Providing Feedback, Protecting Patients

More than halfway through year two of Clean In, Clean Out, the Thoracic Intensive Care Unit (TICU) is embracing an important new emphasis of the UNC Hospitals' hand hygiene program: providing and receiving feedback graciously.

Providing Feedback, Protecting Patients click to enlarge TICU nurses Victoria Holloway (L) and Courtney Wolff (R) in front of the information board that details hand hygiene performance on the unit.

Patients in the TICU are critically ill. Some need heart or lung transplants; others require life-saving surgery. Many patients who come through the unit are immunocompromised, and a single infection can put their life at risk.

“All patients have to be protected from infection, but in the TICU, we have to be especially careful with the patients we see because of their critically ill nature,” explains Jeff Lynch, RN, TICU nurse manager. “After a heart or lung transplant, for example, medical therapies that immunosuppress the patient are given to prevent the body from rejecting the transplant, and the patient is more at risk of acquiring an infection and less able to fight one off. We stress to our staff that we have to do everything we can to protect the patient.”

Patient safety is one reason why, in 2013, Lynch and his colleagues in the TICU embraced the launch of Clean In, Clean Out, the novel UNC Hospitals hand hygiene program that aims to produce and sustain high hand hygiene rates and reduce the overall healthcare-associated infection rate among patients.

Last year, Clean In, Clean Out achieved its hospital-wide hand hygiene goal of reaching 90-percent compliance for inpatient units. The TICU did its part, achieving 93.1 percent compliance by the final month of the program. This year, Clean In, Clean Out set its sights on new goals – among them, an emphasis on providing and receiving feedback graciously. Emily Sickbert-Bennett, PhD, is associate director of hospital epidemiology at UNC Hospitals and one of the coordinators for the program.

“We chose to emphasize feedback this year because it’s the critical intervention to sustaining the success of our hand hygiene compliance,” says Sickbert-Bennett. “When staff members become comfortable talking about hand hygiene and reminding each other when this frequent task is forgotten, as can happen to anyone, we’ll achieve wonderful outcomes for our patients.”

Since the launch of year two of Clean In, Clean Out in October 2014, the TICU has produced a high feedback-to-observation ratio, including providing feedback on more than 75percent of the unit’s nearly 800 observations in December. Several reasons account for the TICU’s success. During year one of the program, leaders on the TICU complimented staff that demonstrated proper hand hygiene. And staff took notice. Staff also noticed that those who received feedback for not demonstrating proper hand hygiene didn’t respond negatively to the observer.

“Not surprisingly, at the beginning of the first year of the program, there was hesitance for staff to approach others about properly performing hand hygiene,” says Lynch. “It can be intimidating, especially when you have to remind someone you don’t know very well to wash their hands next time – you don’t know what kind of response you’ll get in return. But seeing that the reactions of those who were asked to wash their hands weren’t negative made everyone comfortable. They saw that they weren’t going to get a bad response from someone if they asked them to wash their hands.”

This year Lynch credits simple measures for helping further promote the importance of feedback. For example, those who are willing to receive positive feedback or a friendly reminder wear a handprint sticker on their hospital ID badge. The sticker serves to further break down the barrier between the observer and the person entering or exiting a patient room.

We're very open with one another. When we notice someone who needs to improve their practice we can tell them and it doesn't cause offense. As a unit, we view feedback as another way to better protect our patients and to help them heal and prevent infections. --Courtney Wolff, RN, TICU

Jeff Lynch
Jeff Lynch, RN, BSN, CCRN-CSC

“The sticker has made a big difference,” he says. “It signals a commitment to proper hand hygiene and a willingness to be reminded if you forget, which we all sometimes do.”

Another way that the unit has been able to engage staff in participating in Clean In, Clean Out was to create friendly, unit-wide competition. Each month, on the information board in the TICU break room, leaders post an updated report showing how many total observations were made the month prior, the number of unique observers the unit had, the top three observers, and who most often provided feedback. The winner’s name appears in the largest font and is placed on a certificate at the top of the board.

“Nurses, in general, are a competitive group,” says Lynch.  “Critical care nurses tend to be even more competitive. Our patients are very ill, which makes for a high-stress, high-pressure environment. To work here you have to like the challenge and to want to strive to do better. When we highlighted the name of the top performer, it just pushed an already competitive group to work harder.”

Lisa Teal, RN, is an infection preventionist in hospital epidemiology. She has worked closely with the TICU and other units through both years of Clean In, Clean Out. She remembers when it was not always easy providing feedback to colleagues on the unit.

“The indications for proper hand hygiene were not so clear in the past,” says Teal. “Around the hospital, some would make arguments such as, ‘I didn’t touch the patient.’ Now, with Clean In, Clean Out established, understanding when hand hygiene must be performed is very clear and it makes it much easier for staff to know when to give feedback. There is very little room for pushback. Nursing staff in the TICU see hand hygiene as a patient safety issue and realize that the feedback is needed to be successful.”

As the unit sees the results of its emphasis on proper hand hygiene and providing and receiving feedback, Lynch says that it only pushes them to sustain the high achievement.

“When we receive the results, we share the good news with everyone in our staff meeting, and I think that inspires our team members to continue to do better with hand hygiene,” he says. “It’s very rewarding, not only because there’s a sense that we’re doing well among our peers, but more importantly, because we’re helping our patients.”

Clean In, Clean Out

Hand Hygiene PhotoFor more information on Clean In, Clean Out, visit If you would like stickers for your staff, please email  or call Hospital Epidemiology at 984-974-7500. Hospital Epidemiology asked each area to develop an action plan and set goal for improvement of compliance and/or feedback. Work with your area's leaders to set goals for improvement (example paper tool inpatientoutpatient/procedural) and complete an action plan (electronic submission). To learn more about how the hand hygiene program at UNC Hospitals got its start, read PICU paves the way for Clean In, Clean Out campaign.