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Joint Commission Update for Infection Control
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)