Hand Washing as a Nursing-Sensitive Quality Indicator

Introduction

Reports of superbug infections in hospitals and highly infectious diseases in underdeveloped countries heighten the importance of standard sanitation techniques. Moreover, reimbursement rates for hospitals are increasingly tied to the achievement of specific patient care outcomes, a change that has made healthcare quality more important for all stakeholders. Standard technique in hand washing, skin preparation, and wound dressing is core to quality patient care, yet the literature and the media point to an increasingly pervasive degradation in this area (Szilagy, 2013). Standard sanitation technique is unquestionably a nursing-sensitive quality indicator, as nurses are universally engaged in these processes and procedures in some capacity.

The literature indicates that improper hand hygiene among clinicians is one of the major contributors to healthcare-associated infections (HAIs), and that 7.1% of hospital admissions in developed countries involve HAIs. The annual death toll from HAIs is roughly 150,000 people in Europe and 100,000 in the United States. These figures are staggering when one considers that both European and U.S. standards for hand hygiene in healthcare have been developed according to recommendations from the World Health Organization (WHO). Indeed, the WHO standards include the definition of "5 crucial moments of hand hygiene and 6 practical hand rubbing steps through which alcohol-based hand rub solutions have been proven effective" (Szilagy, 2013).

What Are Nursing-Sensitive Indicators?

The phrase "nursing-sensitive indicators" was first used by Maas, Johnson, and Moorehead (1996, as cited in Savitz et al., n.d.) as a way to make patient outcomes affected by nursing practice salient in the literature and in practice. The literature most frequently associates nursing-sensitive indicators with outcomes that are negative — either less desirable or even adverse (Needleman et al., 2001, as cited in Savitz et al., n.d.). Needleman et al. (2001) suggest that this is the case because it is considerably more difficult to associate nursing care with positive outcomes, since these are rarely documented in medical records or in administrative data sets.

Attribution is rarely simple and straightforward, and it is certainly complicated in the context of healthcare, where multiple stakeholders interact and respond to situations that are commonly in flux. In an effort to address the dynamic aspect of attribution and simultaneously recognize the potential and actual substantial contributions of nursing in the delivery of clinical care, Needleman et al. (2001) suggest using the phrase "outcomes potentially sensitive to nursing."

Data Sources for Nursing-Sensitive Quality Indicators

Administrative databases are common sources of data for patient care quality indicators. As with any data source used to assess performance, there are a number of drawbacks to using administrative data to examine the quality of care delivered by healthcare providers. Given the variety of uses for aggregated information in administrative databases, it is readily apparent that the specificity and focus of those uses may differ entirely from the focus required when data is used to inform quality indicators. Administrative databases are foundational to billing and payment for hospital services and typically contain information from the discharge claim. They are structured according to a standardized electronic format common to all hospitals billing for services. Healthcare quality research, evaluation, public reporting, and quality improvement initiatives all access these forms of aggregated administrative data.

The convention for structuring and organizing patient information in administrative databases includes the following: patient "gender, age, diagnoses, procedures, length of stay, admission source, discharge status, total charges, primary payer, and hospital identifier" (Farquhar, n.d.). In addition, information about "race, county or ZIP Code of residence, secondary payer, detailed charges, and identifier of primary physician or surgeon" may also be included (Farquhar, n.d.).

It is significant that the format of data collected and the quality of that data differ across the applications and platforms used for data collection, as well as among medical institutions. Differences may be seen in the format of data detailing the number and sequencing of diagnosis and procedure codes; different institutions may also use diverse methods for audits and edits applied to data both before and after submission, as well as to the data values that are accepted. From this, the value of the AHRQ Quality Indicators becomes evident, since the QIs are based on data that is widely available and can readily be used to assess quality. Specifically, AHRQ quality indicators are uniformly defined and established through standardized algorithms that are adaptable to "virtually any administrative data set" (Farquhar, n.d., p. 8). Because of this, comparisons can be made across hospitals, communities, regions, and even states.

Hand Washing as a Nursing-Sensitive Quality Indicator

Accomplishing adequate and appropriate hand washing using standard technique is closely associated with positive patient outcomes. It has been shown to prevent the spread of disease, reduce the risk of cross-contamination, and contribute to environmental conditions that promote healing and help avoid adverse patient outcomes. The hand washing practices of nurses matter: the consistent use of standard technique in every relevant clinical situation is a meaningful quality indicator. Education and training of clinicians about proper hand washing standard technique is vital to improving hand hygiene compliance and to safeguarding patients' well-being.

Conclusion

Standard hand washing technique is a demonstrably important nursing-sensitive quality indicator with direct implications for patient safety. The evidence reviewed here underscores that compliance training, systematic monitoring, and standardized measurement are essential to reducing healthcare-associated infections. Nurses consistently outperform other clinician groups in hand hygiene compliance, reinforcing the centrality of nursing practice to this quality indicator. Continued investment in WHO-aligned training protocols and rigorous use of AHRQ quality indicator frameworks will remain critical to improving outcomes across healthcare settings.