increasing hand hygiene compliance in the inpatient and outpatient setting l.
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INCREASING HAND HYGIENE COMPLIANCE IN THE INPATIENT AND OUTPATIENT SETTING. TEAM MEMBERS. JANIS BARTEL, MSN, CIC MICHAEL KOLLER, MD NATIONAL PATIENT SAFETY GOAL LIAISONS AMBULATORY MANAGERS. OPPORTUNITY STATEMENT.

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team members

TEAM MEMBERS

JANIS BARTEL, MSN, CIC

MICHAEL KOLLER, MD

NATIONAL PATIENT SAFETY

GOAL LIAISONS

AMBULATORY MANAGERS

opportunity statement
OPPORTUNITY STATEMENT

Compliance with hand hygiene before and after patient care is mandated by the Centers for Disease Control as part of the Hand Hygiene Guidelines. Hand hygiene is a JCAHO National Patient Safety Goal.

slide4
GOAL

90% compliance per JCAHO

most likely causes of non compliance
MOST LIKELY CAUSESOF NON-COMPLIANCE
  • Perceived lack of sink availability
  • Perceived lack of time for hand washing
  • Hand gel dispensers not always functional
  • No effective tracking system for hand hygiene compliance in the outpatient setting
solutions implemented in 2005
SOLUTIONS IMPLEMENTED IN 2005
  • Assembled a project team with a physician from QI, an Infection Control Practitioner, inpatient and outpatient managers and the Director of Housekeeping to share monitoring data
  • Hand gel product changed by the manufacturer and faulty.Product changed back and functioning well.
  • Housekeeping staff regularly checking dispensers in all areas to insure functionality
  • Standardized auditing system for hand hygiene compliance using the portal has been developed in the outpatient areas
solutions implemented in 2005 continued
SOLUTIONS IMPLEMENTED IN 2005(continued)
  • Cartoon series on hand hygiene in “Inside the System” has helped to maintain awareness of the project
  • Monthly audits continued by safety liaisons and feedback of compliance sent to administration
  • Hand washing reminder signs posted in public restrooms on the first floor of the hospital
  • Physicians received a pocket sized bottle of hand gel with song sheet sung to the tune “Jingle Bells” as a Christmas gift
analysis
ANALYSIS

The rates of overall hand hygiene compliance are close to 90% in the inpatient units and above 90% in the outpatient areas

next steps
NEXT STEPS
  • Continue monthly hand hygiene auditing and provide feedback to administrators and health system committees to maintain continuous awareness of compliance.
  • Identify opportunities for improvement in under performing clinical areas and assist in developing strategies to improve compliance
next steps continued
NEXT STEPS (continued)
  • Continue to identify and eliminate barriers to the consistent practice of hand hygiene
  • Continue regular hand hygiene task force meetings