Patient Safety

Observations and Lessons Learned in Patient Safety.

How Mount Sinai Health System Improved Hand Hygiene Compliance by 20 Percent

03/05/2019

By Rebecca Anderson, MPH, Mount Sinai Health System

We all know the importance of hand washing as it relates to stopping the spread of germs. We also all know that knowledge does not always translate into consistent hand hygiene practices.

Health care professionals often have lapses, even though they know the right thing to do. Many different tools and methodologies to measure and improve hand hygiene compliance support organizations on the road to safe patient care.

Measuring Compliance Monthly
At the Mount Sinai Health System (MSHS) in New York, the Joint Commission Center for Transforming Healthcare’s Targeted Solutions Tool® (TST®) for Hand Hygiene, is being implemented across our seven hospitals as a core component of our strategy to decrease hospital-acquired infections and reduce patient harm. The TST® allows for the measurement of hand hygiene compliance and also informs improvement efforts. The data-driven, solutions-oriented focus of the TST® fosters continuous measurement and improvement.

To date, the health system has collected over 300,000 observations with an average of about 6,000 observations per month. Each of the 95 units participating in the initiative collect 60 anonymous observations per month. Trained anonymous observers collect data on all staff types, all shifts, and all inpatient units. The ongoing anonymous observation process allowed for the broad engagement of over 650 staff in the second half of 2018. 

Sharing Successes
MSHS improved hand hygiene compliance from an average of 69 percent in 2015 to 89 percent in 2018. Progress in hand hygiene compliance has occurred simultaneously with a 59 percent decrease in hospital-acquired infections between 2015 and 2018. 

Improvement in hand hygiene has been across all staff types/roles. Broad sharing of the data and improvement plans has been critical to the overall improvement efforts. The improvement in hand hygiene compliance would not be possible without an organizational commitment to hand hygiene being the responsibility of all employees, including both clinical and non-clinical staff. 
Data are shared in many different ways, as the goal is to reach as many employees as possible.

Modes of communication include:

  • Hand Hygiene Dashboard: An online, password-free dashboard is available to all employees via the intranet. The dashboard can be filtered by hospital, unit, and department to allow for specific, actionable data to be widely available. 
  • Executive Quality Dashboard: Hand hygiene is included in the system-wide quality dashboard distributed monthly to all site and health system leadership. The dashboard includes the health system’s highest priorities related to safety and quality. 
  • Reward and Recognition Programs: Hospitals provide unit and department awards for highest compliance and most improvement. 
  • Grand Rounds, Medical Board, and Other Internal Meetings: Hand hygiene is a standing agenda item for many meetings.

Why Share the Data So Broadly?

  1. Transparency: As part of our efforts to engage all employees in safety and quality, data are an essential component to level-setting, creating broad accountability, and encouraging a patient-centered culture.
  2. Targeted Performance Improvement: In order to implement targeted solutions to address barriers on a specific unit or department, data from the TST® are analyzed and then used to drive performance improvement. 
  3. Internal Competition: The sharing of hand hygiene data motivates staff to always do their best and allows for comparison at the hospital, department, and unit level. Recognizing the improvement efforts encourages positive behaviors.

There is a universal recognition of the importance of an ongoing commitment to collecting hand hygiene data to allow for continuous monitoring and improvement. We cannot improve if we do not know how we are doing. That is a key principle from the hand hygiene work that is being applied as we leverage it as a model for system-wide performance improvement. Reliable data can be used to drive improvement and create a safer environment for our patients and staff.

Rebecca Anderson, MPH, is senior director of patient safety initiatives Behalf of the Mount Sinai Health System. She can be contacted by email at