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W ld Cl ClWorld Class CleanWorld Class Care CareAttaining and Sustaining Hand Hygiene Compliance

An Academic Hospital’s Experience using Process Improvement Methodologies.

World Class Clean

Disclosure

Nancy Osborn, RN, CICManager, Prevention and Control Center

Medical Center of Central Georgia

2 © 3M 2011. All rights reserved.

No financial benefit or conflicts of interest.

Housekeeping

• Questions

• Mute feature (*7 = un-mute, *6 = mute)

• “Chat” feature

• Technical difficulties


• Technical difficulties

• CE credits

• Post session follow-up

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How do I get a CE Certificate?

Next week, all of today’s meeting participants will be sent an email containing instructions for obtaining a CE Certificate for today’s meeting.

The email will be sent to the email address you provided when


y pyou logged-in to today’s meeting. If there are others listening with you today who did not log-on, you may forward the CE certificate email to them.

Learning Objectives

• Describe the steps in the process improvement methodology used to improve hand hygiene compliance.

• List the key factors associated with the implementation of a


List the key factors associated with the implementation of a successful hand hygiene improvement initiative.

• List the interventions used in MCCG’s and hygiene improvement program.

How do I get a CE Certificate?

Next week, all of today’s meeting participants will be sent an email containing instructions for obtaining a CE Certificate for today’s meeting.

The email will be sent to the email address you provided when you logged-in to today’s meeting. If there are others listening with you today


gg y g g y ywho did not log-on, you may forward the CE certificate email to them.

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BACKROUND

• MCCG is a 637 bed academic, medical center, designated Level 1 Trauma Center and Magnet hospital for nursing excellence.


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• Primarily serving central and south Georgia, the Medical Center routinely admits patients from more than 125 of Georgia’s 159 counties each year.

Quality/Process Improvement

• The prevention of healthcare associated infections (HAI) and antibiotic resistance are a strategic priority at the Medical Center of Central Georgia (MCCG).

• The relationship between Hand Hygiene and prevention of HAI has been well documented and performance expectations clearly


has been well documented and performance expectations clearly defined in the CDC, Guidelines for Hand Hygiene in Healthcare Settings, World Health Organization Guidelines on Hand Hygiene in Health Care and Joint Commission National Patient Safety Goals.

• Compliance with Hand Hygiene practice compliance and regulatory standards was suboptimal.

Getting Started

• Establish baseline and assess the risk factors for compliance.

• Research!


• Research!

• Form steering committee and teams –

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Getting Started

• Determine pilot areas

• Medical Unit

• Critical Care Unit


• CV step-down unit

• Establish a time line.

• March to October

Getting Started

Tools used during the trial included but were not limited to the following:• Posters

• Patient education brochure and hand sanitizer sample and video.


Patient education brochure and hand sanitizer sample and video.

• Signs - MD Lounge, patient rooms, break rooms, rest rooms, halls.

• Pocket-size hand sanitizer for staff.

Getting Started

Initial Steps Before Pilot

• 601 observations performed throughout the organization.


• staff survey of their knowledge and perception of the current hand hygiene program.

• Results: Staff perceived compliance to be 70%.

Actual results: 32%!

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Baseline % Handwashing Compliance by Observation


PI Objectives

• Adapt and apply PI methodology to examine processes and workflow of staff members and identify risk factors for noncompliance and barriers to hand hygiene compliance.

• Improve hand hygiene compliance from 34% to 65% in year one, increase to 90% and s stain thereafter


increase to 90% and sustain thereafter.

• Increase utilization of hand soap and sanitizer.

• Utilize best practice products, compliance monitoring, implementation and sustainability strategies.

• Participants: patients, families, physicians, staff and visitors.


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MYSTERY SHOPPER QUESTIONS to patients and/or families

Did you receive our hand hygiene

brochure?

Do you know that we want you to

remind & encourage hand hygiene?

How often is staff using hand

sanitizer


Yes No

YesNo

Always

SometimesSeldomNever

Innovation

• Utilization of multiple methods of hand hygiene monitoring: mystery shopper patient interviews, direct observations, patient interviews, product usage.

• Weekly data review with key stakeholders: physicians,


administration, and senior leadership.

• Transparent dissemination of data within 2 – 4 days to departments.

• Professional marketing of “speak-up” buttons, flyers, patient brochure and signage.

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Innovation

Established linkages among hand hygiene,

flu vaccination and HAI.


Innovation

Individual unit “spin” on the campaign;

examples from 7 units.• Staff say “ladybug” if a peer or physician is out of

compliance


compliance.

• Results discussed in huddles, inter -disciplinary rounds, linked to HAI reduction results.

• Assign a peer mystery shopper for a day- give out coupons for job “well done”.

Innovation

• Green for Clean = focus extends to tag clean equipment with green ties.

• Met with each of the key physicians and addressed what would help improve hand hygiene compliance


would help improve hand hygiene compliance.

• Re-organized work processes, used case studies, and “Glo Germ™ ” on the unit to help educate.

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Sustaining

Important aspects of the program

1. Partnership between patients, their families and health-care workers to promote hand hygiene in health care.

P ti t t ld th t t ff h ld ti h d h i ti


• Patients are told that staff should practice hand hygiene every time they enter your room, (signage and education brochure).

• Before putting on gloves.

• Wearing gloves alone is not enough to prevent the spread of germs.

• After removing gloves.

Sustaining

Important Aspects of the Program

1. Patient and Family Participation

2. Product Availability and Convenience.


• Easy access to product.

• Hand hygiene products must always be available and located where needed.

Sustaining

Important Aspects of the Program1.Patient and Family Participation.

2.Product Availability and Convenience.

3.Individual Accountability with Feedback.


3.Individual Accountability with Feedback. • Staff’s compliance (measurable) will be communicated back to

each unit as performance feedback.

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Sustaining

Important Aspects of the Program1.Patient and Family Participation.

2.Product Availability and Convenience.

3 Individual Accountability/Staff Awareness


3.Individual Accountability/Staff Awareness.

4.Culture (“How we do things here”) System of reminders - how to respond to reminders, Script to use as a guide

• “I am washing my hands for your safety”.

• Code words for reminders “Lady Bug”.

Sustaining

Important aspects of the program1. Patient and Family Participation

2. Product Availability and Convenience

3. Individual Accountability/Staff Awareness


3. Individual Accountability/Staff Awareness

4. Culture -System of Reminders

5. Visibility / Communication!

Results

• Hand hygiene compliance improved to 65% within 5 months.

• Hand hygiene compliance improvement continued, exceeding 90% at 6 months.


exceeding 90% at 6 months.

• 51% increase in product use.

• Sustained CLABSI, CAUTI, VAP, below the national NHSN benchmark.

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Innovation

Logo Contest



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Partnership Pledge


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Latest Addition

http://www.hhs.gov/ash/initiatives/hai/training/partneringtoheal.html

Questions?


Questions?

Questions?


Documents

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