Researchers Say RFID-Related Process Improvements Require Managerial Commitment

By Claire Swedberg

A three-university study finds that RFID-enabled hand-washing technology boosted hygiene compliance at hospitals by an average of 20 percent, but without sustained managerial support, those gains disappeared.

A group of university researchers has found that the installation of a radio frequency identification system for monitoring hand-hygiene compliance at health-care facilities is only one part of what is required if hospitals want a long-term solution.

The way in which an RFID system is managed post-deployment can have a significant impact on its success when that technology is used for hand-hygiene compliance. The researchers found that compliance rates increased following the technology's implementation, but in instances when a hospital discontinued its use of the RFID-based monitoring system, hand-hygiene compliance, on average, dropped below the pre-installation rates. Among those hospitals that removed the technology, compliance was approximately 46 percent prior to installation, then typically regressed to about 44 percent after the solution was removed. However, while the technology was in place, the compliance rate increased to about 55 percent, on average, rising to 60 percent among the highest-performing medical facilities.

Proventix's nGage system includes battery-powered RFID badges worn by employees, as well as RFID badge readers installed throughout each hospital unit and at hand-hygiene dispensers.

The study was conducted by members of the University of North Carolina (UNC) at Chapel Hill, Washington University in St. Louis, and the Wharton School at the University of Pennsylvania, in Philadelphia. The resulting paper, titled "Motivating Process Compliance Through Individual Electronic Monitoring: An Empirical Examination of Hand Hygiene in Healthcare," was recently published by Management Science, Articles in Advance. The research focused on the effectiveness of RFID-enabled hygiene-monitoring systems installed within a total of 71 units throughout 42 hospitals.

The study, which concluded this year, follows a previous project in which researchers explored hand-hygiene compliance rates (without technology use) during a typical work day; that research found that compliance rates dropped over the course of the day. The group then began analyzing the use of RFID technology designed to drive up compliance.

There was a high level of variability in terms of compliance improvements from one site to another. Fifty-five of the 71 hospitals experienced an increase in compliance, according to the researchers. The highest increase was 180 percent, while the greatest decrease following the technology's removal was a 75.6 percent drop at one hospital, compared with that facility's peak compliance rate. The group also observed that while compliance rates initially increased immediately following the RFID system's installation, they generally began a gradual decline sometime thereafter. "What we saw was that about two and a half years in, the compliance started to creep back down," says Bradley Staats, a UNC associate professor of operations.

Surprisingly, Staats says, if the RFID-enabled hand-hygiene tracking technology was removed, compliance dropped considerably further—as much as 75.6 percent. In fact, it decreased to levels that were lower than those attained before the technology was installed.

"Our findings suggest that although individual electronic monitoring can dramatically improve process compliance, it requires sustained managerial commitment," the researchers indicated in their recently published paper.

The study used data from installations of Proventix's nGage system that included battery-powered 2.4 GHz RFID badges compliant with the IEEE 802.15.4 (ZigBee) specification (see RFID-based Hand-Hygiene System Prevents Health-care Acquired Infections). Caregivers wore the badges, while RFID badge readers were installed throughout each hospital unit and at every hand-hygiene dispenser (which contained soap and sanitizers). The nGage system tracked when a caregiver entered a patient's room, as well as when the dispenser in that room was or was not used. Management received data related to each individual's compliance rates, as well as collective rates among the hospital or its departments, and could then share the findings with the employees or address individual problems.

The researchers did not visit the actual hospital sites. Instead, they analyzed data that Proventix had collected from its customers and provided to them.

The team found that total hand-hygiene dispenser usage within each unit increased immediately when the system was taken live, compared with compliance rates observed for at least 27 days prior to the systems' activation. The study determined that daily compliance rates averaged about 40 percent before the technology was installed, rising up to about 55 percent before flattening out or dropping several percentage points.

According to the study, the use of RFID-based monitoring may increase compliance due to the development of habitual hand-washing behavior. However, the researchers found, if the monitoring technology was then discontinued, even though workers should have formed a habit of washing their hands, compliance rates instead began to drop, even below previous rates. That could result from a perception that management commitment was gone. The researchers also compared health-care workers' internal versus external motivations, and speculated that employees who already adhered to hand-hygiene practices due to internal motivations (the desire to provide patients with high-quality service) might have shifted their motivation to an external process when an RFID system began tracking when they failed to wash her hands. If that external motivator (such as the RFID system) was then discontinued, staff members might not immediately return to their internally motivated compliance expectations.

Bradley Staats

The success of a real-time location system (RTLS) for monitoring hand-hygiene compliance, then, may have been the result of how the hospital managed that RTLS solution, the study found. Proventix recommends that after a hospital first installs the nGage system, it should gather baseline data for a period of time during which the technology simply tracks the hand-washing dispensers' usage rates. Then, the facilities can begin with interventions that include performance feedback (providing information to caregivers regarding their compliance rates), goal-setting, competition, leadership and incentives.

The study covered a span of time from February 2010 to August 2013. During that period, 12 of the units at nine hospitals discontinued their usage of the RFID systems—typically after a year, when budgets tended to run out. Some hospitals that discontinued the technology, however, continued to track how often the dispensers were used even after their staff no longer wore RFID badges, thus enabling the researchers to determine de-activation compliance rates.

The main issue, Staats says, is more a question of how technology should be managed than whether technology works. "[People] may want a silver bullet, so they purchase something that they think will make their problems go away," he explains. "I think what we see [with the study] is the importance of committed leadership." If a hospital installs the RTLS solution and fails to oversee how it is being used—both initially and then years later—the technology may not be as effective as that hospital had hoped.

The study did not include research into the management policies that were in place in conjunction with each RTLS solution, nor how those policies might have impacted compliance rates. Nonetheless, Staats says, "the data set we have lets us speculate." The most interesting area of potential further research, he notes, is "what are the complementary practices" undertaken by hospital management that yield a boosted compliance rate that doesn't drop over time.

According to Staats, the researchers have no plans to carry out additional testing of RFID systems at this time. However, he adds, RFID and compliance is still area of interest, so if the opportunity arose, he and his colleagues might opt to undertake further studies.