HAND HYGIENEEveryone 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 Performance1. 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)
2. Set goals for improving compliance with hand hygiene guidelines. (2. See also IC.03.01.01, EP 3)
3. Improve compliance with hand hygiene guidelines based on established goals.
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
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
HAND HYGIENE BUNDLE
1. Establish ongoing monitoring and feedback on infection rates
2. Establish administrative leadership and support3. Establish a multidisciplinary design and response
team4. Provide on-going education and training for
staff, patients, families and visitors5. Ensure hand hygiene resources are accessible
facility wide and at the point of care6. Reinforce hand hygiene behavior and
accountability7. Provide reminders throughout the health care
setting8. Establish on-going monitoring and feedback
of hand hygiene compliance
AJIC. Vol.40, No.4, Supplement 1. May 2012.
POLICY AND PROCEDURE
Expectations Products Procedures Program Description
Healthcare Workers Family/Visitors Patients
Joint Commission Monograph Measuring Hand Hygiene Adherence:
Overcoming the Challenges (2009)
Patient Survey Data
Real Time Engagement
TECHNOLOGY FOR REMINDING, MONITORING AND COMPLIANCE
AN OLDIE, BUT A GOODIE?!
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