Inspire People:
- Solicit support and active involvement in the plan to reduce HAIs, obtain buy-in and build accountability for the outcomes.
- Identify a leader for the HAI initiative. This is critical to the success of the project.
- Understand where resistance may come from.
Launch the Initiative:
- Align operations and ensure the organization has the capacity to change, not just the ability to change.
- Launch the HAI initiative with a clear champion and a clearly communicated vision by leadership.
Support the Change:
- The capacity to support change is critical; therefore, all leaders within the organization must be a visible part of the HAI initiative.
- Frequent communication regarding all aspects of the HAI initiative will enhance the initiative.
- Celebrate success as it relates to a reduction in HAIs or a positive change in HAI organizational culture.
- Identify resistance to the HAI initiative as soon as it occurs.
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}
- Define hand hygiene protocol
- Who to follow hand hygiene:
- All personnel and visitors in contact with or in the proximity of patients, including the patient.
- When to follow hand hygiene:
- Before patient contact, sterile procedures.
- After body fluid exposure risk, patient contact, contact with patient surroundings.
- How to follow hand hygiene:
- Hand wash with soap and water or hand rub over all hand surfaces with alcohol-based formulation.
- Hand rub/hand wash for at least 15 seconds.
- Dry hands completely.
- Do not touch potentially contaminated surfaces after hand washing procedure.
- Educate all staff on hand hygiene procedure and implications of non-compliance.
- Train observers and just in time (JIT) coaches.
- Measure current “baseline” adherence to hand hygiene protocol with observers who sample and record compliance within the hospital units.
- Observers should be a role or individual that can maintain anonymity throughout the data collection process, be in a position where they can secretly observe staff while performing their regular job duties, not seem out of place during their time on the unit, and collect data that is representative of the patient population.
- Twenty to thirty observations should be collected each day over a two to three-week period utilizing a standardized data collection form including observation number, date and time, staff role, entry or exit to patient room, hand hygiene - yes or no, observable contributing factor to non-compliance.
- Identify barriers to hand washing.
- Qualitative input from secret observers as to observable contributing factors as to why hand hygiene protocol was not followed.
- Direct interviews with noncompliant caregivers by just-in-time (JIT) coaches within the hospital units to identify non-observable factors as to why hand hygiene protocol was not followed.
- Collect data on barriers to hand washing and calculate the hospital (or unit) baseline compliance, top contributing factors to non-compliance at your hospital (or unit), and the compliance by role(s).
- Analyze the data to identify root causes of why non-compliance is occurring.
- The top causes (or contributing factors) vary across units and hospitals, roles and shifts. Thus, it is crucial that data is first collected and analyzed to identify the factors which contribute to hand hygiene non-compliance in your area. In order to improve hand hygiene, it is essential that solutions targeting the specific causes are implemented.
- Not all causes are applicable to your organization and often there are two or three major causes that need to be addressed.
- For instance, if the unit identifies that “improper use of gloves” is the top contributing cause of hand hygiene non-compliance, then the following targeted solutions can be implemented:
- Detailed training for clinical staff on proper use of gloves.
- Relocate glove dispensers.
- Implement standard work process for hand washing between each patient room or patient care area when delivering food trays.
- Implement standard work process for daily room cleaning and educate all housekeeping personnel.
- Another example of a contributing cause could be “frequent entry or exit.” If the unit finds that this is a top contributing cause through the use of the TST, then the following solutions can be implemented to improve hand hygiene:
- Implement standard work process for hand washing after bringing mobile work machines (such as mobile vital signs devices) into the patient room or care area but before patient contact/interaction (such as taking patient’s vital signs).
- Create a standard “drop spot” for meds and supplies within the patient room that enables nursing to set down meds and supplies and perform hand washing.
- Implement computers and scanners at every bedside to reduce the likelihood of cross-contamination between patients when performing bar code medication administration.
- Implement standard work process for room cleaning and educate all housekeeping staff.
- Create and implement a list of supplies that will be kept within the patient care area.
- Measure progress and effectiveness of change.
- Utilize the same data collection and analysis tools and process utilized to calculate baseline in order to measure progress and effectiveness.
- Identify the changes from baseline performance for each unit, role, and shift, and identify the effectiveness of implemented solution, any barriers to effectiveness, and any additional solutions that need to be implemented.
- Note: The TST includes data collection forms and provides analyses in the form of Pareto (and other) charts that allows your organization to track improvement versus baseline data, to observe HAI data in correlation to hand hygiene compliance rates, and to benchmark against national results.
- Implement a plan to ensure that gains are sustainable.
- The plan should include the following action items:
- Designate someone to “own” the process (for example, the dedicated leader or a unit manager). At least one aspect of their job function should specify that data continue to be collected, monitored and shared with healthcare personnel.
- Replicate the findings to another area within your organization.
- Continue real time data collection to improve data collection.
- Train new hand hygiene observers and JIT coaches, once per year to ensure that observers receive updated training on an annual basis.
- Update the plan whenever changes occur.
- The plan should be completed with the process owner, which signals the transition of responsibility from the project leader.
- The project leader will continue to ensure that data is collected, entered and shared with staff at a frequency determined by the group.
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:
- Capable of capturing 100% of all hand hygiene events (soap and sanitizer) electronically in real-time.
- 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}
- Validated for accuracy in at least one peer reviewed study.\cite{Diller_2014}
- Supported by scientific evidence of efficacy.
- 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:
- Biovigil Hand Hygiene Compliance & Surveillance System
- DebMed: DebMed GMS (Group Monitoring System)
- GOJO Industries: GOJO SMARTLINK Hand Hygiene Solutions
- HandGieneCorp: HandGiene HHMS (Hand Hygiene Monitoring System
- Hyginex
- Hill Rom
- Hygreen
- IntelligentM: IntelligentM Smartband System
- Proventix: nGage
- Stanley Healthcare: Hygiene compliance monitoring system
- UltraClenz: Patient Safeguard System (PSS)
- Versus: SafeHaven with Versus RTLS and Versus Advantages Hand Hygiene Safety (HHS) software
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:
- Before patient contact,
- Before aseptic task,
- After body fluid exposure,
- After patient contact and
- 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)