Disentangling quality and safety indicator data: a longitudinal, comparative study of hand hygiene compliance and accreditation outcomes in 96 Australian hospitals
Mumford, V and Greenfield, D and Hodgen, A and Debono, D and Gospodarevskaya, E and Forde, E and Westbrook, J and Braithwaite, J, Disentangling quality and safety indicator data: a longitudinal, comparative study of hand hygiene compliance and accreditation outcomes in 96 Australian hospitals, B M J: (British Medical Journal), 4, (9) pp. 1-8. ISSN 0959-535X (2014) [Refereed Article]
Objectives: The study aims are twofold. First, to
investigate the suitability of hand hygiene as an
indicator of accreditation outcomes and, second, to
test the hypothesis that hospitals with better
accreditation outcomes achieve higher hand hygiene
Design: A retrospective, longitudinal, multisite
Setting: Acute public hospitals in New South Wales,
Participants: 96 acute hospitals with accreditation
survey results from two surveys during 2009–2012
and submitted data for more than four hand hygiene
audits between 2010 and 2013.
Outcomes: Our primary outcome comprised
observational hand hygiene compliance data from eight
audits during 2010–2013. The explanatory variables in
our multilevel regression model included: accreditation
outcomes and scores for the infection control standard;
timing of the surveys; and hospital size and activity.
Results: Average hand hygiene compliance rates
increased from 67.7% to 80.3% during the study period
(2010–2013), with 46.7% of hospitals achieving target
compliance rates of 70% in audit 1, versus 92.3% in
audit 8. Average hand hygiene rates at small hospitals
were 7.8 percentage points (pp) higher than those at
the largest hospitals ( p<0.05). The association between
hand hygiene rates, accreditation outcomes and
infection control scores is less clear.
Conclusions: Our results indicate that accreditation
outcomes and hand hygiene audit data are measuring
different parts of the quality and safety spectrum.
Understanding what is being measured when selecting
indicators to assess the impact of accreditation is critical
as focusing on accreditation results would discount
successful hand hygiene implementation by smaller
hospitals. Conversely, relying on hand hygiene results
would discount the infection control related research and
leadership investment by larger hospitals. Our hypothesis
appears to be confounded by an accreditation
programme that makes it more difficult for smaller
hospitals to achieve high infection control scores.