How one hospital in India improved hand washing among parents of high-risk newborns

Ankur Sooden

Senior Improvement Advisor, India, USAID ASSIST/URC

(Parents practice good hand hygiene in the newborn intensive care unit of Ram Manohar Lohia Hospital in India. Photo by Ms. Ravleen Kaur, RML Hospital, New Delhi)

Today is WHO Hand Hygiene Day (May 5).

The newborn intensive care unit (NICU) at Ram Manohar Lohia Hospital, a central government hospital in New Delhi, provides highly specialized care to sick and high-risk newborns. To address issues of short staffing, the hospital began encouraging parents and other caregivers to be intensively involved the provision of care for their babies. This also provided these babies with much-needed emotional support that is often lacking in intensive care settings. Unfortunately, it also posed a high risk of infections being carried into the unit by caregiving attendants.

All babies are at risk for infections, but the premature, sick, or low birth weight infants in the NICU are particularly vulnerable – for these babies, a simple infection can quickly become life-threatening.  

Washing hands while entering the unit is a simple and effective way of preventing infections. To prepare parents and other caregivers to work as health attendants, hospital staff conducted a daily orientation for them, which included a session on what hand hygiene practices to follow when entering the NICU. Nonetheless, despite the orientation and training, they continued to observe poor hand washing practices among parents and caregivers.

In May 2016, the head of the NICU attended a workshop on quality improvement (QI) organized by WHO’s Southeast Asia Regional Office (SEARO) and USAID, led by staff from All India Institute of Medical Sciences (AIIMS) and the USAID ASSIST Project. Motivated by the successes achieved in other hospitals, she decided to try using improvement methods to encourage better hand washing – and safer engagement – of parent attendants in the NICU.

An initial assessment showed that only around 20 percent of attendants were complying with hand hygiene standards when entering the unit. The QI team, consisting of three nurses and two unit coordinators, set a goal of increasing this to 80 percent within eight weeks.  

To understand the process of washing hands properly, team members mapped the process by washing their own hands. They also began observing parents and caregivers to understand the steps being followed during entry.

These two exercises highlighted challenges related to attendant flow – since the changing room, handwashing station, and entrance were not located in sequence. A planned shift to a new building provided the team an opportunity to fix workplace organization and attendant flow issues. Learning from the observations, they organized this new unit in a manner that made it easy for attendants to comply with hand hygiene: the handwashing station, along with soap, towels, and gowns were now kept in a linear sequence.

Three weeks into their hand hygiene intervention, the team found it difficult to find causes for poor compliance and to develop new ideas to improve. Pressed with the question of why attendants would not comply, they conducted individual and group interviews with some parents and caregivers to analyze the problem further.  The interviews showed that attendants believed they were cleaning their hands properly – but they, in fact, were not.

Understanding that it was the attendants’ lack of skills rather than lack of intent that was responsible for poor hand washing, the team began focusing on how to build these skills.

It’s important to remember, when conducting an improvement intervention, that not all change ideas are good ideas. The team at Ram Manohar Lohia Hospital found success in changes like making the hand wash training more interactive and engaging peer mentors to demonstrate good practices to other parents.

However, asking parents and caregivers to supervise their peers and provide feedback on handwashing led to negative feelings and discouragement among attendants as did sharing video footage of individuals’ handwashing with them during a training session and asking them to self-evaluate their hand hygiene. The team responded quickly to this feedback and adjusted their approach to share only video footage of handwashing by attendants who were not present in a given training session, an arrangement the attendants found more agreeable.

At the end of the two months, the team achieved their improvement aim: 80% of attendants were now following standard hand hygiene practices when entering the NICU. By improving hand washing among parents and other caregivers, Ram Manohar Lohia Hospital has ensured that the high-risk newborns in their NICU receive the emotional care they need – while reducing their risk of infection.

Learn more about the changes Ram Manohar Lohia Hospital instituted to improve hand hygiene.

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