I read with interest the article, "Impact of Personalized Report Cards on Nurses Managing Central Lines," published in the American Journal of Infection Control.1 In this quality improvement project, through observation and audits of documentation, nurses were provided feedback regarding their deviations from central line protocol. Each of the 19.2% of central line care events that visually failed the audit prompted a review of the medical record.1 Through these audits, 628 central line bloodstream infection-contributing factors were identified. The nurse managers received their respective unit case reports and the nurses received their personalized report cards. During the 16 weeks of the project, the frequency of the contributing factors for line sepsis decreased. Nurses respected the use of the report cards because they were associated with a shift from a blaming culture to one that reinforced education of how factors influenced the development of line sepsis.

My first thoughts as I read the article were, why can't we apply the same approach to hand hygiene? It boggles my mind that noncompliance with hand hygiene continues to be high in many institutions, even when there is convenient access to a range of options that can be used for hand hygiene. A personalized report card may be one of the interventions that would increase compliance with hand hygiene and decrease sepsis. The nurse manager or the manager of the infection control department could discreetly appoint several staff from across disciplines to be responsible for visually auditing health professionals engaged in patient care. If hand hygiene isn't performed or performed incorrectly, the auditor would document the situation and perform a review of the medical record to determine whether there was subsequent sepsis or an increase in the sepsis rate for that patient care area. Confidential report cards for that professional could be given to the unit manager and medical director, as well as the manager of infection control. The report card might contain information as to when and where the deviation from appropriate hand hygiene occurred but also any information regarding an unexpected patient care outcome (ie, the patient developed sepsis following that deviation). I would feel terrible if I learned that my action or inaction caused harm to my patient.

Another piece of information that I would like to see in such a report card is the cost of the deviation. We have all read about increased costs of care related to unanticipated complications and longer lengths of stay. But to see the costs on paper and know that the increased costs of care and a suboptimal outcome of the patient are your responsibility might bring new meaning to this information. Another factor that could be included is the national benchmark for line sepsis, the institution or unit's rate of line sepsis, and the individual's rate of line sepsis. Determining whether or not the professional is constantly above the benchmark for the unit may be grounds for re-education and/or disciplinary action. I believe that the visualization of performance data on several levels would help drive home how each professional's actions impact a patient and his or her family.

One of the outcomes of the quality improvement project was to develop a module on central line sepsis during the orientation for new personnel. Most institutions do have a module on hand hygiene, but the module has little impact on compliance related to performance of hand hygiene. Perhaps the personalized report card would further impress upon clinical staff the importance of infection control procedures such as hand hygiene. Perhaps you are in a Doctor of Nursing Program and are interested in sepsis prevention work. I think that replicating the central line sepsis report card project for hand hygiene would make for a very exciting scholarly project and one that would positively impact health professionals, patients, and families. I'd be thrilled to chair your project!

-Terese M. Verklan, PhD, CCNS, RNC, FAAN

Professor and Neonatal Clinical Nurse Specialist

University of Texas Medical Branch

School of Nursing Galveston

Graduate School of Biological Sciences

Galveston, Texas

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