Meaningful measurement of compliance.

Abstract

To the Editor: Drs. Hersey and Martin suggest that policies are not, in themselves, sufficient to result in healthcare worker and that inclusion of compliance with infection control precautions in staff performance reviews is a necessary communication to promote compliance with practices intended to prevent occupational transmission of hepatitis B virus and human immunodeficiency virus.1 Results of a Canadian nationwide survey and covert observation of practices in some of the surveyed hospitals' critical care units support these recommendations2; however, there are three caveats. First, the Canadian survey found considerable confusion in the use of terms to describe current infection control protocols and considerable discrepancy between individual policies and national guidelines.3 Second, covert observation of glove use for three specific nursing procedures from each of four aspects of care (intravascular, oral, wound, and perineal) revealed composition of observations as an important confounding variable (Figure 1). Third, the study failed to find a strong correlation between level of knowledge and compliance in practice, but did find a persistent negative slope between knowledge-practice correlation coefficients and improving quality of observational data (Figure 2). The implication of these findings is that announcing policies is not enough, but neither is evaluating staff on the basis of confounded observations of glove usage. Meaningful measurement of compliance with effective policies will require standardized observations. Achieving high levels of compliance will require applied research to document effectiveness of policies, meaningful measurement of compliance levels, and two-way communication with staff members to achieve informed consensus. It may be difficult to evolve more effective policies in a stringently regulated environment, such as that imposed by the Occupational Safety and Health Administration standards, but hospital epidemiology's fundamental role should remain oriented toward continuous evaluation and improvement, not enforcement.