Improving Hand Hygiene Compliance through Collaborative Computational Design
Event Type
Oral Presentations
TimeThursday, June 9th11:30am - 12:00pm EDT
DescriptionHand sanitization by healthcare staff remains one of the most effective ways for controlling infection in healthcare settings. However, predicting faithful adherence to hand hygiene compliance (HHC) is difficult in complex environments such as acute care settings. The main challenge is understanding how different human and built systems components interact to achieve specific goals such as HHC at the critical moments of care delivery. The explorative research presented in this session aims to evaluate how Human Factors derived visual salience cues and proximity-compatibility principles might be used in the design of healthcare spaces to support nurse moments of HHC. This presentation will discuss how Collaborative Computational Scenario Planning (CCSP) Models can be used to determine the weighted integrative effects of reinforcing and detracting operational and environmental factors on discrete moments of HHC. The multi-disciplinary team conducting this study is composed of experts in research related to architecture, interior design, systems science/engineering, and health system infection control specialists and nurses. Supervised Machine Learning analysis was conducted on the HHC in various acute care units collected by a large academic medical center spanned from 2017 to 2021 to compute Fuzzy Cognitive Model Edge Probabilities between Hand Hygiene (HH) cues and observed HHC at key moments. Infection control experts were engaged in identifying the weight of various reinforcing and detracting operational and environmental factors. Combining the quantitative and qualitative methods, the team developed integrative CCSP models that allow hospitals to develop targeted planning improvements for better HHC that support safer patient care.
An incentive for conducting this ongoing study is due to clinical staff compliance to hand hygiene campaigns, which has proven to be inconsistent and thus marginally effective in reducing harmful microorganism spread within healthcare settings due to challenges in staff adherence [6]. Research on HHC rates performed by external analysts on a sample of different health systems reported that clinical staff's HHC rates in those hospitals were less than 50% despite widespread education and adoption campaigns [8]. This lack of consistent hand hygiene behavior appears to be multifactorial in nature. However, several studies suggest that adherence to HHC is difficult in complex environments such as acute care settings due to the high workload intensity [9,10]. In 2009 the World Healthcare Organization (WHO) introduced “My 5 Moments for Hand Hygiene” to guide safe hand sanitization practices in healthcare. This concept is based on the ecological visualization of key moments for hand hygiene within the “patient zone” of a healthcare environment [7]. Hand Hygiene Compliance (HHC) rates are typically audited and evaluated at these 5 moments of HH. These findings suggest that providing human-centered environmental affordances and strategic resources responsive to clinical workload may help to reinforce reliable HHC by clinical staff.
Despite a growing body of evidence, to date, there is little study into how EOC can be better designed to moderate the spread of infection within patient care and treatment settings. There has also been minimal investigation into how we can identify and analyze the interactive effects between different components of EOC and operational causal factors that reinforce or degrade clinical staff’s adherence to the practice of HHC at critical moments of care delivery. Theoretical concepts endemic to Human Factors have been recognized for offering a viable basis of design frameworks for “error proofing” healthcare processes and systems [11]. For example, the HFE-derived principle of “salience” within the context of environment design refers to the visual distinctiveness of an object with respect to its surroundings[14]. Similarly, the proximity-compatibility principle (PCP) used in Human Factors design characterizes the immediate visual closeness of designed behavior-support mechanisms information related to user’s tasks[15] Cue salience and PCP within environments support “task ecology” in that the displayed resources with performance-related purposes are both discoverable and easily interpretable within the environmental domain where users knowledge, skills, abilities are guiding work behavior[16]. There is substantive research that indicates that both Environment of Care (EOC) design features and the care delivery process play a significant role in pathogen transfer to vulnerable patients. Several studies in HHC have shown that environmental factors such as visual salience, visibility, accessibility, distance, and ergonomics of hand sanitization dispensers can influence hand sanitization behaviors [17–19]. These HFE constructs offer the potential for ascertaining what changes would be useful to current work processes and environment and offer a basis for scenario modeling where interventions can be introduced and evaluated for their ability to influence HHC performance rates.

An overlooked but potentially useful method for evaluating noncompliance to hand hygiene error is to consider how design features and planned resources within the EOC affect the probability for HHC moments through simulated care delivery scenario planning.
The three primary questions guiding this research will be presented during this session and are as follows:
• What is the probability of HH non-compliance risk at different key HH moments in acute care settings?
• What are the effects of environmental factors of EOC on improving or detracting nurses’ HHC moment probability levels in acute care settings?
• What Human Factors-derived detracting and reinforcing variables (e.g., visual cue salience and PCP) within an EOC have the greatest centrality and influence on nurse HHC during the care delivery process?
The focus of simulations produced by this study is the modeling of reinforcing and detracting factors within the EOC and their effect on nurse critical moments of HHC. Preliminary pilot studies were performed by the research team using TUKHS IDEA data on hand hygiene compliance indicates that compliance rates by nursing staff across progressive care units remain consistently close to 90%. However, adjusted observed probabilities appear to vary between discrete critical HHC moments based on the unit context. These probabilities were then used to calculate weighted probabilities between HH cue moment facilitator and observed HHC at key moments. Using HHC Moment Concept [C] variable probabilities obtained from Machine Learning Logistic Regression outcomes and quantifying coded Reinforcer [R] and Detractor [D] heuristic variables estimated by Infection Control Subject Matter Experts (SME) allowed for the computation of Fuzzy Logic consequent Edge Probabilities that were used for FCM construction. Preliminary Fuzzy Cognitive Mapping (FCM) analysis of environmental factors in TUKHS Medical/Surgical units indicated that the integrative effects of environmentally based factors within the EOC such as “Salient Decision Aids” and “Proximal HSD” had a high degree of centrality in a matrix of critical moments of HHC Concept, Reinforcing, and Decrement Variables (5.6 and 4.3 respectively). Additionally, a proportionate increase of the level of influence of Salient Decision Aids and Proximal HSD variables scenario within the FCM matrix suggests improvements to observations of HHC concepts.