Quick Wins in Quality: Hand Hygiene, Disinfection, Sepsis Reduction
May 1, 2019
Quality improvement professionals are reporting more “quick wins” in which a relatively simple change in processes and procedures yields significant advances in patient care and safety. Germ-zapping robots and handwashing monitors can both be introduced with minimal effort and bring great advances in quality of care.
Seeking quick wins is a good quality improvement strategy, says Craig Clapper, PE, CMQ/OE, partner in transformational advisory services with Press Ganey, a quality improvement consulting company based in South Bend, IN.
“The complex systems in healthcare are made up of small things that work in concert, so it works to make improvements in those small ways and watch them build on one another to improve quality overall in what we see as much more complex systems,” Clapper says.
Many small improvements are the result of self-checking, a component of the Stop–Think–Act–Review (STAR) process for quality improvement, Clapper notes. People using STAR will pause often and especially at critical junctures to self-check, asking if they are prepared for upcoming tasks, assessing their work, and reviewing the results. Frequent use of this technique will reduce errors over time, Clapper says.
Healthcare organizations with employees who are more engaged with their work are more likely to self-check and reduce errors, he notes. (Press Ganey’s recent report on workforce engagement found that higher engagement was associated with higher quality scores. See the related story in this issue for more information.)
“If everybody did that one-second pause 200 times a day, it would cut their harm rate in half,” Clapper says. “That’s a pretty good investment, a little more than three minutes a day, for such a drastic reduction in harm.”
Healthcare organizations can facilitate such self-checking by making the environment more hospitable to it, Clapper says. Some facilities, for example, will delineate an area around the automated medication dispensing machine as a “no interruption” zone or a “quiet zone” with signs, flashing lights, or different-colored tiles and walls. Employees are taught that anyone working in that area must not be disturbed because they are focusing on a critical function and need to concentrate on the STAR process, Clapper explains.
Clapper recalls another facility that was having a problem in their perioperative area in which people would hit the “door open” button and the wrong door would open, not the one they wanted. They mounted a set of shields that discouraged people from hitting one set of buttons if they were coming from a direction that indicated they probably wanted the other doors.
“That kind of fix is generally referred to as error-proofing, and I think we need to invest more in that simple kind of solution,” Clapper says.
Self-checking is among several strategies used to improve patient safety at Indiana University Health in Indianapolis. Katherine Feley, DNP, RN, CPPS, system director of patient safety, says repetition is a key to making such strategies work.
“Repetitive education on these methods is necessary to make them effective. Teaching people about it one time is not going to be enough,” Feley says.
“It also is important to recognize team members when these methods are used appropriately. One of our strategies is a Great Catch program in which we celebrate near misses, and another is a program in which we celebrate team members who displayed mindfulness or situational awareness related to safety culture.”
One example was a pharmacy technician who used STAR to recognize that there was a problem with a prescription filled by the hospital’s automated dispensing machine. She called attention to the potential error, which resulted in a reprogramming of the dispensing system to avoid future errors.
Clapper says the focus on self-checking and smaller solutions is a good approach, even though so much of quality improvement seems to involve grand projects with big goals.
“I think we’ve invested too much in trying to re-educate the staff and write a new policy to solve every problem, when sometimes simple error-proofing will improve safety and quality of care,” Clapper says. “A good philosophy is fewer rules and more tools.”
Robots Zap Pathogens
That philosophy was used at White County Medical Center in Searcy, AR, to improve room cleanliness and reduce infection rates. The hospital already had low rates of hospital-acquired infections but was striving for zero, says Meghann Holmes, RN, infection preventionist.
Antibiotic-resistant superbugs also were a concern, so the hospital decided to supplement its normal room-cleaning and disinfection routine with machines that use ultraviolet light to kill pathogens on exposed surfaces. The hospital acquired the robots and added them to the cleaning protocol for its environmental services department.
The devices were an addition to the standard cleaning protocol rather than replacing any existing steps, Holmes explains.
The environmental services staff cleans the room as usual and then places the robot in the room to shine ultraviolet light on all exposed areas as an extra disinfection measure. Each cycle takes about five minutes, and a typical room will require one cycle on either side of the bed and another in the bathroom.
“That’s going to kill anything that is left behind after the cleaning process. Any time you are wiping down a surface you might miss something, so this is another step that comes along and kills anything left behind,” Holmes says.
Significant Decrease in Infections
The robots at White County Medical Center use a high-intensity, pulsed xenon ultraviolet light that kills Clostridioides difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococci, in addition to other common pathogens.
The hospital began with three robots in use on four units that were at higher risk of infection because of the volume and type of patients. It soon purchased another three devices, which are enough to cover all inpatient rooms and operating rooms in the 438-bed hospital.
Infections decreased 71% in the first year, with a related cost savings of almost $250,000, Holmes says. Each disinfection unit costs about $100,000 to purchase.
For the ORs, the devices are used once at the end of the day, after routine cleaning.
Using the robots adds about 15 minutes to the cleaning time for each room, although staff can still clean the bathroom while the device is disinfecting the rest of the room, and vice versa, Holmes notes.
“I was worried that our environmental services staff would not be on board with that because it does add a little bit of time to their room turnover and like everyone else, they have a lot to do,” Holmes says. “But they absolutely love it. They feel good that they’re doing something extra with this technology. It boosts them to feel like they are contributing more and able to prevent infections by using these devices.”
Monitors Improve Hand Hygiene
Another quick win came from the use of technology that monitors handwashing. Hospital Corporation of America (HCA), based in Nashville, TN, has implemented systems that use radio frequency identification technology to track whether employees are washing their hands between patient encounters.
Employees wear badges that can be detected by devices in patient care areas, and they are allotted a certain amount of time to clean their hands after entering, explains Tammy F. Raz, BSBA, BSHI, MHA, systems business analyst at HCA in Orlando, and administrator of the hand hygiene program.
The technology detects whether the employee comes in close proximity with the handwashing station or hand sanitizer. For some patients, handwashing is required rather than using the sanitizer.
“When they exit the room, they also have a certain amount of time to clean their hands again by going to another handwashing or sanitizer station. We try to keep a very high compliance rate for our staff, and we find that in addition to the system keeping staff aware of the need for hand hygiene, we’re seeing a higher rate of family and visitors disinfecting their hands,” Raz says.
“They see the staff doing it often, and that establishes the idea that hand hygiene is important for everyone entering the room. That’s a huge win.”
The biggest hurdle has been educating employees on the expectations for handwashing when moving quickly from one room to another, Raz says.
“The employees sometimes get confused on the entry and exit requirements. You may have an exit wash for this room but then you’re immediately walking into the next room, so an entry wash is not necessary,” Raz explains.
“It can be hard for them to get that timing down so that they understand there is a time element that is involved in addition to entering and exiting the rooms. We address that with continuing education of staff and making ourselves accessible to answer questions.”
Checklist Reduces Sepsis
A checklist helped reduce infections at Spectrum Health facilities, says Julie Bonewell, RN, BSN, senior director of quality and improvement at the health system based in Grand Rapids, MI.
To prevent surgical site infections, the surgery team at Spectrum Health uses a checklist to make sure preventive interventions have been completed prior to surgery. The team reviewed the literature and completed PDSA (plan-do-study-act) cycles to identify the multiple opportunities throughout the course of care to prevent surgical site infections and included these interventions in the checklist, Bonewell explains.
“The prevention of surgical site infections is complex, necessitating multiple interventions while the patient goes through the surgery process, so the checklist helps assure all of these interventions are completed,” Bonewell says. “As a result, we have seen significant reductions in surgical site infections.”
To help prevent mortality from sepsis, clinicians use a checklist to ensure that all components of the sepsis treatment bundles have been completed within the three-hour and six-hour windows for care. The team also “swarms” around a patient identified as potentially having sepsis so that all team members are available to quickly assess and discuss whether this patient should be treated for sepsis and to get the treatment initiated as quickly as possible, Bonewell says.
“When patients go to see their primary care physician, the medical assistants use standard work for rooming to assure that all necessary preventive tests, lab work, and screenings have been completed,” she says. “Part of this standard work is a report that quickly shows tests for which that patient is due. This standard work has resulted in higher compliance with preventive screening as well as better control of chronic diseases such as high blood pressure and diabetes.”
- Julie Bonewell, RN, BSN, Senior Director, Quality and Improvement, Spectrum Health, Grand Rapids, MI. Phone: (866) 989-7999. Email: [email protected].
- Craig Clapper, PE, CMQ/OE, Partner, Transformational Advisory Services, Press Ganey, South Bend, IN. Phone: (800) 232-8032.
- Katherine Feley, DNP, RN, CPPS, System Director of Patient Safety, Indiana University Health, Indianapolis. Phone: (800) 248-1199.
- Meghann Holmes, RN, Infection Control Preventionist, White County Medical Center, Searcy, AR. Phone: (501) 268-6121.
- Tammy F. Raz, BSBA, BSHI, MHA, Systems Business Analyst, Hospital Corporation of America, Orlando, FL. Email: [email protected].
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