Leadership Plan

Practice Plan

Change management is a critical element that must be included to sustain any improvements. Recognizing the needs and ideas of the people who are part of the process—and who are charged with implementing and sustaining a new solution—is critical in building the acceptance and accountability for change. A technical solution without acceptance of the proposed changes will not succeed. Building a strategy for acceptance and accountability of a change initiative greatly increase the opportunity for success and sustainability of improvements. “Facilitating Change,” the change management model The Joint Commission developed, contains four key elements to consider when working through a change initiative to address HAIs.
Plan the Project:
Inspire People:
Launch the Initiative: 
Support the Change:
Hand hygiene improvement is not amenable to a “one size fits all” approach. It involves a complex set of interactions that requires an approach focused on measurement and understanding of root causes. The Joint Commission Center for Transforming Healthcare Targeted Solutions Tool (TST)® provides health care organizations this type of comprehensive approach and is proven to improve hand hygiene compliance.\cite{joint2012joint}

Technology Plan

The recommendations of specific technologies or products herein are those of the Patient Safety Movement Foundation and do not necessarily represent the opinions of the Joint Commission Center for Transforming Healthcare or its affiliates. The Joint Commission Center for Transforming Healthcare was not consulted on, nor did it participate in the decision or choice of any specific product or technology, and as a matter of policy the Joint Commission Center for Transforming Healthcare does not endorse any specific technologies, equipment, or other products.
There is emerging evidence that electronic hand hygiene compliance systems, when combined with appropriate staff feedback and multi modal action plans can lead to reduced infections and avoided costs. Visit http://www.ehcohealth.org/the-evidence/ for a list of scientific studies.

Essential Criteria to Consider

The system must be:
  1. Capable of capturing 100% of all hand hygiene events (soap and sanitizer) electronically in real-time.
  2. Capable of reporting Hand Hygiene Compliance (HHC) based on the WHO 5 Moments for Hand Hygiene  at the Group, Unit, Ward or Department Level.\cite{Steed_2011}
  3. Validated for accuracy in at least one peer reviewed study.\cite{Diller_2014}
  4. Supported by scientific evidence of efficacy.
  5. Supported with a behavior and culture change tool kit.
Consider an Electronic Monitoring System for Hand Hygiene Compliance to ensure an accurate and reliable data set from which real improvement can be driven, such as:

Metrics

Topic

Observed Hand Hygiene Compliance

Compliance rate of hand hygiene by observation

Outcome Measure Formula

Based on the “My five moments for hand hygiene” method.\cite{Sax_2007,Sax_2009} Moments defined as:
  1. Before patient contact,
  2. Before aseptic task,
  3. After body fluid exposure,
  4. After patient contact and
  5. After contacts with patient surroundings.
The formula can be used to calculate hand hygiene compliance during all 5 moments. Moments 1 and 4, before and after patient contact are key calculations.
Numerator: Number of hand hygiene actions performed
Denominator: Number of hand hygiene actions required (hand hygiene opportunities)
*Rate is typically displayed as Events/10,000 Adjusted Patient Days

Metric Recommendations

Direct Impact: All Patients
Lives Spared Harm:
\(Lives\ =\ \left(Compliance\ Rate_{measurement}\ -\ Compliance\ Rate_{baseline}\right)\ x\ Healthcare-associated\ Infection\ Rate\ _{baseline}\)
Data Collection:  Direct observation of hand hygiene practices in identified clinical settings with one (or two) trained and validated observers. Observers will watch healthcare workers’ hand hygiene practices at the point-of-care. The observer openly conducts observations but the identities of the healthcare workers are confidential. Based on WHO Guidelines on Hand Hygiene in Healthcare (2009) and “Save lives, Clean Your Hands” campaign.(World Health Organization 2009)