Applying Lean Principles to Identify Barriers to Hand Hygiene
Background
Changes Made
• Hand Hygiene (HH) is the single best way to prevent the spread of Healthcare Associated Infections (HAIs) and
provides an ideal opportunity for application of lean principles to healthcare worker (HCW) behavior.
• A Hand Hygiene Toolkit was created as a resource for management and staff
including education on the importance of HH, institutional policies and expectations,
barriers to measuring HH, and suggested approaches for implementation of HH
improvement efforts into daily practices.
• Despite overwhelming evidence and knowledge around the importance of HH, Hand Hygiene compliance of healthcare
workers in hospitals across the country hovers between 18% - 45%.
• Institutional policy for Hand Hygiene was simplified and disseminated throughout
the institution via intranet and email from Senior Leadership.
• Our institution identified similar trends of compliance with HH performance hovering around 30% upon entering and
exiting a patient room on two pilot inpatient units after implementation of an aggregate Electronic Compliance Monitoring
(ECM) system (GoJo Smartlink.)
• To better incorporate Hand Hygiene into daily practices and to integrate with
institution-wide Lean approaches, a HH measure was added to the unit’s KPIs (Key
Performance Indicators) on their MDI (Managing for Daily Improvement) board. The
board was also moved from the nursing workroom to a unit hallway to allow for
multidisciplinary engagement in HH efforts.
Aims
An institutional goal, incorporated into the hospital Annual Operating Plan, was established to reach or exceed 75% hand
hygiene compliance upon entering and exiting a patient room or area.
HH compliance rate is visible 24/7 on a screen
on the unit, and is summarized and shared
weekly at multidisciplinary rounds.
Project Design/Strategy
• A multidisciplinary Hand Hygiene Leadership Committee
was established providing representation from various
clinical, administrative, operational, and quality
improvement disciplines
• UCM is testing ECM to measure hand hygiene, with the
hopes that better data will help us to improve actual hand
hygiene performance.
• Two pilot units were selected to testing an aggregate
ECM system in the adult inpatient setting. The team is
applying Lean Principles to attempt to improve hand
hygiene on those units.
• Voice of the Customer interviews were conducted on the
pilot units to identify current views around HH behavior,
reported compliance of HH for that unit, and the ECM
system (see right for summary of themes.)
• This data was then extracted and analyzed using an
Affinity approach. A team of leaders and front line staff
from the pilot unit used the affinitized data to assist with
the identification of potential failure modes and root
causes of poor hand hygiene compliance.
• The team brainstormed potential solutions to those
opportunities and then evaluated those opportunities
based on impact to goal and ease of implementation. This
allowed the team to prioritize and create an improvement
roadmap.
Affinity Summary
Number of Responses Containing Theme
Affinity Group
Think current # is low/bad
Other Staff (sum of MDs specifically and any other)
Other Staff - MDs
Other Staff (any other than me personally or my discipline)
Patient, family, visitors
Forget
Urgency
Not enough time
GoJo User Interface
Don't Understand GoJo
Don't believe #s (are right or accurate)
Believe the #s
Standards unclear
Dispenser/HH equipment Issues
But I'm not touching anything…
Washed on way out, don't need to again on way in
Empty Rooms
Other count against when it shouldn't
Reminders (including POC, signs, and verbal)
Education
Accountability
Make it a competition
Offer rewards
Provide data
Provide data by discipline
South
West
Both Units
Combined
7
14
11
20
18
34
8
9
17
6
11
17
10
3
1
4
1
8
2
6
1
7
9
1
1
2
8
5
13
2
3
5
23
5
4
9
1
19
10
19
3
10
17
3
2
2
16
17
7
3
3
12
4
3
2
5
11
8
13
2
3
8
2
1
8
12
7
1
7
4
Larger Affinity Group
57
It's not me, it's
you
18
Spectrum of
forget, no time,
urgent/emergent
• Multidisciplinary huddles were created and expectations around attendance set by
hospital leadership to ensure engagement of all disciplines around HH through
huddles held at the MDI board. Hand Hygiene is also a recurring topic at weekly
multidisciplinary rounds.
• A roadmap for designing improvement of hand hygiene compliance was created,
setting monthly Just Do It events with representation from clinical, administrative,
facility planning, environmental services, and ancillary support staff dedicated to
implementation of agreed upon solutions. Events to date have focused on design of
workflow to ensure successful hand hygiene compliance, including:
• Room set up for new patients
• Environmental services workflows & ensuring that pumps are always
full
• Placement of soap and sanitizer pumps
• Documentation and use of workstations on wheels
Team members complete a fishbone diagram to
help understand “why are dispensers empty?”
System counts
against us when it
24
shouldn't
(perception)
How to improve
Acknowledgements
We would like to acknowledge the project teams from 8 South and 8
West including Denise Berry, Martina Buttilgero, Aurea Enriquez,
Cheryl Esbrook, William Fowler, Nateisa Hawkins, Catherine Houda,
Liz Martin, Sherwin Morgan, Mark Myren, Michael O’Connor, William
Pharr, Abigail Poiner, Megan Stulberg, Anthony Stull, Elaine
Tsiakopoulos, David Velasco.
• Future events will address:
• Transporting patients (specifically when PT/OT exit & enter room with
the patient)
• Supply storage and the need to leave a patient room to get supplies
• Empty patient rooms
• Interdisciplinary champions and methods for individualized feedback
Outcomes & Lessons Learned
• Multidisciplinary engagement has been successful as
measured by participation of each discipline in the Just Do
It events. We will also track attendance of each discipline at
unit-based shift huddles.
• The first pilot unit has shown small improvement over the
first few months and
• Hand Hygiene performance continues to be monitored with
anticipated improvement as improvement initiatives are
rolled-out.
Next Steps
The developed Road Map will be followed and executed over
the upcoming year, with Just Do It events guiding the design
and implementation of individual interventions. The Plan-DoStudy-Act approach will be used to assess individual
improvement initiatives and to monitor the overall effect on
Hand Hygiene performance throughout this year-long journey.
As the pilot units learn from their tests of change, those
learnings will be integrated into the Hand Hygiene Toolkit.
Authors: Hand Hygiene Leadership Committee, University of Chicago Medicine