A Roadmap to Success – One Workgroup's Approach to Improving Internal Hand Hygiene Compliance in an Acute Care Medical Center

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      According to the Centers for Disease Control and Prevention, hand hygiene (HH) is the number one way to prevent transmission of infection. The purpose of this performance improvement (PI) project was to improve internal hand hygiene compliance, monitored via the revamped observational compliance program.


      The setting was a 397 bed, acute-care medical center. All inpatient departments and roles were monitored for compliance. The goal was to improve the hospital's internal HH compliance by rebuilding the observation program and regularly implementing initiatives to raise awareness for HH throughout the year. A target of 90% was used as a measure of success. A corrective action plan was utilized within a multi-disciplinary workgroup to establish action items and track progress. Due to a failing observation tool, a new phone application was developed leveraging available hospital technology. An interactive data-stratification dashboard was developed that auto-configured observation data, providing a standard method for reporting. New volunteers (unit-based and travelers) were selected, trained, competencied, and incentivized to participate. Additional initiatives included: targeted in-person education, a coaching catchphrase contest, fun-fact sharing at team huddles, HH technique posters distributed, stickers distributed for appropriately performing HH, a behavioral survey was created to understand barriers and opportunities, and a HH technique blacklight assessment activity was conducted. The data was continuously monitored to track and trend internal compliance rates.


      Internal compliance improved from 57% to 90% between the months of March 2019 (program go-live) and October 2019. The total number of observations was 5145, averaging over 500 per month. Additionally, role based data was now available for targeted education purposes and report card sharing.


      This PI project found that by engaging a multi-disciplinary team, reestablishing a compliance observation program, leveraging innovative technology, and involving hospital leadership, internal HH compliance rates can be improved.
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