HAND HYGIENEEveryone is already at 100%, so why are we talking about this?!

Hand Hygiene “Advanced Math”

Hand Hygiene Guru

THE JOINT COMMISSION National Patient Safety Goal (NPSG.07.01.01)

Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.

Elements of Performance1. Implement a program that follows categories IA, IB, and

IC of either the current Centers for Disease Control and Prevention (CDC) or the current World Health Organization (WHO) hand hygiene guidelines. (See also IC.01.04.01, EP 5)

2. Set goals for improving compliance with hand hygiene guidelines. (2. See also IC.03.01.01, EP 3)

3. Improve compliance with hand hygiene guidelines based on established goals.

PROGRAM INFRASTRUCTURE

System Change Training and Education Evaluation and Feedback Reminders in the Workplace Institutional Safety Climate

Multimodal hand hygiene improvement strategy

CDC-WHO Partnership to Assess HH Infrastructure at Healthcare Facilities

http://www.cdc.gov/handhygiene/

JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE Targeted Solutions Tool™  (TST) is an innovative

application that guides health care organizations through a step-by-step process to accurately measure their organization’s actual performance, identify their barriers to excellent performance, and direct them to proven solutions that are customized to address their particular barriers Habit Active Feedback No One Excused Data Driven Systems

http://www.centerfortransforminghealthcare.org/tst.aspx

HAND HYGIENE BUNDLE

1. Establish ongoing monitoring and feedback on infection rates

2. Establish administrative leadership and support3. Establish a multidisciplinary design and response

team4. Provide on-going education and training for

staff, patients, families and visitors5. Ensure hand hygiene resources are accessible

facility wide and at the point of care6. Reinforce hand hygiene behavior and

accountability7. Provide reminders throughout the health care

setting8. Establish on-going monitoring and feedback

of hand hygiene compliance

AJIC. Vol.40, No.4, Supplement 1. May 2012.

POLICY AND PROCEDURE

Expectations Products Procedures Program Description

PRODUCT PLACEMENT

COMMUNICATION: EDUCATION/REMINDING

Healthcare Workers Family/Visitors Patients

MONITORING

Joint Commission Monograph Measuring Hand Hygiene Adherence:

Overcoming the Challenges (2009)

iScrub

FEEDBACK

Patient Survey Data

Observation Data

Real Time Engagement

TECHNOLOGY FOR REMINDING, MONITORING AND COMPLIANCE

AN OLDIE, BUT A GOODIE?!

CULTURE OF SAFETY (HIGH RELIABILITY ORGANIZATIONS)

Shared value/beliefs about safety in organization

Always anticipating precarious events Informed employees and medical staff Culture of reporting Learning culture “Just culture” Blame-free environment Team work environment Culture of continuous improvement Empowering families to participate Informed and activated patient

Source: Safe Design