A potential limitation to the validity of the assessment tools the pdc relies upon:

Behav Anal Pract. 2021 Mar; 14(1): 51–57.

Abstract

Poor hand hygiene in hospital settings leads to the spread of communicable disease to a population of individuals already medically compromised. The current study used the Performance Diagnostic Checklist-Human Services to develop an intervention targeting hand hygiene compliance for nine participants employed by an inpatient unit. The use of performance feedback and goal setting improved hand hygiene compliance when compared to baseline for eight of nine participants. Results are discussed in terms of strategies for using performance analysis to identify effective interventions to address performance deficits.

Keywords: Performance Diagnostic Checklist-Human Services, performance feedback, task clarification, hand hygiene

Practicing hand hygiene is both a simple and effective way to prevent infections and the spread of germs (Centers for Disease Control and Prevention [CDC], 2016). The CDC promotes two hand hygiene methods: washing with soap and water and using alcohol-based hand sanitizer. For healthcare providers, alcohol-based hand sanitizers are considered one of the most effective products for reducing bacterial load (Syverson, 2006). In a hospital setting, hand hygiene is to be performed before eating, before and after direct contact with patient’s skin, after contact with blood, body fluids or excretions, mucous membranes, or wound dressings, after contact with objects in the immediate area of the patient, when hands move from a contaminated body site to a clean body site during patient care, after glove removal, and after using a restroom (Fox et al., 2015; Mathur, 2011). Hospital-based studies have indicated that noncompliance with hand hygiene has resulted in health care-associated infections, the spread of multidrug-resistant organisms, and has significantly contributed to illness outbreaks (CDC, 2013). In fact, these health care-associated infections affect nearly 1.7 million patients annually with one in 17 of these patients dying from the infection (Haque, Sartelli, McKimm, & Abu Bakar, 2018). Despite these serious concerns, the CDC reports that healthcare providers clean their hands less than half of the times they should.

Because of this enormous discrepancy, much research has been dedicated to determining intervention that improves poor hand hygiene compliance in hospital settings. Generally, these studies evaluated the effect of education (Abdella et al., 2014; Gluck et al., 2010), occupation (e.g., nurses, physicians; Duggan et al., 2008; Teker et al., 2015), modifying the environment (e.g., making sinks more easily accessible; Lankford et al., 2003; Rynga, Kumar, Gaind, & Rai, 2017), peer modeling (Lankford et al., 2003), and performance feedback (Luke & Alavosius, 2011). Each study, and others, have shown improvement on hand hygiene compliance within their hospitals. The variability in interventions used to improve hand hygiene may indicate, that there is no standard intervention for hospitals to rely upon to improve hand hygiene. It is most likely that intervention strategies to improve hand hygiene differ between hospitals and likely within hospital units too. That is, two medical floors with different staff on each floor may need a different intervention to improve hand hygiene compliance. With this variation, it is essential that healthcare leaders identify assessment strategies to rapidly diagnose reasons for performance deficit and prescribe intervention to improve hand hygiene within their hospitals.

The Performance Diagnostic Checklist-Human Services (PDC-HS; Carr & Wilder, 2015; Carr, Wilder, Majdalany, Mathisen, & Strain, 2013) is an assessment tool to identify the function of performance deficits within human services organizations. It is a refinement of the original PDC (Austin, 2000) to target human services organizations. The PDC-HS is comprised of 20 items divided into four sections: (a) Training; (b) Task Clarification and Prompting; (c) Resources, Materials, and Processes; and (d) Performance Consequences, Effort, and Competition. The four sections of the PDC-HS contain four-to-six, yes or no, items about task performance. These items are administered via interview with a key stakeholder and via direct observation of the target behavior. The percentage of items in each section responded to as “No” helps produce a determination as to which category needs to be addressed. Interventions selected are based on the results of each domain of the PDC-HS (see Carr et al., Intervention Planning p. 30 for full table). The PDC-HS has been successfully applied to develop interventions that improve performance deficits in areas like setting up therapy rooms (Carr et al., 2013), error correction procedures (Bowe & Sellers, 2018), and job performance (Smith & Wilder, 2018).

Prior research indicates that indicated interventions or interventions based on the results of the PDC-HS are more effective than nonindicated intervention or interventions not based on the PDC-HS (Carr et al., 2013; Ditzian et al., 2015; Bowe & Sellers, 2018; Wilder, Lipschultz, & Gehrman, 2018). The PDC-HS was first used by Carr et al. (2013) to address inadequate cleaning of treatment rooms by staff in a center-based autism program. A PDC-HS indicated intervention was compared to a nonindicated intervention. The results of the study indicated that the nonindicated intervention was ineffective at improving staff behavior and the indicated intervention was effective.

Ditzian, et al. (2015) extended the research of Carr et al. (2015) and compared a PDC-HS indicated intervention and a nonindicated intervention in addressing staff inadequate securing of doors in a clinical setting. The results demonstrated that the indicated intervention was effective while the nonindicated intervention was ineffective. Bowe and Sellers (2018) used a PDC-HS indicated and a nonindicated intervention to address paraprofessionals’ inaccurate implementation of error correction during discrete trial teaching. The results indicated that mastery criteria was met following the indicated intervention but not following the nonindicated intervention. Wilder,

There have been no studies using the PDC-HS to inform intervention targeting hand hygiene in a hospital setting. The use of this tool may be particularly important given the variability in interventions used to improve hand hygiene compliance. Of the interventions that are commonly implemented to improve hand hygiene, performance feedback may be most desirable. Some of the interventions, such as the professional discipline, improving locations of sinks, or the type of education staff receive on hand hygiene opportunities are not within the control of hospital leaders (Phan et al., 2018). Performance feedback, though, is a concrete intervention that can be conducted with minimal time investment. Mangiapanello and Hemmes (2015) defined performance feedback as a statement that specifies characteristics of a prior response via multiple modalities (e.g., verbal statements; written notes; public display of information). Luke and Alavosius (2011) provided personalized written and verbal feedback regarding participant hand hygiene within 30 s of exiting a patient’s room. Results of this study indicated that hand hygiene increased by applying this technique. Recently, Choi, Lee, Moon, and Oah (2018) compared the efficacy of prompts (using signs posted in bathroom) and feedback (counting the number of people washing their hands in a day) in improving the frequency of handwashing practice. They observed that feedback was more effective than prompts in promoting handwashing practice in both men’s and women’s restrooms.

While performance feedback may be effective in some instances there are several cases in which it has not been effective (Alvero, Bucklin, & Austin, 2001). In an analysis of the use of feedback in research published between 1985 and 1998, Alvero and colleagues showed that feedback alone was consistently effective in 9 of 19 studies published. Thus, it is unclear under what conditions feedback alone is most effective and, thus, should not be the default intervention for hand hygiene compliance. Performance analysis may be necessary to clarify under what conditions performance feedback is an indicated intervention.

In summary, hospitals have struggled to identify an assessment method to diagnose hand hygiene compliance problems. One intervention that has received attention is the use of performance feedback. However, the conditions under which performance feedback is a helpful intervention to increase hand hygiene compliance is unclear. Thus, one purpose of the current study was to determine if performance feedback would be a matched intervention to improve hand hygiene following PDC-HS administration. If this was the case, we wanted to extend the two-previous single-case analyses of the effect of performance feedback on improved hand hygiene compliance with a larger group of participants.

Method

Participants, Setting, and Materials

Nine participants employed by a specialized child/adolescent psychiatric inpatient and partial hospitalization unit providing multidisciplinary treatment to children diagnosed with intellectual and developmental disabilities participated in this study. Three of the participants had a master’s degree and six participants had a bachelor’s degree in Psychology or a related field. Hand hygiene auditing occurred as part of routine practice on the psychiatric unit. Each participant received a 20-min didactic presentation on the conditions under which hand hygiene should occur when working with patients admitted to the psychiatric unit. Additionally, announcements at quarterly staff meetings provided notice of hand hygiene auditing to each participant. Participants were told that auditing included both covert observation of hand hygiene (non) compliance and opportunities for feedback to improve compliance. This research was reviewed and approved by the Colorado Multiple Institutional Review Board.

There were three classrooms (4.5 m x 6.1 m) in the psychiatric unit. Two wall-mounted hand sanitizer dispensers that were equidistant from each classroom were in the hallways of the unit. Participants received a personal hand sanitizer that was attached to their respective name badges. The participants had free access to additional personalized hand sanitizers as needed. There was also one sink with soap in the cafeteria and each classroom.

Dependent Variable, Measurements, and Interobserver Agreement

The dependent variable for the current study was hand hygiene compliance. Hand hygiene was defined as one of three behaviors: (a) the participant placing their hand underneath a hand sanitizer dispenser (thereby activating the dispenser) and rubbing their hands together, (b) the participant squirting hand sanitizer from their personal dispenser into their hands and rubbing, or (c) the participant squirting soap onto their hands and rubbing under water for any length of time. For participants to meet compliance, hand hygiene must have occurred when a participant entered or exited a door onto/out of the psychiatric unit or into/out of a classroom/patient bedroom on the psychiatric unit. Data on whether a participant engaged in hand hygiene compliance or noncompliance during each observation are depicted in Fig. ​2.

Hand hygiene compliance (C) or noncompliance (NC) during each observation for Participants 1 – 9

A member of the study team covertly observed the occurrence or non-occurrence of hand hygiene compliance from near a window or one-way mirror on the psychiatric unit. This practice permitted the study team to observe participants covertly and was the practice of the institution prior to the implementation of the study. Data were collected twice per day three times per week. While participants had opportunities to engage in hand hygiene any time they entered or exited a door onto/out of the psychiatric unit or into/out of a classroom/patient bedroom, only the first five hand hygiene opportunities that were observed by the experimenters during each observation period were recorded. Point-by-point interobserver agreement (IOA) was used to calculate reliability. Each observer’s data was hidden from the other observer. A member of the study team wrote down whether a participant did or did not wash their hands. If they agreed that a participant either did or did not wash their hands, this was counted as an agreement. Disagreements were counted if a study team member recorded a participant as having washed their hands when another study team member recorded the same participant as not washing their hands. IOA was collected on an average of 34% (range, 10 – 58%) of observations for each participant. IOA was 100% for all participants.

Experimental Design

A concurrent multiple baseline across participants design was used to evaluate the effect of performance feedback on improved hand hygiene.

Experimental Procedures

Didactic Presentation

The lead hand hygiene auditor for the institution provided a 20-min didactic presentation. The presentation explained where to find the hand sanitizing dispensers on the psychiatric unit and where to find the personal hand sanitizer dispensers. The auditor directed participants to use either mode of hand hygiene when entering or exiting a patient’s bedroom, classroom, or cafeteria on the psychiatric unit. This training occurred prior to the PDC-HS administration and baseline.

PDC-HS

One week prior to the beginning of baseline condition, a member of the study team completed the PDC-HS with a member of the organization who had previously been responsible for monitoring hand hygiene compliance (Carr & Wilder, 2015). They sat in a quiet office room to complete the PDC-HS survey. The PDC-HS is designed, in part, to be implemented by a behavior analyst during an interview with an individual that directly supervises or manages the employees. The rest of the items were collected by observing hand hygiene opportunities on the unit. These observations were conducted between 10:45 – 11:15am and again from 1:45 – 2:15pm.

Baseline

During baseline, participants were given personal hand sanitizer dispensers and directed to engage in hand hygiene as per the didactic presentation. Observations for each participant were conducted from 10:45 – 11:15am and again from 1:45 – 2:15pm three times per week. The first three participants were observed for five opportunities in one day, the second group of three participants were observed for ten opportunities across two days and the final group of three participants were observed for fifteen opportunities across three days to complete baseline assessment. These periods permitted observation of patient and participant transitions from classrooms to the cafeteria. Both the classrooms and cafeteria were equipped with windows and/or one-way mirrors that permitted the observers an unobstructed view of the rooms. The research team stood approximately 3.05 m away from each other in the hallway of the psychiatric unit and in a place where they could look through the windows to covertly observe hand hygiene compliance. No feedback was delivered to participants contingent on the occurrence or nonoccurrence of hand hygiene compliance.

Performance Feedback and Goal Setting

This condition began immediately following the baseline condition. During performance feedback, the participants were given a written notification that reiterated the hand hygiene compliance goal for the institution (93%), the hand hygiene compliance percentage for the psychiatric unit, and their personal hand hygiene compliance percentage at the beginning of their first scheduled shift after completing baseline. The latter percentage was based on the previous day the participant was observed. One member of the research team delivered the written notification to participants. The other members of the research team never delivered the written notification to remain anonymous to the participants. No other information regarding when to engage in hand hygiene or discussion about participant data occurred. That is, participants did not receive feedback on their performance immediately after opportunities for hand hygiene. Following the delivery of feedback, the research team continued to collect data in an identical manner to baseline. The length of this phase for each participant was dependent upon responding and ranged from two to five days. Each participant remained in this condition until stable responding was observed.

Task Clarification

For Participant 7 only, additional task clarification was implemented after inconsistent response to performance feedback only. Specifically, the participant was informed that hand hygiene opportunities included entering and exiting patient care areas, such as patient rooms, cafeteria, and classrooms and before and after patient contact.

Maintenance

After completing the initial evaluation of the effectiveness of performance feedback, we re-implemented this intervention for one day after a 1-wk delay. Procedures were the same as described in the Performance Feedback condition in which the participants received written feedback with their personal percentage being the percentage of compliant hand hygiene opportunities of the most recent five observations.

Results

Figure ​1 represents data from the PDC-HS administration. Performance Consequences, Effort, and Competition was rated highest with 80% “No” responses. Resources, Materials, and Processes was next highest (40%) followed by Task Clarification and Prompting (20%), and Training (0%) last.

Results from the administration of the Performance Diagnostic Checklist-Human Services

Figure ​2 represents data from all nine participants during baseline and following performance feedback. Participants 2 and 3 did not engage in hand hygiene during baseline, Participant 1 engaged in hand hygiene 20% of the time. In the second group of three participants, Participants 4 and 6 engaged in appropriate hand hygiene during an average of 10% of opportunities while Participant 5 engaged in appropriate hand hygiene on an average of 30% of opportunities. During baseline, Participants 7, 8, and 9 practiced appropriate hand hygiene on average 13%, 27%, and 53% of opportunities, respectively.

After implementation of performance feedback, Participant 1 engaged in hand hygiene an average of 90% of the time. Participant 2’s hand hygiene compliance gradually increased and averaged 69%. Over the last two day’s observations, though, hand hygiene increased to an average of 80%. Participant 3’s hand hygiene compliance immediately increased to 100%. Participant 4 engaged in hand hygiene compliance an average of 90% of the time. Participants 5 and 6 engaged in 100% hand hygiene compliance. With performance feedback alone, Participant 7’s hand hygiene compliance averaged 25%. After clarifying the task, hand hygiene compliance increased to an average of 83%. Participant 8 and 9’s hand hygiene compliance was 100%. During the 1-week follow-up, all nine participants engaged in hand hygiene compliance 100% of the time.

Discussion

The current study interviewed a team leader using the PDC-HS to determine variables contributing to poor hand hygiene compliance on a psychiatric unit. Results of the PDC-HS indicated that performance deficits in hand hygiene were flagged by the Performance Consequences, Effort, and Competition category. General interventions informed by this category would include adding or changing consequences for desired performance (incl. performance feedback), decreasing response effort required to engage in the performance, or removing tasks that compete with engaging in the desired performance. We selected performance feedback and goal setting as a form of performance consequence to improve hand hygiene compliance (Arco, 2008). The intervention consisted of a written note with personal hand hygiene compliance percentage, unit specific compliance percentage, and institutional goal percentage. Eight of nine participants’ compliance improved following performance feedback. One participant required task clarification before hand hygiene compliance improved. The need for additional training may have been due to the staff member not understanding the institutional definition of opportunities when hand hygiene was required. For this reason, Participant 7 received clarification on hand hygiene expectations and continued feedback.

There are a variety of potential interventions to improve hand hygiene compliance in hospital settings. One single-case analysis showed performance feedback was an effective intervention for hand hygiene compliance in a hospital setting (Luke & Alavosius, 2011). Research has shown, though, that even similar settings can need different interventions to improve the same target behavior. For example, Ditzian, Wilder, King, and Tanz (2015) and Carr et al. (2013) identified different domains of the PDC-HS to improve upkeep of outpatient therapy rooms. Thus, it was important to evaluate the domain of the PDC-HS most related to poor hand hygiene on our hospital unit. Results showed performance feedback would be an appropriate intervention based on our PDC-HS administration. To extend previous investigations, we recruited a larger group of participants to evaluate the effect of performance feedback on improvements in hand hygiene compliance using a multiple baseline across participants design. Performance feedback and goal setting alone resulted in improved hand hygiene compliance for eight of nine participants. A combination of performance feedback, goal setting and task clarification improved performance of the last participant.

The institutional goal for hand hygiene was set at 93% compliance. Of the participants enrolled in this study, only five met this goal. Taken together, these nine participants achieved 86.9% hand hygiene compliance after intervention (119 instances of appropriate hand hygiene divided by 137 total opportunities for hand hygiene). Thus, the unit did not meet the goal set by the institution. However, each participant’s behavior improved from their baseline performance. A natural question that emerges from this discrepancy is whether 86.9% compliance is practically worse than 93% compliance. This issue may be particularly relevant considering hand hygiene compliance should occur on 100% of opportunities. Research is needed to determine at what level of hand hygiene most protects against the spread of communicable disease to inform institution-wide initiatives like this (Boyce & Pittet, 2002). Until then, research is needed to identify strategies to improve hand hygiene compliance to closer to 100%. It could be that performance feedback plus another intervention component, such as task clarification, is necessary to achieve higher hand hygiene compliance (Alvero, et al., 2001).

The current study should be interpreted considering several limitations. First, replications of the current study that uses the PDC-HS to determine intervention for hand hygiene should occur. The PDC-HS may be an unnecessary step if performance feedback is always an indicated intervention. Similarly, it would be helpful to evaluate hand hygiene compliance when an indicated intervention based on the PDC-HS is compared against a contraindicated intervention. A second limitation is that participants were recruited from only one unit of the institution. This may limit the generality of these findings to other settings. A third limitation is the inclusion of goal setting within the performance feedback. This intervention was not indicated by the PDC-HS and limits the conclusions that can be made about performance feedback alone being responsible for the improvement in hand hygiene compliance. Future research should continue to evaluate if the PDC-HS identifies performance feedback as a matched intervention to improve hand hygiene compliance across other units and institutions. A fourth limitation was that the length of the study was quite short. Future research should evaluate maintenance of responding across longer periods than 1 week. A final limitation lies in the way in which feedback was given in the current study. Feedback contained several components including the personal compliance percentage, the specific unit percentage, and the institution goal percentage. These components were presented together, and it is unclear which aspect or aspects of this feedback served to change behavior. Future research should utilize a component analysis to determine which aspect of feedback impacts behavior.

Compliance with Ethical Standards

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors. Informed consent was obtained from all individual participants included in the study. The authors declare that they have no conflict of interest.

Footnotes

Utility of Work for Practitioners and Researchers

1) Discussion of the importance for hand hygiene and identification of strategies to improve hand hygiene in hospital settings.

2) Demonstration of the use of the Performance Diagnostic Checklist-Human Services (PDC-HS) to determine variables contributing to hand hygiene noncompliance.

3) Demonstration of clinical evaluation to evaluate environmental modifications to improve hand hygiene compliance.

4) Recommendations for practitioners and researchers interested in using PDC-HS to address performance deficits in human services organizations.

Author Note

This project was completed in partial fulfillment of the first author’s Comprehensive Examination. The authors extend their gratitude to Amanda Mahoney, Annette Griffin, and Jack Spear for their valuable guidance

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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