An estimated 2 million patients get a hospital-related infection every year and 90,000 die from their infection. – Centers for Disease Control and Prevention

In December 2008, The Joint Commission Center For Transforming Healthcare began work on its first improvement project:  addressing failures in hand hygiene. The Hand Hygiene Project focuses on improving and sustaining hand hygiene compliance. Hand hygiene is critically important to safe, high quality patient care. Unfortunately, many infections are transmitted by health care personnel. To sustain improvement and make a difference, a simple slogan or campaign is not enough; demanding that health care workers try harder is not the answer. Comprehensive, systematic, and sustainable change is the only solution.

Hand hygiene solutions were developed by eight leading, highly respected organizations, which have a great deal of experience using Robust Process Improvement™ tools such as Lean Six Sigma and change management processes. These organizations recognized the enormity of the problem when they began using a variety of effective tools to accurately and reliably measure hand hygiene compliance. These tools helped determine where true compliance was in organizations, where they need to be, and what they need to do to improve hand hygiene. It is believed that the high compliance rate that many hospitals report is probably not accurate. In aggregate, these eight hospitals identified that staff wash their hands less than 50 percent of the time. 

After establishing a measurement baseline, the hospital-specific underlying causes of hand hygiene failure were identified and analyzed. Solutions that target these specific causes of failure are currently being rigorously tested.

Successful hand hygiene compliance takes a great deal of sustained work and resources at all levels.  By January 2010, the Joint Commission Center for Transforming Healthcare will have the data to demonstrate whether the solutions can be sustained to achieve a 90+ percent compliance rate.

Causes of failure to clean hands

• Ineffective placement of dispensers or sinks
• Hand hygiene compliance data are not collected or reported accurately or frequently
• Lack of accountability and just-in-time coaching
• Safety culture does not stress hand hygiene at all levels
• Ineffective or insufficient education
• Hands full
• Wearing gloves interferes with process
• Perception that hand hygiene is not needed if wearing gloves
• Health care workers forget
• Distractions

Examples of how to link specific causes to targeted solutions 

Cause:  Ineffective placement of dispensers or sinks
Solution: Provide easy access to hand hygiene equipment and dispensers

Cause:  Hand hygiene compliance data are not collected or reported accurately or frequently
Solutions:   

• Data provide a framework for a systematic approach for improvement
• Utilize a sound measurement system to determine the real score in real time
• Scrutinize and question the data
• Measure the specific, high-impact causes of hand hygiene failures in your facility and target solutions to those causes

Cause:  Hand Safety culture does not stress hand hygiene at all levels
Solutions:  

• Make washing hands a habit – as automatic as looking both ways when you cross    the street or fastening your seat belt when you get in your car
• Commitment of leadership to achieve hand hygiene compliance of 90+ percent
• Serve as a role model by practicing proper hand hygiene
• Hold everyone accountable and responsible – doctors, nurses, food service staff, housekeepers, chaplains, technicians, therapists

Cause:  Hands full
Solution: Create a place for everything:  for example, a health care worker with full hands needs a    dedicated space where he or she can place items while washing hands

Solutions:  Effective hygiene is in our HANDS (Habit, Active Feedback, No One Excused, Data Driven, Systems)

Habit

• Always wash in and wash out upon entering/exiting a patient care area and before and after patient care
• Make washing hands a habit – as automatic as looking both ways when you cross the street or fastening your seat belt when you get in your car

Active Feedback

• Coach and intervene to remind staff to wash hands
• Clearly state expectations about when to sanitize hands to all staff members
• Communicate frequently – provide visible reminders and ongoing coaching to reinforce effective hand hygiene expectations
• Engage staff – real time performance feedback
• Tailor education in proper hand hygiene for specific disciplines
• Provide just-in-time training
• Use technology-based reminders and real time feedback
• Celebrate improved hand hygiene

No One Excused

• Protect the patient and the environment – everyone must wash in and wash out
• Make it comfortable to wash hands with soap or use waterless hand sanitizer
• Hold everyone accountable and responsible – doctors, nurses, food service staff, housekeepers, chaplains, technicians, therapists
• Apply progressive discipline from the top – managers must hold everyone accountable for proper hand washing
• Commitment of leadership to achieve hand hygiene compliance of 90+ percent
• Identify proper hand hygiene as an organizational priority
• Serve as a role model by practicing proper hand hygiene

Data Driven

• Data provides a framework for a systematic approach for improvement
• Utilize a sound measurement system to determine the real score in real time
• Use trained, certified independent observers to monitor appropriateness of hand hygiene
• Scrutinize and question the data
• Measure the specific, high-impact causes of hand hygiene failures in your facility and target solutions to those causes

Systems

• Focus on the system, not just on people
• Make it easy; examine work flow of health care workers to ensure ease of washing hands:
  • Provide easy access of hand hygiene equipment and dispensers
  • Create a place for everything:  for example, a health care worker with full hands needs a dedicated space where he or she can place items while washing hands
  • Limit entries and exits from a patient’s room – make supplies available in room and eliminate false alarms that require staff to leave room to turn alarm off
• Identify new technologies to make it easy for staff to remember to wash hands, i.e. radio frequency identification, automatic reminders, real time scoring

Project team

Cedars-Sinai Health System, California
Exempla Lutheran Medical Center, Colorado
Froedtert Hospital, Wisconsin
The Johns Hopkins Hospital and Health System, Maryland
Memorial Hermann Health Care System, Texas
Trinity Health, Michigan
Virtua, New Jersey
Wake Forest University Baptist Medical Center, North Carolina

For more information, visit www.centerfortransforminghealthcare.org.