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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
1.
2.
3.
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
1.
2.
3.
4.
5.
6.
7.
8.
Establish ongoing monitoring and feedback on
infection rates
Establish administrative leadership 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 reminders throughout the health care
setting
Establish on-going monitoring and feedback
of hand hygiene compliance
POLICY AND PROCEDURE
Expectations
 Products
 Procedures
 Program Description

PRODUCT PLACEMENT
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
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