improving hand hygiene project

IMPROVING HAND HYGIENE COMPLIANCE

IMPROVING HAND HYGIENE COMPLIANCE

Quality Improvement Project using “FOCUS PDCA” Methodology.

Find the problem.

• One of highest priority risk factor in the risk assessment matrix of Infection Prevention & Control Department program at AIGH.

• Hand hygiene is the number one step in any infection prevention and control program.

• It is one of international patient safety goal (no. 5).

• In our daily rounds , it was observed that hand hygiene compliance is below expectation.

•

Risk Assessment & Prioritization

Risk Item LikelihoodHuman Impact

Material Business Impact

Color code

Hand Hygiene Non-Compliance 3 5 5 RED

Find The Problem

• Impact of the problem:• This “SINGLE STEP” is

• First component of STANDARD PRECAUTION.• Decreases all health-care associated infections.• Part of all CARE-Bundles.

Find the status of problem

• Hospital Wide Baseline Data Collection:• Measurement of the perception of staff (Health

Care Workers & Senior Hospital Managers) regarding Infection Control practices in AIGH.

• Measurement of the availability of Facility e.g. Hand washing sinks, Hand rub dispensers, Hand towels…etc.

• Measurement of Compliance of HCW on the 5 Moments for Hand Hygiene.

Perception Questionnaire

HCW Perception Questionnaire

SHM Perception Questionnaire

The perceptions of both healthcare workers and senior managers regarding hand hygiene and

perceived effectiveness of measures for increasing hand hygiene compliance

"In your opinion, how effective are the following interventions to increase compliance with hand hygiene?"

N= 328

N=17

Facility Survey

N (Beds)= 207

N (Sinks)= 131

Hand Hygiene Compliance

YOUR 5 MOMENTS FOR HAND HYGIENE

Clean your hands before touching a patient when approaching him/her!

To protect the patient against harmful germs carried on your hands!

Clean your hands immediately after an exposure risk to body fluids (and after glove removal)!

To protect yourself and the health-care environment from harmful germs!

Clean your hands immediately before an aseptic task!

To protect the patient against harmful germs, including the patient’s own, entering his/her body! Clean your hands after touching a

patient and his/her immediate surroundings, when leaving the patient’s side!

To protect yourself and the health-care environment from harmful germs!

Clean your hands after touching any object or furniture in the patient’s immediate surroundings, when leaving-even if the patient has not been touched!

To protect yourself and the health-care environment from harmful germs!

Observation Form – Basic Compliance Calculation

Facility: Period: Setting:

Prof.cat.

Prof.cat.

Prof.cat.

Prof.cat.

Total per session

Session N° Opp (n)

HW (n)

HR (n)

Opp (n)

HW (n)

HR (n)

Opp (n)

HW (n)

HR (n)

Opp (n)

HW (n)

HR (n)

Opp (n)

HW (n)

HR (n)

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Total Calculation Act (n) =

Opp (n) =

Act (n) = Opp (n) =

Act (n) = Opp (n) =

Act (n) = Opp (n) =

Act (n) = Opp (n) =

Compliance

Instructions for use 1. Define the setting outlining the scope for analysis and report related data according to the chosen setting. 2. Check data in the observation form. Hand hygiene actions not related to an indication should not be taken into

account and vice versa. 3. Report the session number and the related observation data in the same line. This attribution of session number

validates the fact that data has been taken into count for compliance calculation. 4. Results per professional category and per session (vertical):

4.1 Sum up recorded opportunities (opp) in the case report form per professional category: report the sum in the corresponding cell in the calculation form.

4.2 Sum up the positive hand hygiene actions related to the total of opportunities above, making difference between handwash (HW) and handrub (HR): report the sum in the corresponding cell in the calculation form.

4.3 Proceed in the same way for each session (data record form). 4.4 Add up all sums per each professional category and put the calculation to calculate the compliance rate (given in percent)

5. The addition of results of each line permits to get the global compliance at the end of the last right column.

Compliance (%) = Actions x 100 Opportunities

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this document. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. WHO acknowledges the Hôpitaux Universitaires de Genève (HUG), in particular the members of the Infection Control Programme, for their active participation in developing this material.

Observation Form – Optional Calculation Form (Indication-related compliance with hand hygiene)

Facility: Period: Setting:

Before touching a patient

Before clean/ aseptic procedure

After body fluid exposure risk

After touching a patient

After touching patient surroundings

Session N° Indic (n)

HW (n)

HR (n)

Indic (n)

HW (n)

HR (n)

Indic (n)

HW (n)

HR (n)

Indic (n)

HW (n)

HR (n)

Indic (n)

HW (n)

HR (n)

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Total Calculation Act (n) =

Indic1 (n) =

Act (n) = Indic2 (n) =

Act (n) = Indic3 (n) =

Act (n) = Indic4 (n) =

Act (n) = Indic5 (n) =

Ratio act / indic

Instructions for use 1. Define the setting outlining the scope for analysis and report related data according to the chosen setting. 2. Check data in the observation form. Hand hygiene actions not related to an indication should not be taken into

account and vice versa. 3. If several indications occur within the same opportunity, each one should be considered separately as well as the

related action. 4. Report the session number and the related observation data in the same line. This attribution of session number

validates the fact that data has been taken into count for compliance calculation. 5. Results per indication (indic) and per session (vertical):

4.1 Sum up indications per indication in the observation form: report the sum in the corresponding cell in the calculation form. 4.2 Sum up positive hand hygiene actions related to the total of indications above, making the difference between handwash (HW) and handrub (HR): report the sum in the corresponding cell in the calculation form. 4.3 Proceed in the same way for each session (observation form). 4.4 Add up all sums per each indication and put the calculation to calculate the ratio (given in percent)

Note: This calculation is not exactly a compliance result, as the denominator of the calculation is an indication instead of an opportunity. Action is artif icially overestimated according to each indication. How ever, the result gives an overall idea of health-care w orker’s behaviour towards each type of indication.

N=328

N=158N=42

N=114 N=33 N=91 N=72 N=39 N=179

N= 528

Momen

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Momen

t # 4

After

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Momen

t # 5

After

patie

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rroun

dings

Momen

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Befor

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Momen

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3.53.02.5

2.01.51.00.5

0.0

100

80

60

40

20

0

Perc

ent

Pareto Char t for I ncompl iance of 5 Moments for Hand Hygiene

Find The Problem

• The project Mission is:• To improve Hand Hygiene compliance from

26% to 90% by March 2014.

Organize The Team

• Team Leader: Infection Control Director• Facilitator: Quality Director.• Members:

• ICU team.• Supervisor ICP.• Nursing Supervisor.• ICP.• IC Link Nurses.• MOH team.

Clarify Current Process

Hand Hygiene Definition

• Hand Hygiene refers to killing or removal of microorganisms on the hands that have been picked up by contact with patients, staff, contaminated equipment or the environment*.

*CDC (Centers for Disease Control).

Steps of Hand Rub

Steps of Hand Washing

Understand The Variation

Select Remedies

• The team suggested the following solutions to the problem:• Start Awareness Training Program (HH Campaign).

• Prepare Educational Materials.• Schedule Lectures & On Job Training.

• Ensure The Availability of HR/HW Facilities.• Involve hospital leaders and get them on board

Solution Feasibility Cost(Inverse Scoring)

Impact Score

Awareness Training Program 6 10 10 600

Provide the missing Hand Rubs 7 6 9 378

Provide the missing Sinks 5 4 9 180

Apply Educational Posters 10 8 5 400

Assign Physician Champion 10 9 8 720

Involve top management by regular monitoring feedback

7 10 9 630

Recognition/Awarding compliant staff

4 9 6 216

Selection Matrix

Solution Feasibility Cost(Inverse Scoring)

Impact Score

Reminder from patients 4 5 6 120

Notice to non-compliant staff 8 9 6 432

Auditing by some other team 3 6 7 126

Hand print culture 8 4 7 224

Selection Matrix

Remedies In Order

• Assign Physician Champion (720).• Involve top management by regular monitoring feedback

(630).• Awareness Training Program (600).• Notice to non-compliant staff (432).• Apply Educational Posters (400).• Provide the missing Hand Rubs (378).• Hand print culture (224).• Recognition/Awarding compliant staff (216).• Provide the missing Sinks (180).• Auditing by some other team (126).• Reminder from patients (120).

Plan

PlanACTION RESPONSIBLE PERSON DUE DATE

Assign Physician Champion IC Committee 1 month

Involve top management by regular monitoring feedback

Dr. Fatma Noman Ongoing

Awareness Training Program hospital-wide:- Hand Hygiene Day

IC TeamMay 5

-Lectures. Dr. Fatma Noman Next Month (For Doctors)Monthly for Nurses

Focus Training Program in ICU & NICU:-Daily Interactive training/ Video Presentation.

IC Team Next Month

-Small group lectures. IC Team Monthly schedule

Notice to non-compliant staff

Dr. Fatma Noman Ongoing

PlanACTION RESPONSIBLE PERSON DUE DATE

Apply Educational Posters IC Team/Admin Request to be sent within next week

Provide the missing Hand Rubs

IC Team/Admin Request to be sent within next week

Hand print culture Campaign

IC Team Start next month with small group lectures

Do Pilot

Do (Pilot)

• ICU & NICU was identified as the areas of greatest RISK and was selected for implying the pilot.

• Reasons:• Vulnerable Patients.• Complex Care.• Confined Area.• Easy to monitor compliance.• Many HH opportunities.

ICU & NICU Hand Hygiene Campaign

• Demographic data about ICU & NICU: No. of ICU Beds: 12 Beds No. of NICU Incubators: 19 No. of ICU Physicians: 7 No. of NICU Physicians: 4 No. of ICU Nurses: 36 No. of NICU Nurses: 20 Average no. of admissions per month for ICU: 26 Average no. of admissions per month for NICU: 17

ICU & NICU Hand Hygiene Campaign

• Time Frame: The campaign lasted over one month (February).

• Educational Tools: Posters. Interactive Visual Training (Video). On job training. Hand Hygiene advocate badges.

Doctor Giving Hand Print

Dr. Fatima Giving On-site Training For Hand Hygiene

ICU1 Dr Fatima Teaching Hand Hygiene to

Doctors

ICU1HOD Giving Hand Print

Hand Print

ICUDr Fatima Training Doctors and staff

on Hand Hygiene

Hand Print CultureColonies Of Micro Organisms Growing

Meeting With Assigned Physician Champions (Wearing HH Badge), Discussing The Status Quo

Of Hand Hygiene Compliance

ICN Demonstrating Trend Of Hand Hygiene Trend To Physician Champion

CHECK PILOT RESULTS

Hand Hygiene Compliance RateCritical Areas

N=103

N=110

Act (Generalize Hospital Wide)

PROGRESSPLANNED ACTIVITIES WHAT WAS DONE

Assign Physician Champion:•Dr. Yasser Al-Basatiny… Medical Director. •Dr. Bashar…Medicine•Dr. Bassam… Surgery•Dr. Mohammad Ali….ICU•Dr. Ebiedo… Pediatrics•Dr. Mona Bhutta …. Obs/Gyne•Dr. Khalid Kandeel… Emergency Room

• A senior member doctor from each department was assigned as Physician champion

• The Physician Champions were provided with a badge “I am Hand Hygiene Advocate” to make him stand out

• He / She would act as Role model to motivate staff of his department esp. doctors and promote hand hygiene practices

• He/she will be regularly provided the compliance rate of different staff categories

PROGRESSPLANNED ACTIVITIES WHAT WAS DONE

Involve top management by regular monitoring feedback

• Monthly Hand Hygiene compliance rate (figures and graph) reported to Infection Control Committee members and Medical Director(ICC Chairperson) where It showed compliance rate by o Staff categorieso Unit wise

Awareness Training Program hospital-wide:- Hand Hygiene Day

• Distribution of hand-outs/badges• Video show in open areas (5 Moments for Hand

Hygiene).Lectures followed by demonstration of steps of Hand Hygiene by Infection control nurses.

• There are 80 attendees participated.

PROGRESSPLANNED ACTIVITIES WHAT WAS DONE

-Lectures. • General Orientation Day (Why Hand Hygiene So Important).

• Monthly Orientation for new staff (5 Moments for Hand Hygiene & The Proper Steps).

• Weekly lectures for Nurses (Hand Hygiene & Breaking The Chain of Infection).

• These lectures done in the Multi-purpose hall and lasted for an hour.(Contents: Role of Hand Hygiene in preventing HAIs, 5 moments, steps, IPSG 5, standard precautions, Bundles of care).

-Small group lectures. • Unit-wise lectures & post – test (attendants are asked to demonstrate back the steps with Hand Rub)/

• (5 Moments for Hand Hygiene Video) lasting 15 to 30 minutes

PROGRESSPLANNED ACTIVITIES WHAT WAS DONE

Notice to non compliant staff Five Doctors were given a verbal feedback with polite reminders by the Infection Control Director.

Ten nurses and fifteen technicians given a one on one explanation by the ICP to make them accountable to their actions.

No written warnings/punishments.

Apply Educational Posters Number of posters were increased from occasional to 400 posters all over the hospital:• 5 Moments• Steps of using Alcohol Hand-Rub (English and

Arabic)• Steps of Hand wash with soap and water

PROGRESSPLANNED ACTIVITIES WHAT WAS DONE

Provide the missing Hand Rubs

120 hand rub dispensers newly installed in addition to the 333 functional dispensers .

Hand print culture Campaign 13 Hand imprint samples were taken from doctors , Nurses and others during Teaching Rounds and The Results were demonstrated to themTo give them feedback and idea that although visibly clean; their hands were carrying germs ..to motivate them doing Hand Hygiene before contact with patients and contacting Sterile sites.

Act (Generalize Hospital Wide)

• The first phase of the campaign/program started on the critical areas, thereafter it was extended to all hospital locations.

• Time Frame : lasted over a month• Educational Tools - Campaign posters. - Interactive trainings. - In service education. - Competencies.

Act (Generalize Hospital Wide)

N=386

N=115

Monitoring

• After the marked improvement done by the project, the IC team kept an eye on the process and continuously measured the compliance rate to hold the gains and maintain the staff adherence to the hand hygiene practice.

Target