Hand Hygiene Everyone 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 Performance • 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) • Set goals for improving compliance with hand hygiene guidelines. (2. See also IC.03.01.01, EP 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
AJIC. Vol.40, No.4, Supplement 1. May 2012. Hand Hygiene bundle • Establish ongoing monitoring and feedback on infection rates • Establish administrativeleadership and support • Establish a multidisciplinary design and response team • Provide on-going education and training for staff, patients, families and visitors • Ensure hand hygiene resources are accessible facility wide and at the point of care • Reinforce hand hygiene behavior and accountability • Provide remindersthroughout the health care setting • Establish on-going monitoring and feedback of hand hygiene compliance
Policy and Procedure • Expectations • Products • Procedures • Program Description
Communication: Education/Reminding • Healthcare Workers • Family/Visitors • Patients
Monitoring • Joint Commission Monograph • Measuring Hand Hygiene Adherence: Overcoming the Challenges (2009) iScrub
Feedback Real Time Engagement Observation Data Patient Survey Data
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