Evaluation of Barriers to Audit-and-Feedback Programs That Used Direct Observation of Hand Hygiene Compliance: A Qualitative Study

IMPORTANCE: Audit and feedback based on direct observation is a common strategy to improve hand hygiene compliance, but the optimal design and delivery of this intervention are poorly defined. OBJECTIVE: To describe barriers encountered by audit-and-feedback programs for hand hygiene across acute care hospitals within the Veterans Health Administration. DESIGN, SETTING, AND PARTICIPANTS: A qualitative study was conducted at a geographically diverse convenience sample of 10 acute care hospitals within the Veterans Health Administration. Participants included 108 infection prevention team personnel and frontline staff. All data were collected between June 30, 2014, and March 18, 2015. Data were analyzed between September 6, 2017, and January 5, 2018. MAIN OUTCOMES AND MEASURES: Barriers to audit and feedback for hand hygiene compliance were evaluated. Semistructured interviews of key personnel were performed through site visits at 6 locations and telephone interviews with 4 sites. Focus groups were conducted with frontline staff. Interviews and focus groups were audio recorded and transcribed. All transcripts were analyzed using thematic content analysis. RESULTS: Overall, 108 individuals participated in the study. Semistructured interviews were conducted with 38 individuals, who were predominantly infection prevention team members. Focus group interviews were conducted with 70 frontline hospital staff members. Surveillance activities at all 10 sites made use of a variety of staff members with the intention of covertly collecting direct observations on hand hygiene compliance. Monitoring programs were challenging to maintain because of constraints on time and personnel. Both auditors and frontline staff expressed skepticism about the accuracy of compliance data based on direct observations. Auditors expressed concern about the Hawthorne effect, while frontline staff were worried that their compliance was not visible to auditors. In most hospitals, approaches to monitoring hand hygiene compliance produced friction between frontline staff and infection prevention teams. The feedback process for audit results did not consistently reach frontline staff and, in many hospitals, did not seem to facilitate improvement efforts. CONCLUSIONS AND RELEVANCE: Auditing hand hygiene compliance with direct observation was problematic across these acute care hospitals. Auditing was perceived to collect inaccurate data and created tension with frontline staff, and the feedback process did not appear to encourage positive change. Strategies are needed to collect more reliable hand hygiene data and facilitate multidisciplinary collaboration toward improved compliance.