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Joint Commission Update for Infection Control
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.
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, p. 3.) 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.
"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."
1.Joint Commission for Transforming Healthcare. Hand hygiene project: Best practices from hospitals participating in the Joint Commission Center for Transforming Healthcare Project. November 2010: http://bit.ly/fqI2yb