There is new evidence that use of a hand hygiene improvement tool developed by The Joint Commission’s (TJC) Center for Transforming Healthcare can not only improve compliance, but also contribute to significant reductions in health care-associated infections.

Investigators at Memorial Hermann Health System (MHHS) in Houston reported that after implementing TJC’s Web-based Targeted Solutions Tool (TST) for hand hygiene in 150 inpatient units throughout its 12-hospital system, and conducting a process improvement project from October 2010 to December 2014, hand hygiene compliance improved from 58.1% at baseline to 95.6% in the final year of the project, based on 31,600 observations. Further, during this same period, rates of central line-associated bloodstream infections decreased by 49% and ventilator-associated pneumonia in the adult ICU decreased by 45%.1

The improvements stem from MHHS’s participation in TJC’s Center for Transforming Healthcare’s inaugural project in 2009, designed to improve hand hygiene. As part of this effort, MHHS and seven other organizations worked to systematically identify strategies for amassing hand hygiene compliance data. They also identified the root causes and factors related to non-compliance, and then implemented interventions to combat these issues.

The Center for Transforming Healthcare then used the information collected during this phase of the project to develop its TST, an application that is based on robust process improvement methodologies such as Lean, Six Sigma, and change management. Investigators noted that the tool guides organizations through a hand hygiene improvement effort. Four hospitals, including Memorial Hermann’s Northwest Hospital, then pilot tested the tool with all four facilities, demonstrating substantial increases in hand hygiene compliance.

At this point, investigators reported that MHHS elected to implement the TST in all 12 of its hospitals as soon as the tool became available in September 2010. MHHS then commenced a study to measure the effect, which included a baseline period to collect pre-implementation data, an improvement phase during which TST-guided interventions were employed, and a control phase to assess whether the improvements achieved in hand hygiene compliance were sustained. Investigators reported that data show MHHS was able to maintain substantially improved compliance throughout its 12 hospitals for 25 months following implementation.


  1. Shabot M, et al. Using the targeted solutions tool to improve hand hygiene compliance is associated with decreased health care-associated infections. Jt Comm J Qual Patient Safe 2016;42:6-17.