Infection Prevention
Medicine Service
Nursing Service
Volunteers
* Joint Commission Center for Transforming Healthcare
The views expressed in this presentation are
those of the authors and do not necessarily
represent the views of the Department of
Veterans Affairs or the University of Texas
Health Science Center at San Antonio.
 I have a small IIR grant from Pfizer to study
clinical outcomes of coccidioidomycosis.
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1846: Ignaz Semmelweis:
◦ Mothers of babies delivered by students and
physicians had a higher mortality rate.
◦ Mothers of babies delivered by midwives had a lower
mortality rate.
◦ Physicians practiced autopsies, and delivered babies
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When using antiseptic solution for hand
hygiene, mortality drop…
Doctors were offended: “they should wash
their hands”.
Semmelweis- died alone in an asylum,
age 47.
CDC. Guideline for Hand Hygiene in Health-Care
Settings. MMWR 2002; 51:No. RR-16
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An estimated 2 million patients get a
hospital-related infection every year and
90,000 die from their infection. – Centers for
Disease Control and Prevention
“…(Hand washing) gradually became accepted as
one of the most important measures for preventing
transmission of pathogens in health-care facilities”
NPSG 07.01.01 Comply with HH guidelines
CDC. Guideline for Hand Hygiene in Health-Care
Settings. MMWR 2002; 51:No. RR-16
 Discrepancy
between peer
review and blinded review HH
observations in acute care at
ALM Hospital
A 256 bed VA acute care hospital, affiliated with UTHSCSA
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Medical service: Infectious Diseases and
Hospital Epidemiology
Nursing: Nurse Managers, Nursing Staff
Leadership: Hospital Director, Chief of Staff,
Nursing Leadership
Quality improvement: Infection Prevention
and Control Staff
Volunteers: Healthcare students
 To
improve HH compliance by
changing the culture of patient
safety
Mission: to transform healthcare to high reliability
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A powerful process improvement tool
that guides health care organizations
through a step-by-step process to:
◦ Accurately measure their organization’s
performance
◦ Identify their barriers to excellent
performance
◦ Direct them to proven solutions that are
customized to address their particular
barriers.
Cedars-Sinai
Cleveland
Clinic
Exempla
Fairview
Froedtert
Intermountain
Johns
Hopkins
KaiserPermanente
Mayo Clinic
Memorial
Hermann
NY-Presbyterian
North Shore-LIJ
Northwestern
OSF
Partners HealthCare
Stanford Hospital
Trinity Health
Virtua
Wake Forest Baptist
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Habit- as automatic as looking around before
crossing the road… Gel in, Gel out
Active Feedback- Coaching, Voice expectation
to all staff, Engage staff, Frequent
communication, Celebrate improvement
No One is Excused- Protect the patients, Hold
everyone accountable, Commitment, Role
modeling, Apply progressive discipline from the
top
Data Driven
Systems- Focus on the systems, not the
individual.
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Notification of key stakeholders.
Training of blinded (unbiased) HH reviewers:
◦ Six college students in health care career fields
◦ STVHCS Infection Prevention Hand Hygiene Training Module.
◦ Inter-rater agreement between HH trainer and student was validated
(k=1).
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Selection of Pilot Unit: 5A, 24 beds.
Just in Time (JIT) Coaches:
◦ Scripts were used to actively intervene when hand hygiene noncompliance is observed and to understand contributing factors to noncompliance
◦ Healthcare workers are coached and encouraged to practice safe patient
care
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Establishment of timeline
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To improve HH compliance on an
inpatient medicine unit at ALMD by
30% using the Joint Commission
Targeted Solutions Tool ® hand
hygiene methodology over a six week
period.
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Metrics of hand hygiene (HH)
compliance based on WHO/CDC HH
recommendations determined by
blinded reviews were compared before
and after implementation of Just In
time Coaching.
69/183
There was a 43%
improvement in HH
compliance on Unit 5A
after implementation of
HH Project (p <.0001).
*Joint Commission Targeted Solution Tool for Hand Hygiene (unbiased reviewers
,
Just In Time Coaches, analysis of contributing factors.)
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44% increase in hand hygiene compliance:
from 38% to 82%.
Top three contributing factors:
◦ Distractions
◦ Perceptions of need
◦ Frequency of entrance/exit.
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Healthcare workers perceived that hand
sanitizer was not required prior to donning
gloves.
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A 1% improvement in HH compliance =
savings of approximately $39,650 a year in a
200 bed hospital by mathematical modeling.
Taking into account an increment of 43% in
HH compliance, savings of $204,504 a year in
MRSA transmission prevention alone is
projected.
Cummings, Anderson, & Kaye,Infection
Control and Hospital Epidemiol
2010;31:357-364
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JIT coaching was associated with
improvement in hand hygiene compliance.
Distraction was the key contributing factor
for noncompliance.
Healthcare workers identified that they did
not recognize hand hygiene was needed prior
to donning gloves, a misperception.
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The project will be extended to other acute
care units, including surgery and
hemodialysis.
Solutions to contributing factors are being
explored in greater depth.
One solution that is being considered for
implementation is a patient education
program “It is okay to ask.” to address factor
of distraction.
The Joint Commission’s Targeted Solutions Tool, Joint Commission Center
for Transforming Health Care, retrieved 9/12/2011
http://www.centerfortransforminghealthcare.org/service
 CDC. Guideline for Hand Hygiene in Health-Care Settings. MMWR
2002; 51:No. RR-16
 Cummings, Anderson, & Kaye,Infection Control and Hospital Epidemiol
2010;31:357-364
 WHO Guidelines on Hand Hygiene in Healthcare, 2009. Available
at:http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf
Accessed 10/4/2011
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