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Reality Check: Joint Commission drops 90% hand hygiene compliance expectation
Leading hospitals had a shocking 48% baseline
The Joint Commission has amended an infection control standard that called for hand hygiene compliance of more than 90%, conceding that the expectation was too high after a group of eight leading hospitals could muster only an 82% rate in a performance improvement project.
The original goal of the project was to achieve and sustain 90% compliance. Collectively, the hospitals came up short, causing the Joint Commission to rethink the wording in its hospital standards. Previously, the standard called for hospitals to demonstrate hand hygiene compliance at a rate greater than 90%. A hospital that failed to comply would receive a Requirement for Improvement (RFI) and have 90 days to show improvement to 90%.1
"Because of this project, we now know how difficult it is to reach 80% let alone 90%," says Melody Dickerson, RN, MSN, a Robust Process Improvement (RPI) Black Belt at the Joint Commission. "Now the standard says the hospital `needs to work to improve compliance.'"
Though ultimately a success story to a large degree, the Joint Commission project had one other rather startling footnote: the baseline hand hygiene compliance rate at the hospitals was a collective 48%.
"When we first started this project all the organizations thought that they were around 80%–85%," she says. "It was only when we did a true non-biased measurement that we found exactly where we were. It was surprising and shocking, but when you look at the literature that's about where most people are."
Historically, the odds of a health care worker having washed their hands before touching a patient have been roughly equivalent to a coin flip. Heads the patient wins, tails they could be joining the 100,000 souls lost every year to healthcare-associated infections (HAIs). However, many hospitals in the project have reported a decline in HAIs as their hand hygiene compliance rate dramatically increased, the Joint Commission reported. Though the compliance level jumped an impressive 34% at the hospitals overall, the reality is that a disturbing number of patient encounters are still carried out with unwashed hands.
"It begs the question: Was greater than 90% even an obtainable goal when you consider where you're starting from?" says Dickerson, one of the project leaders. "What we found through this process is that some organizations are greater than 90%; others have not had as great of success. A lot of that depends where you start from."
Hand hygiene the top problem
Though the baseline levelsassessed through using non-biased hand hygiene observers or "secret shoppers"were disappointing, the participating hospitals were not complacent. They all listed hand hygiene compliance as their top patient safety problem after agreeing to collaborate on The Joint Commission Center for Transforming Healthcare's first Robust Process Improvement (RPI) project by. (See list of hospitals, below.) .
Hospitals picked hand hygiene as top patient safety challenge
Hand hygiene was chosen as "the number one patient safety challenge" by eight leading hospitals for the first Robust Process Improvement (RPI) project by the Joint Commission Center for Transforming Healthcare.
The eight hospitals that participated in the Joint Commission hand hygiene project are:
Top 10 reasons HCWs fail to wash hands
A distracted worker with hands full
In a hand hygiene improvement project by the Joint Commission's Center for Transforming Healthcare, the following common barriers to compliance were observed across the eight participating hospitals.
The project started in December 2008, when representatives from the eight hospitals met to define the scope of the project, which is the first step in the five-step Six Sigma methodology: define, measure, analyze, improve, control. From April 2009 through August 2010, the participating hospitals defined and measured hand hygiene, according to a Joint Commission report on the project.
The hospitals identified the major barriers to hand hygiene and worked on developing targeted solutions for each root cause or contributing factor.
"Probably the big three are hands full, distractions and gloves," Dickerson says. Concerning the latter, a recurrent problem is non-clinical staff members going from room to room without changing gloves.
"A big part of it is an education problem," Dickerson says. "And part of it is changing people's perception. They perceive that if they put on gloves they don't need to wash their hands and that is, in fact, not the case. So it is education, but it also requires change management."
Project solutions were developed and change enacted according to the Joint Commission's Targeted Solutions Tool (TST), which allows organizations to customize solutions to address their specific barriers to excellent performance. (See related story, below.) Hand hygiene was defined as washing or cleaning hands with an alcohol based foam or gel or soap upon entry and exit of a patient care area or environment. Information was gathered by using the hand hygiene observers and "just-in-time" coaches.
A tool to target the solution
From getting started to holding the gain
In a hand hygiene improvement project by the Joint Commission's Center for Transforming Healthcare, participating hospitals used a Targeted Solutions Tool (TST). Available to all accredited organizations, the Joint Commission TST model provides the user with the data collection tool, data entry programming, self-supported observer training module and real-time reporting of compliance rates complete with charts that can be downloaded and printed for display.
The TST includes a six-step process:
Step 1: Getting Started. This first step includes determining who will be on the team and understanding stakeholders involved in the process. For example, in the ICU the hospital's dietary staff does not see patients, so their buy-in would be low. But on the medical/surgical unit, they deliver trays to every patient.
Step 2: Training observers entails training hand hygiene data collectors, or observers, and just-in-time coaches. It involves giving them the tool to begin collecting data and documenting contributing factors and compliance. The tool has a structured education program and a test at the end.
Step 3: Measuring compliance comprises collecting data and entering in data tool, a Web-based application that is part of the TST.
Step 4: Determining factors includes getting charts, which includes compliance charts, analysis charts and means chart.
Step 5: Implementing solutions by analyzing data from charts to identify the top three contributing factors for failure to wash hands. For each contributing factor, the TST provides a set of implementation guidelines.
Step 6: Sustaining the gain, which means rethinking the data collection plan to continue to monitor the process. Keeping compliance at a high rate requires continuous reinforcement.
(Editor's note: The Joint Commission TST and related materials are available at: http://bit.ly/91ODmt)
"The just-in-time coaches give immediate feedback to someone when they see them not washing their hands," Dickerson says. "In the early stage of the project we did have them collect data because there are contributing factors that we can't see, like distractions or [a worker's] perception that hand hygiene is not required.
Although any staff member in an organization could be trained to be a hand hygiene observer, members of the leadership teams were encouraged to participate as just-in-time coaches. Ultimately, the goal was to engage all staff to do just-in-time coaching, which will lead to sustained improvements.
"You need to work with the staff to implement solutions so they feel like they have been a part of the process," she says. "Then you see this whole culture shift within the unit. Now all of a sudden everyone is a just-in-time coach. If somebody from another department comes on the floor -- and it's not just nurses, it's laboratory, dietary, environmental services, volunteers -- and they are not washing their hands they, are reminded by [all] staff."
Making HH a part of work flow
A prime objective was helping workers blend hand washing into their routines, making it a part of the process rather than a separate task.
"One thing a lot of hospitals found when they were going through this project is that you may have a lot of alcohol based hand rubs in the patient care areas, but [they are not] where they need to be," Dickerson explains. "They need to be in your line of work flow. You track the path that they take when they enter the room and you want to have a hand hygiene dispenser at the place where they stop, which might be next to a computer where they do their charting."
Visual remindersincluding posters on walls in units, on elevators and by dispensers, and stickers on dispenserswere used to some extent by all the hospitals. It's a familiar approach, but one take home point is that signage needs to be switched out regularly so it doesn't become lost in the woodwork. In addition, visual cues and reminders also can help workers who become distracted.
"Some places will implement a code word, a phrase that is code for `wash your hands," she says.
The lingering question after such efforts is whether the gain can be maintained rather than slowly lapsing toward baseline levels.
"The last step is in the control phase -- unlike other projects that organizations may have gone through for hand hygiene and other things," Dickerson says. "They do this great project -- focus on this one aspect of care for weeks or months -- and then all of a sudden you're working on something else. That's a really strong message to the staff that it was `the flavor of the week' and now we are on to something else."
Thus it's critical to maintain observations, though at a lower rate than during the active phase of the project. "It won't be the 10 to 20 observations that you were collecting during the active phase of the process but it might be 10 observations a week," she adds. "Continue to share that information with staff and [make sure you] continue to see improvement in your numbers over the long term. It seeds the message to staff that this has an ongoing importance to our organization."
Joint Commission pushing for flu shot improvement
Expanded standards under field review
As this issue went to press, more stringent standards for influenza immunization of hospital workers were under consideration by the Joint Commission. As proposed in a field review open to comment through May 17, hospitals would have to document and report flu immunization efforts more completely and strive for continuous improvement.
Infection control standard 02.04.01 currently requires that hospitals establish an annual influenza vaccination program that is offered to licensed independent practitioners and staff. The Joint Commission is proposing adding the following stipulations and performance aspects to the standard:
(For more on the Joint Commission field review on flu immunization in hospitals and other settings go to: http://bit.ly/ew1yv2)
Joint Commission ready to partner up
TJC center to link with Partnership for Patients
The Joint Commission has pledged its full support for the recently formed Partnership for Patients, a public-private effort to make hospital care safer by reducing health care associated infections and other preventable adverse events.
The Joint Commission applauded the Centers for Medicare & Medicaid Services' leadership in developing a multi-faceted framework for addressing critical safety and quality issues. The framework is unique because the federal government recognizes that hospitals need to be given assistance with innovative and customized tools in order to achieve effective and sustainable solutions to these difficult problems, TJC noted.
"We hope that The Joint Commission and its Center for Transforming Healthcare will play a vital role in the Partnership for Patients by identifying and testing solutions for preventing patient harm and improving the continuity and effectiveness of care, as well as providing technical assistance to health care organizations as they seek to implement these solutions," TJC said in a statement.
By the end of 2013, the Partnership for Patients aims to decrease preventable hospital-acquired conditions by 40% and reduce by 20% hospital readmissions caused by preventable complications during a transition from one care setting to another.
(For more information on the partnership go to: http://1.usa.gov/gj8iFV)