INCREASING HAND HYGIENE COMPLIANCE IN THE INPATIENT …

Report
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
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.
GOAL
90% compliance per JCAHO
MOST LIKELY CAUSES
OF 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
• 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)
• 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
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Percent Compliance
RESULTS OF INPATIENT OVERALL COMPLIANCE
Hand Hygience Overall Compliance
Individuals
Temporary: UCL=92.02, Mean=82.30, LCL=72.58 (mR=2)
UCL
90
Liaisons Audited Adjacent Units (Aug, Sept, Oct, 2005)
85
Mean
80
75
LCL
ay
04
(2
3)
J u (26
)
n
04
(
J u 23
l0 )
4
(
A 15
ug )
0
S 4(
ep 5)
04
(1
O
ct 4)
04
(
N
ov 18)
04
(2
D
ec 0)
04
J a (75
)
n
05
F
eb (75
05 )
M (11
ar
4
05 )
A (33
pr
4
05 )
(3
M
ay 35
)
0
J u 5 (3
ne 28
05 )
(
J u 349
l0
)
5
A (37
ug
0
05 )
(
S
ep 389
05 )
O (39
ct
0
05 )
(4
N
ov 01
05 )
(3
D
ec 78
05 )
J a (41
5
n
06 )
(4
F
eb 22
06 )
(4
23
)
M
04
(2
6)
20
pr
2)
(1
120
A
4
04
ar
0
eb
M
F
Percent Compliance
RESULTS OF OUTPATIENT OVERALL COMPLIANCE
Ove rall Hand Hygie ne Compliance
Ambulatory Obse rvations
UCL = 120.19
100
UCL = 97.11
Mean = 90.15
LCL = 83.19
80
Mean = 70.28
60
40
LCL = 20.38
Conf idential: For Quality Improvement Purposes
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
• 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)
• Continue to identify and eliminate barriers to the
consistent practice of hand hygiene
• Continue regular hand hygiene task force meetings

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