Sanja Mirkov, BPharm, PGDipPH Clinical Quality Improvement Coordinator
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Transcript of Sanja Mirkov, BPharm, PGDipPH Clinical Quality Improvement Coordinator
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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May
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Jul-0
9
Sep
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May
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Jul-1
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Nov
-11
Jan-
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Mar
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May
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Jul-1
2
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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