21285 anw summit poster hand hygiene prt

KEY DRIVERS FOR SUSTAINING CULTURAL CHANGE• Commitment from senior leadership to establish work as an organizational priority.• Multidisciplinary team representing all units and departments.• Use of a structured process improvement methodology.• Ongoing communication and education for staff.• Use of reliable data to drive decisions.• Continued monitoring; appropriate follow up of identified opportunities.• Public posting of unit compliance appears to have contributed to some

improvement in a short amount of time.• We must stay the course and understand that cultural change in an organization of

our size takes time.

Changing Our Safety Culture: How Our Hand Hygiene Improvement Initiative is Leading the WayEllie Carter, CLS, MPH, CIC; Madeleine Hart, MA, CPHQ; Jason J. Reed, MD, Chief of Staff

ABOUT ABBOTT NORTHWESTERN HOSPITAL• As the largest hospital in the Twin Cities, Abbott Northwestern

Hospital is recognized nationally and locally for its exceptional expertise and care.

• Located in the heart of Minneapolis, Abbott Northwestern Hospital employs nearly 6,000 staff, providing services annually to more than 200,000 patients and their families from across the Twin Cities and Upper Midwest.

CALL TO ACTIONIt is a well-known mantra, stated by the World Health Organization: Hand hygiene is the single most effective way to prevent infection. Yet, nationwide compliance with hand hygiene in health care settings remains abysmally low. Leading up to 2012, despite multiple efforts to improve, Abbott Northwestern Hospital’s hand hygiene compliance rates had reminded virtually unchanged. Opportunities existed for a leadership-driven and accountability-based approach to improving hand hygiene compliance. In 2012, Abbott Northwestern’s Vice President of Medical Affairs, Dr. Dennis O’Hare, set into motion a comprehensive physician-, performance improvement-, and infection prevention department-led hand hygiene improvement initiative. From the outset, this core team agreed that the backbone of our improvement program must:• Have full and continued support of leadership.• Be established as an organization-wide priority.• Utilize the tried and true tenets of Performance Improvement

methodologies.• Ensure a culture of accountability among all levels of staff.Without these, any improvements would not be sustainable.

UNDERSTANDING CURRENT CULTUREOur team began with a thorough literature review to learn and understand current best practices. This review elucidated some common themes and contributed to planning the program components we aimed to adopt:• Create a multidisciplinary team, representative of the entire body of

staff.• Take steps to understand the unique culture of our organization

(conduct focus groups of physicians, nurses, and ancillary staff).• Conduct physician attitude and knowledge surveys.• Develop a multi-pronged initiative to address the many facets that

contribute to the behaviors and actions underlying hand hygiene compliance.

*Vital Smarts© matrix

1% 3% 3%

19%

75%

1% 3% 8%

26%

62%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Always Most of the time

Sometimes Rarely Never

How often do you approach other physicians?

How often do you approach non-physician staff?

BUILDING THE FOUNDATION FOR CULTURE CHANGEThe major building blocks for supporting change include: • Ensuring that everyone has the right tools available, at the right time,

in the right place, including product and signage.• Clearly and regularly communicate the focus and importance of the

work.• Ensuring understanding and demonstration of all aspects of hand

hygiene.• Building in accountability at all levels.

ENGAGING OUR PATIENTS AND THEIR FAMILIES FOR CHANGE

Clean Hands Kit contents:• Expectations for hand hygiene

practices• Talking points about holding each

other accountable • The “Accountability Commitment”

inviting staff to sign, acknowledging that they commit to hold others accountable and expect to be held accountable by others

• “F.O.A.M.”fliers for department posting

USING A MULTI-PRONGED APPROACHThe scope of the work required a systematic approach that would address the numerous drivers of hand hygiene compliance. Sub groups were formed to further delineate tasks, timelines and responsibilities to address each essential component for ensuring success, including data display, product standardization, signage, education, and patient and family engagement. A detailed communication plan was developed to ensure continuous and effective messaging.From the very beginning, the team recognized the work would need to address personal as well as group motivation for performing proper hand hygiene – every patient, every time. Physician leadership and engagement was also recognized as a key factor to success.

Accountability

Education

Communication

Structure

Ensure system of personal

responsibility

Ensure common knowledge base

Broadly and frequently

Ensure the right tools at the right

time

abbottnorthwestern.comS411321B 16522 0613 ©2013 ALLINA HEALTH SYSTEM. TM A REGISTERED TRADEMARK OF ALLINA HEALTH SYSTEM.

Abbott NorthwesterN hospitAl

Clean hands save lives.

F.O.A.M.(for others and me)

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It’s OK to ask those around you to clean their hands. • Ask your doctors and care team to clean their

hands if they did not before caring for you.

You should also clean your hands often.

You and your visitors should clean your handsbefore eating, after using the restroom, and after touching surfaces in the hospital room.• Use soap and water or an alcohol-based hand rub

to clean your hands.

The #1 way to prevent the spread of infections

ABBOTT NORTHWESTERN HOSPITAL

Visual collateralHouse-wide distributed posters, fliers, electronic imaging with our team-created slogan “F.O.A.M. (For Others And Me)” with quarterly refreshed images. “Ask me if my hands are clean” buttons for staff to wear, inviting patients and other staff to inquire about hand cleanliness.

Video collateralF.O.A.M. (For Others And Me): produced by and starring our own staff, this video uses humor to introduce the concept of accountability for hand hygiene.Approach & Coach: the term coined by the Hand Hygiene Improvement Team, further demonstrated different scenarios to appropriately hold colleagues accountable for hand hygiene. In Your Hands: Phyllis’ Story: an interview with a patient and her family about the personal impact of acquiring MRSA while admitted at our hospital.

MEASURING CHANGEIn 2012, the entire Allina Health system of hospitals adopted a standardized process for collection of hand hygiene compliance data. An unofficial best practice described in peer reviewed literature describes a process referred to as “third-party observers” or “secret shopper observers”. These observations occur as covertly as possible in a department where the observer typically does not work. This process has been demonstrated to reduce potential bias that can result when an individual is observing their own departmental colleagues. This has become an accepted standard for collection of hand hygiene compliance data.

Acknowledging accomplishments is an important aspect of changing culture. Our senior leaders personally recognize departments that achieve goal for three consecutive months by presenting our “Clean Hands High Five” trophy to staff. In a bold move toward true transparency, Abbott Northwestern Hospital’s Chief of Staff, Dr. Jason Reed, initiated the public posting of unit-specific hand hygiene compliance rates each month, along with the hospital-wide physician hand hygiene compliance rate. These posters are prominently displayed on each unit with an accompanying message inviting anyone to speak up if they believe hand hygiene was missed. Dr. Reed shares his e-mail and phone number for patients and visitors to contact him personally with any questions or comments.

“At Abbott Northwestern, we strive to always clean our hands before we enter and when we exit every patient’s hospital room. All of our caregivers and staff partner with patients, families and visitors to reduce the spread of infection. We need everyone’s help. Never hesitate to ask me or anyone here: Are your hands clean?”

Jason Reed MD, Chief of Staffmobile: (612) 296-0284email: [email protected]

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ABBOTT NORTHWESTERN HOSPITAL

Last month’s Hand Hygiene rates:

% on station E3100/W3500

Physician hospital-wide compliance: %Measured by percent of observations of

foaming in and out of patient room.

Compare to national average of 40-55%


HEALTH CARE WORKER (HCW) TYPE KEY11 = Patient Transport (Teal)

17 = Phlebotomy

staff (Dk Teal)

1 = Physician 4 = Respiratory Therapist

(Olive Green) 6 = IV Team (Navy) 12 = Radiology (Gray) 18 = CRNA

2A = Nurse Practitioner 5A = Registered Nurse

(Navy)

7 = Care Coordinator/SW

13 = Dietitian 19 = CST

2B = Medical Student 5B = Licensed Practical

Nurse (Purple) 8 = Pastoral Care

14 = Tray Passer

(Black/Khaki)

20 = Ophthalmic

Personnel

2C = Physician Assistant 5C = Nursing Assistant

(Teal)

9 = Physical Medicine

Staff (Royal Blue) 15 = Other Healthcare

Provider

21 = Dialysis RN

3 = Pharmacy (Maroon) 5D = RN Student 10= Environmental

Services(Dark Brown) 16 = Volunteer

22 = Op Tech

04/01/14

Observer Name

Title

Month

Year

INSTRUCTIONS: Complete a minimum of 10 random hand hygiene observations per month. If you have multiple units, complete a

sample from each area, totaling 10 audits.

Use this log to record your interactions with staff that you observe to be non-compliant. Continue to acknowledge and thank staff

that are performing proper hand hygiene, but do not include those interactions on this form.

Mail your completed forms to PI Office: MS 11137 or email [email protected]. Fields in this form can be

completed electronically. Download and save with your name/date.

Unit or Dept HCW Type Record staff response to being coached regarding non-compliance

1

2

3

4

5

6

7

8

9

10

CLEAN HANDS SAVE LIVESHand Hygiene Practice Expectations

19055 0314 ©2014 ALLINA HEALTH SYSTEM. TM – A TRADEMARK OF ALLINA HEALTH SYSTEM.

Basic Hand Hygiene Expectations1. The 5 Moments for Hand Hygiene a. Before each patient contact or encounterb. Before clean/aseptic procedure or taskc. After body fluid exposure riskd. After touching patient environmente. After each patient contact or encounter2. Every time upon entry or exit of a patient’s rooma. Expected even if direct patient contact is not anticipated/did not occurb. After taking care of a patient on Enteric Precautions, hand washing with soap and

water must occur3. Allina-wide Policy on Hand Hygiene includes

more details and can be found on the Abbott Northwestern Hospital infection control policies and procedures page on the AKN.

More specifics on Hand Hygiene Expectations How do I demonstrate to our patients and my colleagues that I am practicing proper hand hygiene?In situations where you have both or one hand free upon entry:· Grab foam before entry, then rub your hands together when your patient can see it.· Remember, when both hands are full, perform

hand hygiene once you’ve put down the item(s).

What do I do if my hands are full when entering or exiting a patient room?If you ENTER or EXIT a room with something in

your hands (equipment, tray, etc.) clean your hands immediately after putting down the item(s). You should also clean your hands before you pick up something to bring into a patient’s room.

What is considered the “threshold” of a patient’s room? If the door threshold is crossed, hand hygiene is expected regardless of whether the patient or anything in the patient’s environment was touched or not. According to the Allina Isolation Precautions policy, this includes either passing beyond the swing of a door OR passing over the threshold of a sliding door.

If I cross the threshold and don’t plan to touch anything and I didn’t touch anything in the patient room, do I still need to foam in and out? Yes.

If I foam out of a patient room and go directly to another patient room, do I need to foam in to that patient’s room?No, as long as you don’t touch anything along the way outside the patient rooms.

continued on reverse

Our individual and collective hand hygiene practices are everyone’s business.It is critical for our safety culture and for patient reassurance that both our patients and your

colleagues are able to see hand hygiene being performed when necessary to protect all of our safety.

Accountability Kit contents:• Tools and information on

conducting “Approach & Coach” interactions

• Refreshed expectations for hand hygiene practices

• FAQs on what the hand hygiene compliance observers are looking for

• Resources available for partnering with our patients

Level 3 Achievement:Goal met for 3 consecutive months

Action: Leaders present “High Five” Trophy

Level 2 Achievement: Goal met for 2 consecutive months

Action: Certificate sent to unit/department leaders

Level 1 Achievement: Goal met for 1 month

Action: Congratulations to Leaders via letter

Level 3 Awareness: Goal not met for 3 consecutive months

Action: Meeting with V.P. s to discuss plan for improvement

Level 2 Awareness: Goal not met for 2 consecutive months

Action: Letter & request to develop formal action plan

Level 1 Awareness: Goal not met for 1 month

Action: Feedback to Leaders via letter

GOAL MET GOAL NOT MET

The Accountability Model consisted of two parallel pathways for hospital departments to follow based on achievement of our monthly hand hygiene goal or falling short of goal. Departments achieving goal were acknowledged by senior leadership and awarded a trophy for sustained achievement.Departments falling short of goal were assisted in planning a 30-60-90 Action Plan, outlining their planned tactics to achieve goal by the completion of the 90-day period.

Modeling behavior using “Approach & Coach”Holding each other accountable for hand hygiene is imperative to our success. However, getting staff to take the leap of faith necessary to actually approach a peer (let alone to approach someone in a place of more authority) proved difficult to implement. The Hand Hygiene Team decided our hospital leaders must first lead the way and role model what exactly Approach & Coach looks like by demonstrating it in front of their own staff. Approach & Coach entails acknowledging staff for proper hand hygiene as well as subtly asking staff why hand hygiene was missed. Supervisors all the way up through our Senior Leadership Team committed to conducting at least 10 Approach & Coach interactions per month with their staff. As of mid-2013, more than 11,000 Approach & Coach interactions have been conducted.

RESULTSHand Hygiene Compliance Rates and Intervention Timeline

2014 Goal = 85%

Hospital-Wide

20%

40%

60%

80%

100%

Aug-1

2

Sep-1

2

Oct

-12

Nov-12

Dec-1

2

Jan-

13

Feb-1

3

Mar

-13

Apr-13

May

-13

Jun-

13

Jul-1

3

Aug-1

3

Sep-1

3

Oct

-13

Nov-13

Dec-1

3

Jan-

14

Feb-1

4

Mar

-14

Apr-14

May

-14

Jun-

14

Jul-1

4

Aug-1

4

Clean Hands Kit

Accountability

Model and

Approach & Coach

Patient Story

Video

For Others & Me

Video

Focus Groups &

MD Survey

Team Formation

Approach &

Coach Expansion

August 2012 - August 2014

Announced to staff:

Public display of data

Public display of data

& Accountability Kit

BUILDING A CULTURE FOR CHANGEMessaging the change The hospital’s Marketing and Communications department was a key partner in developing impactful hospital-wide messaging and images.

Early on, the team acknowledged the importance of involving our patients and visitors as essential partners. Current research informed us that these individuals are generally not comfortable speaking up to remind their providers to clean their hands if they did not personally see them do so. Multiple methods were used to invite patients, families and visitors to partner with us to help better serve them and ensure their safety including in-room posters and video reminders via the hospital’s closed-circuit TV system.

CELEBRATING CHANGE

HARDWIRING BEHAVIOR CHANGEProviding tools for changeToolkits were developed that include materials to support our leaders as they embarked upon the culture change journey in their respective departments.

The Accountability ModelIn 2013 the Institutes for Healthcare Improvement (IHI) delivered a webinar lead by two top performers in the U.S. for improving hand hygiene – Vanderbilt University Medical Center and The Johns Hopkins Hospital.The Abbott Northwestern Hospital team modified and adopted one of the approaches used at Vanderbilt and coined it our “Accountability Model”.

Accountability Gap

Cultural Change Influencers

Motivation Ability

Personal 1 It’s the right thing to do• First do no harm• Avoid infection among patients and staff

2 Ensure people have skills• New employee orientation education• Infection Control section of annual

mandatory staff education• F.O.A.M Video emphasizes personal

accountability and coaching others

Social 3 Harness peer pressure • Voices from video “I want to be held

accountable” • Clean Hands Kit Accountability

Commitment• Data transparency; encourage

competition; acknowledge positive performance

4 Find strength in numbers• Broad use of Clean Hands Kit • Sharing messages and materials at key

staff meetings• Allina intranet Infection Control links to

video, Clean Hands Kit and monthly data

Structural 5 Design rewards & accountability • Leadership recognition of units/

departments • “Clean Hands High 5”• Follow up with lower-performing

departments/units• Senior Management Team unit adoption

6 Change the environment • New Foam In Foam Out signage and

standardized placement• Increased availability of foam in public

areas• Patient room “OK to Ask” signs and video

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Hand HygieneAccountability CommitmentFrom Allina Health’s “Our promise”:We will be fearless advocates and tireless partners on your path to better health.

To protect the safety of our patients and ourselves, I commit to:• Allowing others to hold me accountable if I forget to clean my hands• Holding others accountable if I observe someone who may not have cleaned their hands

Our unit: ___________________________________________ Manager: __________________________________________

Signed:

abbottnorthwestern.comS411321J 14061 1012 ©2012 ALLINA HEALTH SYSTEM. TM A REGISTERED TRADEMARK OF ALLINA HEALTH SYSTEM.

Abbott NorthwesterN hospitAlClean hands save lives.

Hand Hygiene Talking Points for ManagersPlease use these suggested topics and activities when discussing hand hygiene with your staff. hand hygiene Accountability

1. The best way for our hospital to achieve sustained improvement with hand hygiene is to hold each other accountable for hand hygiene. We all get busy and at times we may forget.

2. Nursing, ancillary staff, and physician representatives have given their support to this approach. 3. It does not matter who you are or who the other person is; it is not personal, it is about patient

and staff safety. a. A suggested way to approach someone who may not have cleaned his/her hands:

• Say “Did I miss seeing you clean your hands?”• Be respectful and discreteb. A suggested way to respond when someone asks you to clean your hands:• Say “thank you,” then perform hand hygiene Consider role-playing with staff so they can practice accountability with each other.hand hygiene Compliance Data

1. Data on inpatient hospital units are collected using Secret Shopper observations2. Data from elsewhere in the hospital are collected by the department’s or clinic’s own staff3. The data are not about individual performance; they are a reflection of a team’s performance,

reported by unit and by type of health care worker4. We all play a role in our team’s performance and we can help each other do better.hand hygiene expectations1. The 5 Moments for Hand Hygiene (share and discuss diagram with staff)

a. Before each patient contact or encounterb. Before clean/aseptic procedure or taskc. After body fluid exposure riskd. After touching patient environmente. After each patient contact or encounter2. Every time upon entry or exit of a patient’s rooma. Expected even if direct patient contact is not anticipated/did not occurb. When a patient is on Enteric Precautions, hand washing with soap and water must occur

3. Allina-wide Policy on Hand Hygiene includes more details and can be found on the Abbott Northwestern Hospital infection control policies and procedures page on the AKN.

abbottnorthwestern.comS411321B 14061 1012 ©2012 ALLINA HEALTH SYSTEM. TM A REGISTERED TRADEMARK OF ALLINA HEALTH SYSTEM.


Abbott NorthwesterN hospitAlClean hands save lives.

abbottnorthwestern.com

S411321I 14061 1012 ©2012 ALLINA HEALTH SYSTEM. TM A REGISTERED TRADEMARK OF ALLINA HEALTH SYSTEM.



Memorandum

To: Patient Care and Ancillary Department Leaders

From: The Abbott Northwestern Hand Hygiene Improvement Team

Date: Nov. 26, 2012

Subject: Hand Hygiene Improvement

Dear Patient Care and Ancillary Department Leaders:

Enclosed you will find the materials that make up the Abbott Northwestern Hand Hygiene

Improvement “Clean Hands Kit.”

Please use these communication tools in your continuing efforts to engage staff in achieving our goal:

Improve hand hygiene compliance from 61 percent to 80 percent by Dec. 31, 2012.

We hope the materials help you to inform and talk with your staff about how they can individually

contribute to improving hand hygiene. Your kit includes:

1. talking points for Managers

Some suggested topics/activities that you can use when discussing hand hygiene with your staff.

2. hand hygiene Accountability Commitment Form

This is an OPTIONAL exercise for you and your staff. Use the form to publicly commit to each

other and the hospital that you care enough about patient and staff safety to hold each other

accountable, and you expect to be held accountable. A larger, poster-sized commitment form is

available upon request. See contact information below.

3. secret shopper FAQs

The who, what, when, why and how on the Secret Shopper hand hygiene observation process.

4. “Your 5 Moments for hand hygiene”

The World Health Organization’s visual description of when hand hygiene should be performed.

This is part of the Allina Hand Hygiene Policy.

5. F.o.A.M Flier for employees

This flier is being sent to your department and all internal mail routes for posting in employee

areas. You will see more of this messaging throughout the hospital in the coming months.

6. Current hand hygiene data

Our team is hard at work preparing several more hand hygiene improvement strategies to

accompany this kit. One example is a short video that will model “the right words at the

right time.” The video uses humor and role play to help staff become more comfortable with

holding each other accountable for hand hygiene. Watch for its release next month. If you

have additional ideas on how to keep the hand hygiene improvement momentum going, please

contact Maddy Hart (ext. 3-4462) or Ellie Carter (ext. 3-4375).

Thank you for your dedication to protecting our patients and staff!

Sincerely,The Abbott Northwestern Hand Hygiene Improvement Team

CLEAN HANDS SAVE LIVES

Approach & Coach in Action

Protecting patient and staff safety

by practicing hand hygiene is everyone’s business.

Abbott Northwestern’s safety culture depends on:

· Individuals practicing proper hand hygiene, and

· Our collective hand hygiene practices as a care team.

When patients and colleagues see us cleaning our hands, they can be reassured

we are protecting everyone’s safety.

PLEASE POST


CLEAN HANDS SAVE LIVES

Partners in Hand Hygiene Accountability

How to include hand hygiene in conversations with your patients

“OK to Ask” signage for posting in patient rooms· Signage available to order through SMARTworks: #S411026

Make it a point to tell your patients that we may

need their help to remember to clean our hands

AND that it is also important for them to clean

their hands often:· When orienting a patient to their room· When rounding on your patients

If a patient ever does ask you to perform hand

hygiene, simply thank them for the reminder and

do it (even if you already did and they didn’t see it).Helpful resources: “OK to Ask” patient TV information slide

“OK to Ask” 5-minute video from CDC on hospital channel 50


Desi

gn: m

ondo

fragi

lis n

etw

ork

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.

October 2006, version 1.

abbottnorthwestern.com

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Hand Hygiene Secret Shopper FAQs

why are we using secret shoppers to collect hand hygiene data?

• It is a more accurate measurement of hand hygiene practices

(this is supported by literature)

• The Allina Quality Council has asked all Allina hospitals to measure in this

way so reporting on hand hygiene compliance is more consistent.

who are the secret shoppers?

• At Abbott Northwestern, they are pool of 60 staff consisting of:

Assistant Clinical Nurse Managers

Ancillary staff representing the departments of transport, social work, lab, PT/OT, RT,

and radiology.

• Each shopper is on a monthly rotation and collects observations according to the schedule

• Shoppers collect observations on inpatient units only (not including Mental Health Service units).

They do not observe on the unit they normally work.

what are the secret shoppers looking for?

• Opportunities for hand hygiene:

Mostly staff entering OR exiting patient rooms

An observation may include room entry, exit or both

• A variety of staff types: nurses, doctors, lab, environmental services, nutrition, transport, therapies,

and any other support staff

• If someone exits a room rubbing their hands together or drying with a paper towel, it is counted

as a “yes” for performing hand hygiene

• If someone exits a room, performs hand hygiene and goes directly into another patient room

without touching anything along the way, it is counted as a “yes” for performing hand hygiene

for both exiting and entering the next room

• If someone exits a room with something (equipment, tray, etc.) in their hands, the observer will

wait for hand hygiene to occur after the item is put down

• If observing hand hygiene on staff exiting the room of a patient on Enteric Precautions, only

washing with soap and water will counted as a “yes” for performing hand hygiene.

how are the secret shoppers doing their observations?

• They are watching for all opportunities for hand hygiene; not just for staff doing it or not doing it

• They try to be as inconspicuous as possible, so the resulting data will be as close to real-life

as possible.

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Hand HygieneAccountability CommitmentFrom Allina Health’s “Our promise”:We will be fearless advocates and tireless partners on your path to better health.

To protect the safety of our patients and ourselves, I commit to:• Allowing others to hold me accountable if I forget to clean my hands• Holding others accountable if I observe someone who may not have cleaned their hands

Signed:

21285 anw summit poster hand hygiene prt

Health & Medicine

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