Establishing the Foundation to Support Health System Quality Improvement: Using a Hand Hygiene Initiative to Define the Process

Abstract

Objectives As hospitals are increasingly consolidating into larger health systems, they are becoming better positioned to have far reaching and material impacts on safety and quality of care. When the Mount Sinai Health System (MSHS) was formed in 2013, it sought to ensure the delivery of safe, high-quality care to every patient. In 2014, the MSHS addressed hand hygiene as the first major system-wide process improvement project focused on quality and safety. The goals of this study were to evaluate a system-wide hand hygiene program and to create a foundation for future process improvement projects. Methods The MSHS implemented the Joint Commission’s Targeted Solutions Tool as a way to improve hand hygiene compliance and reduce harm from hospital-acquired infections, specifically Clostridium difficile infections. A multifaceted approach was used to improve hand hygiene and promote a culture of patient safety. Results The MSHS improved hand hygiene compliance by approximately 20% from a baseline compliance of 63.3% to an intervention compliance of 82.8% (P < 0.001). Additional correlation analysis revealed a significant correlation between increasing hand hygiene compliance and reduction in C. difficile infections. Conclusions Through a focus on leadership engagement, data transparency, data and observer management, and system-wide communication of best practices, the MSHS was able to improve hand hygiene compliance, reduce infection rates, and build an effective foundation for future process improvement programs.

Impact of a Multimodal Improvement Strategy to Promote Hand Hygiene at a Hospital in Mauritius

“…Decision makers at healthcare facilities can pick a set of multimodal strategies from the table based on the specific hurdles being faced at their location. Several institutions have found success in the application of particular tools like the Joint Commission Targeted Solutions tool, WHO's Multimodal Hand Hygiene Improvement Strategy, Continuous Quality Improvement processes and through the use of behavioral change theories like the Behaviour Centered Design and the Health Action Process Approach [5][6][7][8][9][10]. [11,12].…”

Reducing Carbapenem-Resistant Enterobacteriaceae Using the Targeted Solution Tool

“…The Joint Commission Center for Transforming Healthcare's Web-Based TST for improving HH guides health care organizations through a step-by-step improvement process based on the 5 stages of a Six Sigma Project: Define, Measure, Analyze, Improve, and Control (DMAIC) 23. The tool enables the hospital to identify the actual level of compliance with HH through accurate measurement, and improve HH compliance by acting on systematic and sustainable changes to processes, for which efficacy has been previously demonstrated 19,24. Several resources are available to users, including training materials for data collectors, an HH observation form, a platform for real-time data analysis, and a set of implementation guides on the targeted solutions addressing the contributing factors identified within the organization.…”

“…23 The tool enables the hospital to identify the actual level of compliance with HH through accurate measurement, and improve HH compliance by acting on systematic and sustainable changes to processes, for which efficacy has been previously demonstrated. 19,24 Several resources are available to users, including training materials for data collectors, an HH observation form, a platform for real-time data analysis, and a set of implementation guides on the targeted solutions addressing the contributing factors identified within the organization. The data collection process focused not only on recording observed HH compliance but also on identifying contributing factors and barriers to optimal HH.…”

PathoSPOT genomic epidemiology reveals under-the-radar nosocomial outbreaks

“…Whole-genome sequencing was performed on the first patient blood isolate positive for MRSA as part of an ongoing genomic surveillance program as previously described [4]. Hand hygiene is monitored by the Infection Prevention and Control department by the use of anonymous observers using the Joint Commision's Targeted Solutions Tool (TST) [17], which was implemented in November 2014. This tool allows staff members to document reasons for non-compliance and target areas of interventions.…”