Culture change isn’t about training, education and environment

Over the past decade lots of folks have been throwing around the term food safety culture to describe how a business operates. Education, training, equipment, tools, the environment, investment and support from higher-ups all influence how well an organization addresses risk, there’s something else that binds it together.

The culture, or value system, can be difference between having an outbreak or not. The values dictate decisions from the front-line staff to the CEO.

Maybe it’s the hippie in me but its sort of like the vibe of the organization that can be gauged by asking does anyone really care?

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And if they do, do they know what they should be caring about?

The health care world struggles with the same issues, with similar consequences. According to Yahoo News the Vanderbilt University Hospital dealt with a culture change around infection control. And it’s taken six years to turn things around.

Dr. Gerald Hickson had two primary concerns after his wife’s double-knee replacement operation at Vanderbilt University Hospital in July 2008: making sure she received appropriate pain control and getting her moving as quickly as possible to avoid blood clots. But as he sat with her during her recovery, Hickson made a disturbing discovery. Most of the nurses, doctors and other hospital workers filing in and out of the room to care for his wife, who was at risk of contracting an infection after surgery, were not washing their hands.

A compulsive person by nature, Hickson started counting. He found 92 instances when staff members should have soaped up or used antiseptic foam. The total number of times they actually did? 32. Hickson did not want to humiliate anyone, but he was also fiercely committed to protecting his wife. With polite Southern collegiality, he calmly pointed out the 60 opportunities when staffers could have provided safer care but didn’t. Some staffers were immediately embarrassed. Several wondered if he was kidding, got defensive and offered explanations for their lapses. 

Hickson reported his findings to Dr. Tom Talbot, VUMC’s chief epidemiologist, and Talbot ran with it, spearheading an ambitious clean hands initiative that was launched in July 2009. Since then, hand-washing rates at Vanderbilt have jumped from 58 percent to 97 percent; at the same time, the number of several stubborn infections has dropped, one of them by as much as 80 percent. “We get into bad habits, all of us do, and sometimes we need somebody to remind us to get back on the right pathway,” says Hickson. “That’s the key to transforming health care.”

Talbot orchestrated a number of practical changes right away, including installing additional hand sanitizer dispensers at the entrance and exit of every patient’s room or bay and within easy reach inside. Staffers were instructed to clean their hands before and after every encounter with patients, even if all they planned to do was have a conversation. Even the smallest details were addressed. Clinicians who complained that their skin had become irritated by excess antiseptic gel were told to cut back to a dime-size portion, and moisturizing lotion dispensers were added throughout the hospital.

That was the easy part. Talbot knew that it would take an all-out culture shift to see dramatic improvement. A prior hand-washing program, which focused largely on education and random surveillance, had done little to boost rates. This time, Talbot drilled down on what he believed would be the keys to success: training, communication and shared accountability up and down the staff hierarchy.

Because the hospital’s top leadership would be the ultimate enforcers, Hickson and Talbot knew they needed buy-in before the program was officially launched. The old days of giving high-performing doctors a pass on unprofessional conduct — “Oh, that’s just Dr. So and So, that’s how he is” — would be over. Every hospital worker, no matter his or her rank, would be held to the same high standards. “We had to have support from leadership, so if we had pushback, we would elevate that up and they wouldn’t blink,” says Talbot. “Instead, they would say, ‘That’s not the kind of behavior we expect here.’”

Competition is a big motivator at Vanderbilt, too. Hand-washing scores for individual units and departments are tallied up from highest to lowest, and results are posted every month in break rooms and other staff areas so that everyone can see how his or her team compares with the one down the hall. “You want to look better than other services when that scorecard comes out,” says Johnson. “You don’t want to be at the bottom. That’s just human nature.”

Today, after more than 200,000 hand-washing observations, Vanderbilt’s overall hand-washing compliance rate has almost doubled. At the same time, three major types of infections linked to the insertion of tubes and catheters have been reduced considerably, according to Talbot. Urinary tract infections related to catheters in intensive care units have dropped by 33 percent; pneumonia linked to ventilators by 61 percent; and bloodstream infections associated with central lines — the tubing that delivers fluids and medications to patients — by 80 percent in ICUs.

Culture change is not about mission statements and core values written on a poster. It’s about fostering feelings within the organization from top-to-bottom that this stuff matters.

Sanitizers not enough says UK; wash hands after visiting the farm

The UK Public Health Agency (PHA) is reminding families about the importance of washing hands after visiting the farm.

petting.zoo.handwash.10All animals naturally carry a range of organisms, some of which can be transmitted to people. Some organisms which may be contracted on farms present a serious hazard and can potentially cause severe infection, particularly in young children.

To reduce the risk of illness, both adults and children should wash their hands thoroughly using soap and water after they have handled animals or touched surfaces at the farm and always before eating or drinking.

Antibacterial hand gels and wipes are not a substitute for washing hands with soap and water, as gels and wipes may be unable to remove contamination in the way that running water can. However, using such gels after hand washing with soap and water may reduce further the risk of picking up these infections.


Dr Philip Veal, Consultant in Health Protection at the PHA, said: “Farm animals often carry a range of organisms which can be passed to children and adults. These organisms can include serious infections such as E. coli O157 which is extremely contagious and easily passed from animals to children and then within the household.

“Hand washing with soap and water will reduce the risk of picking up these infections, which can be particularly harmful to young children. By being aware and by doing these simple things we can help to avoid illness and enjoy a fun day out.”

Best practices for planning events encouraging human-animal interactions

03.Apr.14

Zoonoses and Public Health

G. Erdozain , K. KuKanich , B. Chapman  and D. Powell

http://onlinelibrary.wiley.com/doi/10.1111/zph.12117/abstract?deniedAccess

Educational events encouraging human–animal interaction include the risk of

zoonotic disease transmission. It is estimated that 14% of all disease in the US caused by Campylobacter spp., Cryptosporidium spp., Shiga toxin-producing Escherichia coli (STEC) O157, non-O157 STECs, Listeria monocytogenes, nontyphoidal Salmonella enterica and Yersinia enterocolitica were attributable to animal contact. This article reviews best practices for organizing events where human–animal interactions are encouraged, with the objective of lowering the risk of zoonotic disease transmission.

Hawthorne effect: hand hygiene rates increase three-fold when auditors visible

Hand hygiene rates were found to be three times higher when auditors were visible to healthcare workers than when there were no auditors present, according to a study in a major Canadian acute care hospital.

handwash_south_park(2)The study, titled, “Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study,” published today on-line in the BMJ Quality & Safety Journal, by first author Dr. Jocelyn Srigley, who did the study as part of her Master’s thesis while a Clinical Fellow in Infection Prevention and Control at University Health Network and University of Toronto and senior author Dr. Michael Gardam, Director, Infection Prevention and Control, University Health Network and Women’s College Hospital. Link: http://qualitysafety.bmj.com/cgi/rapidpdf/bmjqs-2014-003080?ijkey=JPbRe7gYzAFsm1Z&keytype=ref

The study examined the Hawthorne effect, also known as observation bias – the tendency of people to change their behavior when they are aware of an observer – using an electronic monitoring hand hygiene system in real-time, eliminating many of the biases inherent to human observation. Ultrasound “tags” on soap dispensers transmitted a signal to a nearby receiver each time the levers were pushed, and a time-stamped hand hygiene wash was recorded in a central data base.

Two inpatient units in University Health Network were electronically monitored, with 60 healthcare workers volunteering to be part of a study of the electronic monitoring system. Staff were aware that data would be used in a variety of studies, but were “blind” to the questions asked in the studies. Auditors did not announce their presence during audits but wore white lab coats. Auditors were also blinded to the questions asked in the research. Hand hygiene dispenses were electronically measured while the auditors were visible, and were compared to the same locations prior to the arrival of the auditors at one, two and three weeks before the audit, as well as to a different area of the unit not visible to the auditor. Auditors typically did not go into patient rooms, so separate hand washing rates were determined for dispensers inside patient rooms and those in hallways. Twelve audits were included between November 2012 and March 2013.

handwash.water.jpgThe study found that there was an approximately three-fold increase in the rate of hallway hand washes per hour amongst healthcare staff when an auditor was visible (3.75 per hour), compared to a location where the auditor was not visible (1.48 per hour) and to the previous weeks (1.07 per hour). Hand washing rates with the auditor present were compared to separate groups at different time periods and locations to ensure that the differences found were not due to hand hygiene patterns that could be attributable to time of day or location. In each instance, the hand washing rates were significantly higher when the auditors were present, with the increase occurring after the auditors’ arrival, suggesting that the arrival of the auditor triggered the increase in hand hygiene.

“The difference in hand hygiene rates, when an auditor is present compared to those times when one is not, is huge in this study, and we showed this effect to be very consistent,” says Dr. Gardam, who is also an Associate Professor of Medicine at the University of Toronto.

“The magnitude of what we found calls into question the accuracy of directly observed hand hygiene rates and the usefulness of measuring and reporting them,” says Dr. Gardam. “That said, human auditing of hand hygiene has been helpful to draw attention to this important preventative measure—we just can’t stop focusing on it because our posted rates are not nearly as high as we think they are.”

Dr. Srigley says that although the researchers were “surprised at the tripling effect” of having an auditor present, there may still be some value in doing audits as there could be opportunities for in-the-moment education with health care staff. Dr. Srigley is the Associate Medical Director of Infection Prevention and Control at Hamilton Health Sciences, composed of seven hospitals in the Hamilton area.

Dr. Gardam suggests that a “front-line staff ownership” approach which engages rather than “nags” staff is a good option. This approach was first brought to University Health Network about six years by Dr. Gardam, in which front-line staff have developed their own reminders to influence staff to wash their hands, including: pancake breakfasts, public unit reporting, pledges, posters, and holding each other accountable.

“We need to change how we look at these complex problems,” says Dr. Gardam, “We need to help people change by engaging them and having them come up with local solutions.”

Tea towels should only be used once, then washed?

hitchiker.towelNever be anywhere without a towel.

A tea towel (or dish towel).

But do I need 50 clean ones a day?

New South Wales Food Authority chief scientist Lisa Szabo said last week that, “Tea towels should be replaced after every use. … It’s best to wash tea towels after each use and have a good supply of fresh ones to hand.”

That’s a lot of washing for anyone who has cooked from scratch.

So I reached out to friend of the barfblog, Dr. Don ‘Data’ Schaffner, who offered what seems to be reasonable advice: use disposable paper towels towelyafter a handwash where pathogens may be present, and a dish towel for other things. He has a paper coming out on the topic, but is a strong believer, like me, in peer-review and publish before press release.

Toilet psychology: why do men wash their hands less than women?

By hiding in toilet cubicles for a new study, psychologists observed how long people spend using the loo, and how long they wash their hands for afterwards. That men usually wash their hands less conscientiously than women is a well-established finding. Thomas Berry and his colleagues wanted to find out more about the reasons for this gender difference.

toilet.hideFor one day, between 10am and 4pm, a male researcher secreted himself inside one of three cubicles in a gents toilet facility at a U.S. University. For optimal observational purposes he chose the cubicle adjacent to a row of three urinals. Nearby, in a similarly designed female toilet facility, a single female researcher positioned herself in one of the three cubicles available. Don’t worry, both researchers were provided with a “customised wooden bench” for comfort.

They were also equipped with stopwatches. The researchers used an “unobtrusive sight procedure” – that is, they spied on other visitors to the lavatories using the gaps beneath and by the side of the cubicle doors (for some reason, US toilet cubicles always have a gap of about a centimetre either side of the door). The researchers also used an “acoustic procedure”. That is, they listened to the visitors’ actions. The study authors explained:

“… research assistants recorded the facility [urinal or cubicle], and then started a stopwatch when the patron’s feet stood relatively still. For the men, the research assistants also recorded the orientation of the feet to gauge the patron’s use of the commode (i.e. as a commode or a urinal). When research assistants heard the flushing of the patron’s commode or urinal the stopwatch was turned off … and the duration of the restroom event was recorded.”

Similar procedures were followed for recording each visitor’s “hand washing event” if there was one. A clever twist was that for part of the study, the researchers put “out-of-order” signs over the men’s urinals. This was to see how much they’d hand wash if they were forced to urinate in a cubicle, rather than at a urinal.

The psychologists managed to observe the toilet behaviour of 34 women using cubicles; 32 men who used a cubicle to defecate; 40 men who had no choice but to use the cubicles for urinating (because of the out-of-order signs); and 64 men who used a urinal. The bare statistics show that the hand-washing rates for these four groups were 91 per cent, 87.5 per cent, 75 per cent and 59.4 per cent, respectively.

The difference in hand washing rates between women using a cubicle and men using a cubicle (for defecating) was not statistically significant. In contrast, both women using a cubicle, and men using a cubicle (for defecating), showed significantly higher hand-washing rates than men who used a urinal.

The data are somewhat compromised because, as the researchers delicately put it – the women’s “facility use is a constant (i.e., commode) and their behaviour (urination, defecation, or menstrual care) is confounded within the one environment.” However, taken together, the results suggest that the reason men wash their hands less than women overall, is not because of gender norms (i.e. men are less bothered about being clean), but because of the differences in the toilet environment and toilet behaviour for men and women. In fact, after using a toilet cubicle to defecate, men tended to wash their hands for longer than women (but remember we don’t know what the women had been doing).

A bucket with a Styrofoam cup is not a handwashing station: dirty dining: Taqueria El Palenque

How can a restaurant operate with no running water? Not in a safe or sanitary way.

Darcy Spears of KTNV ABC Channel 13 writes that one restaurant in Las Vegas tried to do it anyway, and that landed them at the top of the health district’s demerit list in this week’s Dirty Dining report.

Taqueria El PalenqueThe health district shut the place down on April 30 and it is still closed. 

When inspectors were there, they found the restaurant had been operating for nearly a week with no running water. That got us to wondering what they did to keep things clean. How could employees wash their hands? How could they wash dishes? They couldn’t even flush a toilet.

The health district’s pictures show the bathroom sink was a bucket with a Styrofoam cup. There was another bucket next to the toilet. Employees were washing their hands with room temperature water in large pots and a trashcan.

Inspectors didn’t know where the water came from.

Did you wash your hands? Soap dispenser alarm at Proctor and Gamble

Procter and Gamble is literally sounding the alarm to get people to wash their hands after they use the restroom. A soap dispenser blares after people use the bathroom. Here’s how it works: The toilet door locks are rigged with pressure sensors that connect to an alarm on the soap dispenser. When toilet doors are opened, the alarm sounds. It stops as soon as the button for the soap is pressed. The alarms are being tdested in fast food restaurants, schools, and offices in the Philippines. 

Study: hand hygiene ‘too complex’ for Australian doctors

Doctors at most public hospitals are failing to follow national hand hygiene guidelines, a new study shows.

This is because the current five-step approach is too complex, says Professor Mary-Louise McLaws, an infectious diseases expert at the University of New South Wales.

handwash_south_park(2) handwash_south_park(2)Her study focused on how regularly health workers wash their hands before seeing a patient, which is the first hand-hygiene opportunity in the five-step plan adopted in Australia in 2009.

The approach should be simplified to focus on washing hands before and after seeing each patient, says Prof McLaws, who has published a report in the Medical Journal of Australia.

Human instinct will take care of other protocols, such as washing after coming into contact with bodily fluids.

“We need to simplify it. Five behaviour changes were thrown at the doctors and nurses all at once.

“The nurses got it. They are exemplary compared with doctors. But they work in teams and support each other.”

Antibacterial soaps can reduce risk of foodborne illness

Friend of the blog Don Schaffner has published some new research that shows  the use of antibacterial soaps can reduce the spread of harmful bacteria – that often leads to foodborne illness – more effectively than using non-antibacterial soaps.

The research, published in the peer-reviewed Journal of Food Protection (Vol. 77, No. 4, 2014, pp. 574-582), used new laboratory data, together with simulation techniques, to compare the ability of non-antibacterial and antibacterial products to reduce the risk of the infectious disease shigellosis, which is often spread during food preparation.

antibacterial.soapLead researcher Donald Schaffner of Rutgers University’s Department of Food Science says the data show that the use of three antibacterial wash products result in a statistically significant reduction in the presence of Shigella (the bacterium that causes shigellosis) compared to the use of the non-antibacterial soaps.

“This exciting research blends quantitative microbial risk assessments with an impressive set of laboratory data to show that antibacterial treatments are more effective than non-antibacterial treatments in reducing disease,” said Dr. Schaffner.

In the study, 163 subjects were used to compare two non-antibacterial products and three antibacterial products, with a study design intended to simulate food handling. The participants’ hands were exposed to Shigella and then treated with one of the five products before handling food melon balls. The resulting levels of Shigella on the food were then measured.

The levels of Shigella were then used to predict the outcome from an event in which 100 people would be exposed to Shigella from melon balls that had been handled by food workers with Shigella on their hands.

The data show all three antibacterial treatments significantly lowered the concentration of Shigella compared to the non-antibacterial treatments. Based on this model, the paper predicted that by washing with the antibacterial treatments, the number of illnesses could be reduced tenfold.

“This research provides strong evidence that antibacterial soaps are significantly more effective than non-antibacterial soaps in reducing Shigella on the hands and its subsequent transfer to ready-to-eat foods,” the authors write.

The American Cleaning Institute (www.cleaninginstitute.org) and the Personal Care Products Council (www.personalcarecouncil.org) provided funding for the research as part of the groups’ ongoing commitment to product and scientific stewardship to affirm the safety and benefits of these products.

An abstract summarizing the paper, “Quantitative Microbial Risk Assessment of Antibacterial Hand Hygiene Products on Risk of Shigellosis,” can be found online athttp://www.ingentaconnect.com/content/iafp/jfp/2014/00000077/00000004/art00006#aff_3

Proper handwashing requires proper tools

The state government in New South Wales – that’s where Sydney is – has come out with a new push for handwashing as a cornerstone of food safety.

I agree. But proper handwashing requires proper tools – vigorous water-flow, soap and paper towels.

jon.stewart.handwashing.2002Almost no Australian restaurants have all three components, based on my anecdotal but extensive observation (and wet shorts because I don’t use blow-driers).

NSW Minister for Primary Industries, Katrina Hodgkinson visited the NSW Food Authority’s stand at the Sydney Royal Easter Show and said, “Handwashing is the most simple and yet the most effective means of reducing your risk of food poisoning.”

If it was simple, so many people wouldn’t get sick; proper handwashing requires access to proper tools.