Sanja Mirkov, BPharm, PGDipPH

Clinical Quality Improvement Coordinator

Improvement Science Professional Development Program

The Hand Hygiene Project

The Hand Hygiene Project Content and Aim

AimEstablish reliable HH practices within CMH healthcare facilities To increase correct HH practice rate from 60 to 80% by 30th June 2013System Stable in state of statistical control - improvement can be achieved only through a

fundamental change

Guidance Methods for developing fundamental change:1. Benchmarking or learning from others – e.g. literature search2. Creative thinking – provoking new ideas for change - Using change concepts3. Logical thinking about the current system – e.g. workflow checklist, comparison

of measurements in the Gold Audit

Constraints1.Common ineffective approaches to improvement applied previously: Trouble with performance – add more inspection2. Negatively framed promotional activities in the past3. Financial constraints for using technology

Strategy1. A literature review identified successful interventions to inform CMH

multimodal strategy with an emphasis on behavioural change

2. Strengthen the team (complementary skills, equal commitment, accountability, trust, respect and support)

3. Increase staff capability (education, training, dissemination of information) and motivation (social marketing, persuasion, modelling)

4. Create physical (facilities, workflow, reminders, institutional safety climate) and social environment (human networks as channels for communication and behavioural change, engagement, community organising) that influence staff capability and motivation

5. Identify potential quality improvement projects

6. Perform PDSAs

7. Implement successful quality improvement projects

• The behaviour change wheel─ Capability, Opportunity, Motivation

Mitchie et al Implementation Science 2011;6:42

• Social Networks Christakis et al. PLoS ONE 5(9)

• Diffusion of innovation curve Rogers

Strategy

Hand Hygiene Primary Drivers

Education, Training & Promotion

Facilities, Workflow and Reminders

Monitoring and Reporting

Organisational Culture Change

Driver Diagram

Establish reliable HH practices

within CMDHB healthcare facilities

To increase HH practice rate from

60 to 80% by 30th June 2013

Education, training and

health promotion

Empowering staff to take action

Listen to customers. Give people access to information.

Personal AHR for physicians in EC

Primary Drivers Secondary Drivers Change Concept*refer to The Improvement Guide 2nd ed Appendix A

Interventions

Phlebotomist’s procedures

Monitoring and reporting systems

Facilities workflow reminders

Culture change,

leadership and social

movement

Simplify and standardise workflow relevant to hand

hygiene

Empowering patients and visitors to take action

Performance Alcohol hand rub consumption

Hand hygiene campaigns

Real time reporting of performance, clinical, economic

outcomes and patient experience

Smooth workflow. Reduce number of components. Standardisation

Real time feedback by Gold Auditors

Use proper measure

Reports design and dissemination

Senior leaders and managers engagement

Listen to customers. Focus on outcome to the customer. Give people access to

information

Hand Hygiene Staff Survey

Take care of basics. Conduct training.Give people access to information.

Daily Dose communication and dissemination

Patient information leaflets & video

Real time reporting of performance, clinical, economic

outcomes and patient experience

PerformanceGold Audit

Hand Hygiene posters

Identification of central people in the network

Patient stories

Communication, engagement, community organising

Hand hygiene champions meetings

Build reminders into the system

Nursing engagement

Allied Health engagement

Non-Clinical Support Services engagement

Doctors’ engagement

Outpatients engagement

Focus on outcome to the customer. Focus on purpose. Give people access to

information

ClinicalHAI rate, mortality, pathogen

burden

EconomicLOS, cost

Patient Experience

Use reminders to build habitsTake advantage of fashion trends

Availability of AHROffer product anytime and any place. Optimise level of inspection. Optimise

maintenance

Focus on outcome to the customerGive people access to information

Focus on outcome to the customer.Focus on purpose. Give people access to

information

Listen to customers.Focus on purpose. Give people access

to information

Audience segmentation

Develop alliances and cooperative relationships

Set up sustainable supply of AHR

Simple rewardsBehavior change

Social influence. Mobilise social norm

Teaching presentations

E-learning module

Case study presentations

Aim

Volume per 1000 patient days Target 20L per 1000 patient days

The Hand Hygiene

Project

CCC procedures

Name ofMeasure

Is this an Outcome, Process or Balancing

Measure?

Operational Definition (e.g., numerator &

denominator)

Gold Audit on hand hygiene practice, adherence per hand hygiene moment,

adherence per HCW group

Process (Correct moments / Total moments) x 100 =

compliance rate (%)>70% National Standard

Volume of hand gel per 1,000 patient days

Process > 20L / 1,000 pt days WHO standard

The WHO Hand Hygiene Self-Assessment

Framework

Balancing Total Score related to Hand Hygiene Level

The rate of S aureus, MRSA, ESBL, C. Difficile

associated infections

Outcome Number of cases / 1,000 patient days

Measures

Idea for Testing in a PDSA Theory and prediction about what will happen when you test this idea

Phlebotomists’ blood collection procedures

Help staff embed best evidence-based practice into their procedures. Smooth workflow. Reduce number

of components. Standardisation. Staff education.conduct training, develop alliances and cooperative

relationshipsTest: Number of procedures reduced from 5 to 2

Gold Audit October 77%Gold Audit March 81.8%

Critical Care ComplexHand hygiene for most common 5 procedures:

before/ after insertion of the central line, catheter,

suction, NG tube, rectal tube

Reasons for M2 and M3 being missed is confusion about the procedure. Smooth workflow. Reduce

number of components. Standardisation.Gold Audit October M2= 21% M3 = 31%

Gold Audit March prediction 50%

Hand gel consumption Use proper measure. Expect increase in consumption with increase in performance

Change Concepts & Ideas for PDSAsOpportunity

Change Concepts & Ideas for PDSAsCapability & Motivation

Idea for Testing in a PDSA Theory and prediction about what will happen when you test this idea

Sending repetitive messages via central people in the network(26 per year)

Content: Teaching, training video, patient stories, audit feedback, celebrations, campaigns

Develop alliances and cooperative relationships, education, training, motivation, persuasion, role modelling1. Gold Audit Correct HH adherence rate per HCW group 2. Cumulative number of staff attended sessions over time – Behaviour adoption curve3. Number of staff initiating own sessions - Behaviour adoption curve

Identifying the new network of hand hygiene champions e.g. Allied Health workforce

Meetings with the central people in the network e.g. HH Champions meeting

Develop alliances and cooperative relationships, education, training, motivation, persuasion, role modelling – celebrating successful initiatives

Hand Hygiene Staff Survey Questions exploring reasoning, behavioural, normative and control beliefs – to be administered following the Gold Audit

Results of your PDSAsRun chart of Hand Hygiene Compliance from Gold Audit Results

0%

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Litres of Alcohol based hard gel purchased per 1000 bed days at MMH

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Lit

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Purchased litres per 1000 bed days Median 20 litres per 1,000 bed days target

litres of hand gel purchased per 1,000 bed days at MSC

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Litres of ABR purchased per 1000 bed days Median Target of 20 litres per 1000 bed days

Dissemination of staff education via CNE / HH Champions network

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Profound Knowledge Worksheet

Appreciation for a System• Facilities and workflow• Reminders• Institutional safety culture

Psychology•The Behavioral change wheel (Michie et al)• Altruism, empathy, morality, solidarity• Social marketing• Liberating leadership• Positive psychology

Theory of Knowledge• Statistics• Public health• Behaviour adoption life cycle curve (Rogers curve, Christakis et al)• Human factors engineering• Teaching, simulation

Understanding Variation • Hand hygiene activity monitoring• HAI burden• Volume of hand gel

Process Changes and Results

• Positive, consistent messaging

• Engagement at a ward/unit/occupational group level

• Identification and engagement of “activists-in-place”─ Endogenous generation of improvement activities

• Ongoing communication and feedback, education and training, persuasion, role modelling

• Provision of supportive physical and social environments

• Acknowledgement of staff initiatives

©2011 Institute for Healthcare Improvement/R. Lloyd

March Gold Audit Interim Report

• Ward A ─ October 40.7%─ March 73%

• Ward B─ October 38.5%─ March 58.6%

• Ward C─ October 58%─ March   58.2%            

©2011 Institute for Healthcare Improvement/R. Lloyd

Next Steps

• Developing additional resources

• Broadening the base of our champions and members of the HHWG

• Beginning the top-down phase of our social marketing campaign

• Considering improving measurement