Leadership Plan

• Hospital governance and senior administrative leadership must commit to becoming aware of this major performance gap in their own organization.
• Hospital governance, senior administrative leadership, and clinical/safety leadership must close their own performance gap by implementing a comprehensive approach.
• Healthcare leadership must reinforce their commitment by taking an active role in championing process improvement, giving their time, attention and focus, removing barriers, and providing necessary resources.
• Leadership must demonstrate their commitment and support by shaping a vision of the future, clearly defining goals, supporting staff as they work through improvement initiatives, measuring results, allocating resources, and communicating progress towards goals. Actions speak louder than words. As role models, leadership must ‘walk the walk’ as well as ‘talk the talk’ when it comes to supporting process improvement across an organization.
• There are many types of leaders within a healthcare organization and in order for process improvement to truly be successful, leadership commitment and action are required at all levels. The Board, the C-Suite, senior leadership, physicians, directors, managers, and unit leaders all have important roles and need to be engaged.

Practice Plan

• Build a strong foundation for change  by assessing the culture for change, defining the change, building a strategy,  engaging the right people, and painting a vision of the future. This should be  done at the outset of the project.

• Solicit support and active  involvement in the plan to reduce HAIs, obtain buy-in and build accountability  for the outcomes.
• Identify a leader for the HAI  initiative. This is critical to the success of the project.
• Understand where resistance may come  from.

• Align operations and ensure the  organization has the capacity to change, not just the ability to change.
• Launch the HAI initiative with a  clear champion and a clearly communicated vision by leadership.

• The capacity to support change is  critical; therefore, all leaders within the organization must be a visible part  of the HAI initiative.
• Frequent communication regarding all  aspects of the HAI initiative will enhance the initiative.
• Celebrate success as it relates to a  reduction in HAIs or a positive change in HAI organizational culture.
• Identify resistance to the HAI initiative  as soon as it occurs.

• Define hand hygiene protocol

• Who to follow hand hygiene:

• All personnel and visitors in  contact with or in the proximity of patients, including the patient.

• When to follow hand hygiene: 

• Before patient contact, sterile  procedures.
• After body fluid exposure risk,  patient contact, contact with patient surroundings.

• How to follow hand hygiene:

• Hand wash with soap and water or  hand rub over all hand surfaces with alcohol-based formulation. 
• Hand rub/hand wash for at least 15  seconds.
• Dry hands completely. 
• Do not touch potentially  contaminated surfaces after hand washing procedure.

• Educate all staff on hand hygiene  procedure and implications of non-compliance. 
• Train observers and just in time  (JIT) coaches.
• Measure current “baseline” adherence  to hand hygiene protocol with observers who sample and record compliance within  the hospital units. 

• Observers should be a role or  individual that can maintain anonymity throughout the data collection process,  be in a position where they can secretly observe staff while performing their  regular job duties, not seem out of place during their time on the unit, and  collect data that is representative of the patient population.
• Twenty to thirty observations should  be collected each day over a two to three-week period utilizing a standardized  data collection form including observation number, date and time, staff role,  entry or exit to patient room, hand hygiene - yes or no, observable  contributing factor to non-compliance.

• Identify barriers to hand washing.

• Qualitative input from secret  observers as to observable contributing factors as to why hand hygiene protocol  was not followed.
• Direct interviews with noncompliant  caregivers by just-in-time (JIT) coaches within the hospital units to identify  non-observable factors as to why hand hygiene protocol was not followed.

• Collect data on barriers to hand  washing and calculate the hospital (or unit) baseline compliance, top  contributing factors to non-compliance at your hospital (or unit), and the  compliance by role(s).
• Analyze the data to identify root  causes of why non-compliance is occurring.

• The top causes (or contributing  factors) vary across units and hospitals, roles and shifts. Thus, it is crucial  that data is first collected and analyzed to identify the factors which  contribute to hand hygiene non-compliance in your area. In order to improve  hand hygiene, it is essential that solutions targeting the specific causes are  implemented.
• Not all causes are applicable to  your organization and often there are two or three major causes that need to be  addressed.

• For instance, if the unit identifies  that “improper use of gloves” is the top contributing cause of hand hygiene  non-compliance, then the following targeted solutions can be implemented:

• Detailed training for clinical staff  on proper use of gloves.
• Relocate glove dispensers.
• Implement standard work process for  hand washing between each patient room or patient care area when delivering  food trays.
• Implement standard work process for  daily room cleaning and educate all housekeeping personnel. 

• Another example of a contributing  cause could be “frequent entry or exit.” If the unit finds that this is a top  contributing cause through the use of the TST, then the following solutions can  be implemented to improve hand hygiene:

• Implement standard work process for  hand washing after bringing mobile work machines (such as mobile vital signs  devices) into the patient room or care area but before patient  contact/interaction (such as taking patient’s vital signs). 
• Create a standard “drop spot” for  meds and supplies within the patient room that enables nursing to set down meds  and supplies and perform hand washing. 
• Implement computers and scanners at  every bedside to reduce the likelihood of cross-contamination between patients  when performing bar code medication administration.
• Implement standard work process for  room cleaning and educate all housekeeping staff.
• Create and implement a list of  supplies that will be kept within the patient care area.

• Measure progress and effectiveness  of change.

• Utilize the same data collection and  analysis tools and process utilized to calculate baseline in order to measure  progress and effectiveness.
• Identify the changes from baseline  performance for each unit, role, and shift, and identify the effectiveness of  implemented solution, any barriers to effectiveness, and any additional  solutions that need to be implemented. 
• Note: The TST includes data  collection forms and provides analyses in the form of Pareto (and other) charts  that allows your organization to track improvement versus baseline data, to  observe HAI data in correlation to hand hygiene compliance rates, and to  benchmark against national results.

• Implement a plan to ensure that  gains are sustainable.

• The plan should include the  following action items:

• Designate someone to “own” the  process (for example, the dedicated leader or a unit manager). At least one  aspect of their job function should specify that data continue to be collected,  monitored and shared with healthcare personnel.
• Replicate the findings to another  area within your organization.
• Continue real time data collection  to improve data collection.
• Train new hand hygiene observers and  JIT coaches, once per year to ensure that observers receive updated training on  an annual basis.
• Update the plan whenever changes  occur.

• The plan should be completed with  the process owner, which signals the transition of responsibility from the  project leader.
• The project leader will continue to  ensure that data is collected, entered and shared with staff at a frequency  determined by the group.

Technology Plan

Essential Criteria to Consider

1. Capable of capturing 100% of all hand hygiene events (soap and sanitizer) electronically in real-time.
2. Capable of reporting Hand Hygiene Compliance (HHC) based on the WHO 5 Moments for Hand Hygiene  at the Group, Unit, Ward or Department Level.\cite{Steed_2011}
3. Validated for accuracy in at least one peer reviewed study.\cite{Diller_2014}
4. Supported by scientific evidence of efficacy.
5. Supported with a behavior and culture change tool kit.

• Biovigil Hand Hygiene Compliance & Surveillance System
• DebMed: DebMed GMS (Group Monitoring System)
• GOJO Industries: GOJO SMARTLINK Hand Hygiene Solutions
• HandGieneCorp: HandGiene HHMS (Hand Hygiene Monitoring System
• Hyginex
• Hill Rom
• Hygreen
• IntelligentM: IntelligentM Smartband System
• Proventix: nGage
• Stanley Healthcare: Hygiene compliance monitoring system
• UltraClenz: Patient Safeguard System (PSS)
• Versus: SafeHaven with Versus RTLS and Versus Advantages Hand Hygiene Safety (HHS) software

Metrics

Topic

Observed Hand Hygiene Compliance

Outcome Measure Formula

1. Before patient contact,
2. Before aseptic task,
3. After body fluid exposure,
4. After patient contact and
5. After contacts with patient surroundings.

Metric Recommendations