indicator-based strategies designed to improve the reported indicator that may not improve outcomes and may even cause harm. Evidence-based improvement strategies would be favored in an environment in which organizations focus on improving patient outcomes—when such strategies exist and are easy to implement. Conversely, indicator-based improvement strategies would be favored in an environment in which the hospital focuses on protecting its reputation, when evidence-based improvement strategies are unproven or resource intensive, or when measurement of the indicator is easily manipulated to show improvement.

This framework can be applied to a specific example. Observational studies suggest that patients with community-acquired pneumonia (CAP) who receive early antibiotic administration (ie, within 4 hours of emergency department arrival) have better outcomes than those receiving delayed antibiotic therapy.⁴ However, public reporting of time to first antibiotic dose within 4 hours as a quality indicator had an unintended consequence—widespread antibiotic treatment of patients without CAP. Some hospitals even adopted policies mandating that antibiotics be administered to patients with suspected CAP before chest radiographs were obtained.⁵ Ultimately, time to first antibiotic dose within 4 hours was withdrawn as a reportable indicator.⁴

In this example, an evidence-based improvement strategy would have focused on early identification of patients with suspected CAP, rapid confirmation of the diagnosis, and prompt initiation of antibiotic treatment if indicated. Evidence-based improvement strategies might have required additional nursing, physician, radiology, or pharmacy resources. If early treatment is better, this approach would have improved patient outcomes. Conversely, indicator-based improvement strategies such as protocols that require antibiotic administration prior to chest radiography were easy to implement with existing resources but were unlikely to benefit patients.

Other publicly reportable indicators also lead to the use of indicator-based improvement strategies. Public reporting of post–cardiac surgery mortality has been associated with a decrease in access to care for high-risk patients and an increased coding of comorbidities.⁶ The reporting of hospital-standardized mortality ratio in Canada led to reductions in this outcome to an extent that was inconsistent with the use of evidence-based improvement strategies.⁷ When public reporting is mandated without guidance on how improvement should be achieved or without additional resources to support improvement, it is not surprising that indicator-based improvement strategies are used.

A large body of evidence supports the association between improvements in hand hygiene and reductions in HAI.³ However, no evidence-based strategy exists that will reliably improve the hand hygiene compliance of health care workers.⁸ Multimodal interventions may be successful but are resource intensive, require sustained effort, and have not been associated with levels of compliance greater than 80%.³

The criterion standard for measuring hand hygiene compliance is direct observation, a method subject to observer bias, selection biases, and the Hawthorne effect.³ Minor changes in measurement methods can evoke these biases and lead to spurious improvement. For example, measured compliance can be increased by using an auditor who works on the unit (observer bias and Hawthorne effect); delaying audits on poorly performing units (selection bias); or instructing the auditor to actively inform health care workers that their hand hygiene compliance is being monitored (Hawthorne effect).

Hospitals may have good reasons for selecting an auditing method that will overestimate compliance. For example, audits may be delayed on poorly performing units to allow time to implement quality improvement or auditors may inform health care workers they are being auditing because they believe it is unethical to monitor covertly. However, as the pressure to perform increases, organizations seeking rapid improvement will be more likely to maintain or substitute methods that overestimate compliance than to use methods that measure true (ie, worse) compliance because doing so would make their hospitals appear to be underperforming relative to their peers. With no simple evidence-based improvement strategy available and with a plethora of indicator-based improvement strategies from which to select, the public reporting of hand hygiene compliance should lead to an increase in the use of indicator-based improvement strategies.

Ontario provides a real-world example. In 2009, reporting hand hygiene compliance became mandatory for all 211 Ontario hospitals, and 2 years of data on individual hospital performance are now publicly available.⁹ Median compliance with hand hygiene performed before patient contact (or contact with a patient's environment) increased from 52% to 67% in the second year of reporting and levels were even higher for compliance after patient contact.⁹ Considering that a recent systematic review reported a median level of hand hygiene compliance of 21% for hand hygiene before patient contact,¹⁰ these results are remarkable. Additionally, although credible studies describing sustained levels of overall hand hygiene compliance exceeding 80% are scarce,³ 23% of Ontario hospitals reported hard hygiene compliance before patient contact above this threshold, including 6 hospitals with before-contact compliance greater than 95%. The high and rapidly increasing levels of hand hygiene compliance in Ontario are more consistent with indicator-based improvement than evidence-based improvement strategies, although only time and a lack of improvement in HAI rates can confirm this hypothesis.

If indicator-based improvement strategies predominate, they may undermine the incentive to achieve substantive, evidence-based improvement. Consider the situation at Ontario hospitals that report top performance. Even if HAI rates remain high, what would motivate health care workers or administrators to develop, fund, and operate quality improvement efforts for hand hygiene when compliance is already nearly perfect? Conversely, hospitals with poorer performance will find the pressure to improve rapidly escalating as patients, hospital boards, and the media ask why compliance is better at other hospitals. As additional hospitals switch from evidence-based to indicator-based improvement strategies in order to achieve rapid improvement, a vicious cycle of pseudoimprovement is created with resources increasingly directed away from the evidence-based improvement strategies most likely to benefit patients.

Public reporting of hand hygiene compliance places clinicians in a position in which they must choose between protecting patients by striving for real hand hygiene improvement or protecting their reputations by reporting high rates of hand hygiene compliance. The first path is difficult and often unsuccessful. To encourage progress along this path, it would be better to avoid public reporting before evidence-based improvement strategies are implemented and direct resources toward identifying better ways of measuring and improving hand hygiene.