Improvement Science Professional
Development Program
The Hand Hygiene Project
Sanja Mirkov, BPharm, PGDipPH
Clinical Quality Improvement Coordinator
The Hand Hygiene Project
Content and Aim
Aim
Establish reliable HH practices within CMH healthcare facilities
To increase correct HH practice rate from 60 to 80% by 30th June 2013
System
Stable in state of statistical control - improvement can be achieved only through a
fundamental change
Guidance
Methods for developing fundamental change:
1. Benchmarking or learning from others – e.g. literature search
2. Creative thinking – provoking new ideas for change - Using change concepts
3. Logical thinking about the current system – e.g. workflow checklist, comparison
of measurements in the Gold Audit
Constraints
1.Common ineffective approaches to improvement applied previously:
Trouble with performance – add more inspection
2. Negatively framed promotional activities in the past
3. Financial constraints for using technology
Strategy
1. A literature review identified successful interventions to inform CMH
multimodal strategy with an emphasis on behavioural change
2. Strengthen the team (complementary skills, equal commitment,
accountability, trust, respect and support)
3. Increase staff capability (education, training, dissemination of information)
and motivation (social marketing, persuasion, modelling)
4. Create physical (facilities, workflow, reminders, institutional safety climate)
and social environment (human networks as channels for communication
and behavioural change, engagement, community organising) that influence
staff capability and motivation
5. Identify potential quality improvement projects
6. Perform PDSAs
7. Implement successful quality improvement projects
Strategy
• The behaviour change wheel
─ Capability, Opportunity, Motivation
 Mitchie et al Implementation Science
2011;6:42
• Social Networks
 Christakis et al. PLoS ONE 5(9)
• Diffusion of innovation curve
 Rogers
Hand Hygiene Primary Drivers
Education, Training & Promotion
Facilities, Workflow and Reminders
Monitoring and Reporting
Organisational Culture Change
Driver Diagram
The
Hand Hygiene
Project
Primary Drivers
Secondary Drivers
Change Concept
Interventions
*refer to The Improvement Guide 2 nd ed Appendix A
Education,
training and
health promotion
Empowering staff to take
action
Take care of basics. Conduct training.
Give people access to information.
Empowering patients and
visitors to take action
Listen to customers. Give people
access to information.
Availability of AHR
Offer product anytime and any place.
Optimise level of inspection. Optimise
maintenance
Daily Dose communication and
dissemination
Teaching presentations
E-learning module
Patient information leaflets & video
Aim
Establish reliable
HH practices
within CMDHB
healthcare
facilities
To increase HH
practice rate from
60 to 80% by
30th June 2013
Facilities
workflow
reminders
Simplify and standardise
workflow relevant to hand
hygiene
Build reminders into the
system
Monitoring and
reporting
systems
Use reminders to build habits
Take advantage of fashion trends
Focus on outcome to the customer
Give people access to information
Performance
Alcohol hand rub consumption
Use proper measure
Clinical
HAI rate, mortality, pathogen
burden
Focus on outcome to the customer. Focus
on purpose. Give people access to
information
Economic
LOS, cost
Focus on outcome to the customer.
Focus on purpose. Give people access to
information
Patient Experience
Listen to customers.
Focus on purpose. Give people access
to information
Doctors’ engagement
Nursing engagement
Allied Health engagement
Non-Clinical Support Services
engagement
Outpatients engagement
Personal AHR for physicians in EC
CCC procedures
Phlebotomist’s procedures
Hand Hygiene posters
Performance
Gold Audit
Senior leaders and managers
engagement
Culture
change,
leadership and
social
movement
Smooth workflow. Reduce number of
components. Standardisation
Set up sustainable supply of AHR
Develop alliances and cooperative
relationships
Listen to customers. Focus on outcome
to the customer. Give people access to
information
Audience segmentation
Social influence. Mobilise social norm
Behavior change
Real time feedback by Gold Auditors
Volume per 1000 patient days
Target 20L per 1000 patient days
Real time reporting of
performance, clinical, economic
outcomes and patient experience
Case study presentations
Reports design and dissemination
Patient stories
Identification of central people in
the network
Hand Hygiene Staff Survey
Real time reporting of
performance, clinical, economic
outcomes and patient experience
Hand hygiene champions
meetings
Hand hygiene campaigns
Simple rewards
Communication, engagement,
community organising
Measures
Name of
Measure
Is this an Outcome,
Process or Balancing
Measure?
Operational Definition
(e.g., numerator &
denominator)
Gold Audit on hand hygiene
practice, adherence per
hand hygiene moment,
adherence per HCW group
Process
(Correct moments / Total
moments) x 100 =
compliance rate (%)
>70% National Standard
Volume of hand gel per
1,000 patient days
Process
> 20L / 1,000 pt days
WHO standard
The WHO Hand Hygiene
Self-Assessment
Framework
Balancing
Total Score related to
Hand Hygiene Level
The rate of S aureus,
MRSA, ESBL, C. Difficile
associated infections
Outcome
Number of cases / 1,000
patient days
Change Concepts & Ideas for PDSAs
Opportunity
Idea for Testing in a PDSA
Theory and prediction about what will happen
when you test this idea
Phlebotomists’ blood
collection procedures
Help staff embed best evidence-based practice into
their procedures. Smooth workflow. Reduce number
of components. Standardisation. Staff education.
conduct training, develop alliances and cooperative
relationships
Test: Number of procedures reduced from 5 to 2
Gold Audit October 77%
Gold Audit March 81.8%
Critical Care Complex
Hand hygiene for most
common 5 procedures:
before/ after insertion of the
central line, catheter,
suction, NG tube, rectal tube
Reasons for M2 and M3 being missed is confusion
about the procedure. Smooth workflow. Reduce
number of components. Standardisation.
Gold Audit October M2= 21% M3 = 31%
Gold Audit March prediction 50%
Hand gel consumption
Use proper measure. Expect increase in consumption
with increase in performance
Change Concepts & Ideas for PDSAs
Capability & Motivation
Idea for Testing in a PDSA
Theory and prediction about what will happen
when you test this idea
Sending repetitive messages via Develop alliances and cooperative relationships,
central people in the network
education, training, motivation, persuasion, role
(26 per year)
modelling
1. Gold Audit Correct HH adherence rate per
Content: Teaching, training video, patient stories, HCW group
audit feedback, celebrations, campaigns
2. Cumulative number of staff attended sessions
over time – Behaviour adoption curve
Identifying the new network of
3. Number of staff initiating own sessions hand hygiene champions
Behaviour adoption curve
e.g. Allied Health workforce
Meetings with the central people
in the network
e.g. HH Champions meeting
Hand Hygiene Staff Survey
Develop alliances and cooperative relationships,
education, training, motivation, persuasion, role
modelling – celebrating successful initiatives
Questions exploring reasoning, behavioural,
normative and control beliefs – to be administered
following the Gold Audit
Cummulative number of staff
11
/0
2
13 /13
/0
2
15 /13
/0
2
17 /13
/0
2
19 /13
/0
2
21 /13
/0
2
23 /13
/0
2
25 /13
/0
2
27 /13
/0
2
01 /13
/0
3
03 /13
/0
3
05 /13
/0
3
07 /13
/0
3
09 /13
/0
3
11 /13
/0
3
13 /13
/0
3
15 /13
/0
3
17 /13
/0
3
19 /13
/0
3
21 /13
/0
3
23 /13
/0
3
25 /13
/0
3/
13
0%
Dissemination of staff education via CNE / HH Champions
network
250
200
150
100
50
0
Apr-11
Mar-11
Purchased litres per 1000 bed days
Median
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Litres of ABR purchased per 1000 bed days
Median
01/01/13
01/12/12
01/11/12
01/10/12
01/09/12
01/08/12
01/07/12
01/06/12
01/05/12
01/04/12
01/03/12
01/02/12
01/01/12
01/12/11
01/11/11
01/10/11
01/09/11
01/08/11
01/07/11
01/06/11
Litres of Alcohol based hard gel purchased per 1000 bed days at MMH
01/05/11
01/04/11
01/03/11
01/02/11
20
01/01/11
40
01/12/10
40%
01/11/10
140
01/10/10
Run chart of Hand Hygiene Compliance from Gold Audit Results
Feb-11
Jan-11
Dec-10
Nov-10
Litres
60%
Oct-10
Sep-10
100%
01/09/10
Jan-13
Nov-12
Sep-12
Jul-12
May-12
Mar-12
Jan-12
Nov-11
Sep-11
Jul-11
May-11
Mar-11
Jan-11
Nov-10
Sep-10
Jul-10
May-10
Mar-10
Jan-10
Nov-09
Sep-09
Jul-09
May-09
Results of your PDSAs
120
litres of hand gel purchased per 1,000 bed days at MSC
80%
120
100
100
80
80
60
60
40
20%
0
20
0
20 litres per 1,000 bed days target
Target of 20 litres per 1000 bed days
Profound Knowledge Worksheet
Appreciation for a System Psychology
• Facilities and workflow
• Reminders
• Institutional safety culture
•The Behavioral change wheel (Michie et al)
• Altruism, empathy, morality, solidarity
• Social marketing
• Liberating leadership
• Positive psychology
Theory of Knowledge
Understanding Variation
• Statistics
• Public health
• Behaviour adoption life cycle curve (Rogers curve,
Christakis et al)
• Human factors engineering
• Teaching, simulation
• Hand hygiene activity monitoring
• HAI burden
• Volume of hand gel
11
Process Changes and Results
• Positive, consistent messaging
• Engagement at a ward/unit/occupational group level
• Identification and engagement of “activists-in-place”
─ Endogenous generation of improvement activities
• Ongoing communication and feedback, education and training,
persuasion, role modelling
• Provision of supportive physical and social environments
• Acknowledgement of staff initiatives
March Gold Audit
Interim Report
• Ward A
─ October 40.7%
─ March 73%
• Ward B
─ October 38.5%
─ March 58.6%
• Ward C
─ October 58%
─ March 58.2%
©2011 Institute for Healthcare Improvement/R. Lloyd
Next Steps
•
Developing additional
resources
•
Broadening the base of
our champions and
members of the HHWG
•
Beginning the top-down
phase of our social
marketing campaign
•
Considering improving
measurement
©2011 Institute for Healthcare Improvement/R. Lloyd