200 1 IHI Expedition Impacting Hand Hygiene at the Front Line Session 1 Tuesday, July 30, 2013 These presenters have nothing to disclose Lisa Maragakis, MD, MPH Tom Talbot, MD, MPH Diane Jacobsen, MPH, CPHQ Siew Lee Grand-Clément, RN, MSN, CPHQ Expedition Coordinator 2 Kayla DeVincentis, CHES, Project Coordinator, Institute for Healthcare Improvement, currently manages web-based Expeditions and the Executive Quality Leaders Network. She began her career at IHI in the event planning department and has since contributed to the State Action on Avoidable Rehospitalizations (STAAR) Initiative, the Summer Immersion Program, and IHI’s efforts for Medicare-Medicaid enrollees. Kayla leads IHI’s Wellness Initiative and has designed numerous activities, challenges, and educational opportunities to improve the health of her fellow staff members. In addition to implementing the organization’s first employee health risk assessment, Kayla is certified in health education and program planning. Kayla is a graduate of Northeastern University in Boston, MA, where she obtained her Bachelors of Science in Health Science with a concentration in Business Administration.
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IHI ExpeditionImpacting Hand Hygiene at the
Front Line Session 1
Tuesday, July 30, 2013
These presenters have nothing to disclose
Lisa Maragakis, MD, MPH
Tom Talbot, MD, MPH
Diane Jacobsen, MPH, CPHQ
Siew Lee Grand-Clément,
RN, MSN, CPHQ
Expedition Coordinator2
Kayla DeVincentis, CHES, Project Coordinator, Institute for Healthcare Improvement, currently manages web-based Expeditions and the Executive Quality Leaders Network. She began her career at IHI in the event planning department and has since contributed to the State Action on Avoidable Rehospitalizations (STAAR) Initiative, the Summer Immersion Program, and IHI’s efforts for Medicare-Medicaid enrollees. Kayla leads IHI’s Wellness Initiative and has designed numerous activities, challenges, and educational opportunities to improve the health of her fellow staff members. In addition to implementing the organization’s first employee health risk assessment, Kayla is certified in health education and program planning. Kayla is a graduate of Northeastern University in Boston, MA, where she obtained her Bachelors of Science in Health Science with a concentration in Business Administration.
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WebEx Quick Reference
• Welcome to today’s session!
• Please use chat to “All Participants” for questions
• For technology issues only, please chat to “Host”
• WebEx Technical Support: 866-569-3239
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Chat Time!
What is your goal for participating in this Expedition?
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Join Passport to:
• Get unlimited access to Expeditions, two- to four-month, interactive, web-based programs designed to help front-line teams make rapid improvements.
• Train your middle managers to effectively lead quality improvement initiatives.
Diane Jacobsen, MPH, CPHQ, Director, Institute for Healthcare Improvement (IHI) is currently directing the CDC/IHI Antibiotic Stewardship Initiative, NSLIJ/IHI Reducing Sepsis Mortality Collaborative. Ms Jacobsen served as IHI content lead and improvement advisor for the California Healthcare-Associated Infection Prevention Initiative (CHAIPI) and directed Expeditions on Antibiotic Stewardship, Preventing CA-UTIs, Reducing C. difficileInfections, Sepsis, Stroke Care and Patient Flow. She served as faculty for IHI’s 100,000 Lives and 5 Million Lives Campaign and directed improvement collaboratives on Sepsis Mortality, Patient Flow, Surgical Complications, Reducing Hospital Mortality Rates (HSMR) and co-directed IHI's Spread Initiative She is an epidemiologist with experience in quality improvement, risk management, and infection control in specialty, academic, and community hospitals. A graduate of the University of Wisconsin, she earned her master's degree in Public Health-Epidemiology. from the University of Minnesota.
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Today’s Agenda11
Ground Rules & Introductions
Pre-Program Survey Results
Call to Action for Hand Hygiene
The Joint Commission Targeted Solutions Tool
Using the Model for Improvement
Action Period Assignment
Ground Rules12
We learn from one another – “All teach, all learn”
Why reinvent the wheel? – Steal shamelessly
This is a transparent learning environment
All ideas/feedback are welcome and encouraged!
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Overall Program Aim
To provide hospitals with practical change ideas and innovative approaches to impact Hand Hygiene at the frontline in their organization
Expedition Objectives
By the end of the Expedition participants will be able to:
Describe the impact of hand hygiene on healthcare-associated infections
Discuss methods for measuring effectiveness of hand hygiene in your organization and creative approaches to assessing your progress over time
Identify and begin improving at least one key process to increase hand hygiene focus and practice in your hospital
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Schedule of Calls
Session 1 – Call to Action for Hand HygieneDate: Tuesday, July 30, 2:30 PM – 4:00 PM ET
Session 2 – Measurement ApproachesDate: Tuesday, August 13, 2:30 PM – 3:30 PM ET
Session 3 – Supplies, Equipment, and the EnvironmentDate: Tuesday, August 27, 2:30 PM – 3:30 PM ET
Session 4 – Leadership and Culture for Hand HygieneDate: Tuesday, September 10, 2:30 PM – 3:30 PM ET
Session 5 – Frontline EngagementDate: Tuesday, September 24, 2:30 PM – 3:30 PM ET
Session 6 – Marketing and Communications Campaigns
Date: Tuesday, October 8, 2:30 PM – 3:30 PM ET
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Faculty16
Lisa Maragakis, MD, MPH is an Assistant Professor of Medicine at The Johns Hopkins University, Department of Medicine, Division of Infectious Diseases and the Hospital Epidemiologist and Director of the Department of Hospital Epidemiology and Infection Control at The Johns Hopkins Hospital. She received her medical degree and post-doctoral Infectious Diseases training at The Johns Hopkins University School of Medicine and a master’s degree in public health from The Johns Hopkins University Bloomberg School of Public Health. She recently served as a Councilor on the Board of Directors of the Society for Healthcare Epidemiology of America (SHEA), as Vice-Chair of the SHEA Guidelines Committee and as the liaison representing SHEA to the Healthcare Infection Control Practices Advisory Committee at the Centers for Disease Control and Prevention. Her research interest is the epidemiology, prevention and control of healthcare-acquired infections caused by antimicrobial-resistant gram negative bacilli.
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Faculty17
Tom Talbot, MD, MPH, FSHEA, FIDSA, Associate Professor of Medicine and Preventive Medicine, Vanderbilt University School of Medicine and Chief Hospital Epidemiologist, Vanderbilt University Medical Center, conducts research on healthcare epidemiology and infection control and oversees healthcare-associated infection prevention programs. Dr. Talbot currently serves as a member of the Centers for Disease Control and Prevention’s Healthcare Infection Control Practices Advisory Committee (HICPAC).
Pre-Program Survey Results
Diane Jacobsen,
MPH, CPHQ
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Poll Question – Who is in the room?
Please select the roles or departments represented on the call today from your organization. Check all that apply:– Nursing
– Physicians
– Infection Prevention
– Quality Improvement
– Leadership
– Pharmacy
– Allied Health Professional
Please chat any additional roles into the chat box.
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Survey Results:Top Barriers to Improving Hand Hygiene
1. Lack of accountability or enforcement of compliance.
2. Staff are unaware of importance or proper procedure.
3. Leadership does not support hand hygiene campaigns or activities.
4. Sanitizer or sinks not reliably stocked and poorly located.
5. Staff are not engaged or supportive of hand hygiene activities.
6. Staff are too busy and do not have time to properly wash hands.
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Survey Results:Measurement Approaches
Direct Observation
– Secret or Embedded Observers: 87%
– Unit Representatives Who Observe Own Unit Practice: 60%
Sanitizer Consumption: 14%
Healthcare-associated Infection Rate: 30%
– As a surrogate outcome
Technology for Electronic Monitoring: 6%
– Including RFID
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Survey Results:Average Hand Hygiene Compliance
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80% or greater
60%-80%
40%-60%
Less than 40%
Not sure
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Call to Action for Hand Hygiene
Lisa Maragakis, MD, MPH
Healthcare-associated Infections and Resistant Organisms
Central line-associated bloodstream infections (CLABSI)Surgical Site Infections (SSI)Ventilator-associated pneumonia (VAP)Catheter-associated urinary tract infection (CAUTI)Methicillin-resistant S. aureus (MRSA) Vancomycin Resistant Enterococcus (VRE)Multidrug resistant Gram negative bacilliClostridium difficile
Upon entering and exiting a patient roomBetween patient contacts if >1 patient in a roomBefore and after touching a patient who is not in a room (on a stretcher or wheel chair in the hall)Before donning and after removing glovesBefore handling invasive devicesAfter contact with blood or body fluids or excretions, mucous membranes, non- intact skin or wound dressingsAny time needed such as after sneezing, or coughing before handling food or oral medications to patient roomBefore & after touching wounds
Soap and water required AFTER care of patient on isolation for C. difficile or Norovirus
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A Sobering Letter…
“Today would have been my beloved wife’s birthday. She died in your hospital…”
…“I witnessed many gross violations... not limited to one building, one floor, or one individual. …staff with colds coughing and sneezing in my wife's room without masks on…doctors not washing their hands upon entering the room, … they replied that these were simply ‘guidelines’, and that the staff person could opt to proceed at their own risk…..”
Line Insertion Line Maintenance
1. Perform hand hygiene before and after catheter
insertions or manipulation
2. Use chlorhexidine for skin
preparation2. Hub care
3. Use full barrier precautions
during insertion 3. Site care
4. Avoid using the femoral
site in adult patients4. Tubing care
5. Assess the need for the catheter each day and remove
ASAP
Best Practices to Prevent CLABSI
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Best Practices to Prevent SSI
Clean hands (surgical scrub)
Use antimicrobial prophylaxis when indicated
– Right time (within 1 hour of incision)
– Right dose
– Right agent
– Appropriate duration
Chlorhexidine skin prep applied correctly
Clippers for hair removal (not razors)
Control glucose and temperature
Use appropriate FIO2
Best Practices to Prevent VAP
Hand hygiene
Elevate the head of the bed >30 degrees
Oral care with chlorhexidine
Sub-glottic suctioning ET tube
Sedation vacation
Daily assessment of readiness to wean
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Respiratory Etiquette
Clean hands
Cover your sneeze
Get immunized (flu vaccine)
Immunize your patients for flu and pneumococcus
Wear a mask if you have a cold
Do not work if you have influenza-like illness or any febrile respiratory illness
Does hand hygiene work?
YES!! Alcohol hand rub and old fashioned hand washing work well
Reduces organisms on HCW hands
Reduces infection rates
Reduces mortality
Doebbeling 1988, AIM:109;394-8Larson 1988, ICHE:9;28-36Pittet D, et al. Lancet 2000;356:1307-1312.
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Ignaz Philipp Semmelweis (1818-1865)
Post-Partum Mortality Intervention Trial
0.0%
5.0%
10.0%
15.0%
20.0%
Before After
Physicianward
Midwifeward
Two wards, each with 3500 deliveries/year� Physicians and medical
student– 600-800 mothers died/year
� Midwives– 60 mothers died/year
Intervention: Rub hands in chlorinated lime solution until slippery and cadaver smell gone before every vaginal exam
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Infection Rates with Improved Hand Hygiene
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
1993 1994 1995 1996 1997 1998
Ne
w M
RS
A p
er
10
0 a
dm
iss
ion
s
0
5
10
15
20
25
30
35
In
fec
tio
ns
pe
r 1
00
ad
mis
sio
ns
MRSA incidence
NosocomialInfections
Pittet, Lancet 2000; 356: 1307-12
• Alcohol hand rubs and hospital-wide campaign to increase HH compliance• Improved HH compliance (48% to 66%)• Decreased
� MRSA incidence (2.16 to 0.93 episodes per 10,000 patient days) � Overall healthcare-associated infections (17% to 10%)
HH vs. MRSA Transmission Rate for JHH Adult ICUsOctober 2007 to June 2010
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Profession Compliance
Registered Nurses 26%
Physicians 21%
Nurses Aides 14%
Respiratory Therapists 10%
Radiology Technicians 0%
Environmental Staff Services 0%
Medical Students 83%
Hand Hygiene Compliance by Profession
Kim P. Am J Infect Control April 2003
Pittet, Ann Intern Med, Jan 19, 1999; Boyce Editorial
Why is Compliance So Poor?
Skin dryness and irritation with frequent washing
No time to wash hands (too busy)
Inconvenient sink location
Adherence not typically tracked individually – no records kept
Not rewardedAdverse events aren’t immediate and their relationship to the missed HH opportunity isn’t always clear
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Another Sobering Letter….
Dear Editor: “The editorial on hand washing calls for all hospital staff to start regularly washing their hands between each patient contact. If, as the authors claim, there is such compelling evidence for the need to wash hands between each patient contact then why do I and the vast majority of my colleagues not do it? Firstly, I have never seen any convincing evidence that hand washing between each patient contact reduces infection rates…. Secondly... Washing hands between eachcontact (at 1-2 minutes per wash) would take on average 1-2 hours.Where will this time come from, and who will fund it? If hand washing is to be performed between every patient contact then it would have major resource implications. For this it needs to be shown to be effective and worth the 15% extra staffing that would be needed to cover the extratime.”
-Andrew Weeks, specialist registrar in obstetrics and gynaecology BMJ 1999
Pittet D. Ann Intern Med 1999
Correlation Between High Workload and Lower HH Compliance
Ward 20-40 opp/ hr care
ICU 43 opp/ hr care
Decrease of compliance by 5% per 10 opportunites per hour
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So is there any good news??
Yes!
Multifaceted interventions; rigorous monitoring and feedback; rewards, recognition, and accountability can lead to improvements and good HH performance
Improvement requires perseverance, dedication, engagement, leadership support, creativity and adaptability
Hand Hygiene Compliance for JHH: January 2009 – May 2013
Is the cornerstone and of upmost importance to our infection prevention efforts
Leads to decreased HAIs and MDRO transmission
Is difficult BUT POSSIBLE to achieve
SHEA, IDSA and their partners are in the process of updating the Compendium of Strategies to Prevent Healthcare-associated Infections which will include a new section on Hand Hygiene
Questions?44
Raise your hand
Use the Chat
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Faculty45
Siew Lee Grand-Clément, RN, MSN, CPHQ, Center Solutions
Development Director, the Joint Commission, leads solution
development activities for the Joint Commission Center for
Transforming Healthcare. A Black Belt in Robust Process
Improvement, she also serves as an RPI instructor and Mentor of
Yellow Belts, Green Belts, and Black Belts. Prior to her current role,
Siew Lee was the Associate Director of International Accreditation
for Joint Commission International (JCI). Siew Lee brings extensive
experience and diverse knowledge in nursing, staff training and
development, and healthcare quality to her role at the Joint
Commission. She has worked in multiple adult clinical areas in both
small community hospitals and large academic medical centers.
Siew Lee received her Bachelor of Science in Nursing with a minor
in Community Health from University of Central Oklahoma, and her
Master of Science and Advanced Practice Nursing training from
Our Mission: Transform health care into a high reliability industry
and to ensure patients receive the safest, highest quality care.
Leadership
• The responsibility of leadership to make high reliability the priority
• The responsibility of leadership to make high reliability the priority
Safety Culture
• The importance of creating a culture of safety within an organization
• The importance of creating a culture of safety within an organization
RPI
• The use of proven quality methods – Lean Six Sigma & Change Management (known together as robust process improvement™) – to systematically improve processes and avoid common, crucial failures
• The use of proven quality methods – Lean Six Sigma & Change Management (known together as robust process improvement™) – to systematically improve processes and avoid common, crucial failures
For a typical 200-bed hospital, the TST for hand hygiene could save 8 lives and $2.3-$2.8M per year
Note: (†) Assumes a 35% reduction in HAIs through a hospital-wide implementation of the TST for hand hygiene, based on the impact of 5 published studies (Refs 1-5)Sources: [1] Pittet (2001) J Hosp Inf, S40-S46; [2] Lam (2004) Pediatrics, e565-571; [3] Won (2004) Inf Cont Hosp Epid, 742-746; [4] Pessoa-Silva (2007) Pediatrics, e382-e390; [5] Rosenthal (2005) Am J Inf Cont, 392-397; [6] Figures adjusted to 2011 dollars using consumer price index - CDC "The Direct Medical Costs of Healthcare-Associated Infections in US Hospitals and the Benefits of Prevention," R. Douglas Scott II, March 2009; [7] Based on 1.7M HAIs contracted annually and 944K US hospital beds – AHA, 2011 [8] CDC – HAI mortality rate of 5.8%
TST can prevent ~65-70 HAIs for every 100 beds†
# of HAIs / 100 beds / year
200
150
100
50
0
120
-65-70
After TSTBefore TST7
185
$2.3-2.8 millionCosts that could be saved
HAIs cost $18-21K per infection in direct medical costs6
130-140Number of HAI
cases that could be
prevented
8Lives could be saved
HAIs have a 5.8% mortality rate8
A typical 200-bed hospital can expect significant benefits by implementing the TST tool
Data Collection MethodHH data collector (observer) Just-in-time coach
Purpose To be an unbiased observer for hand hygiene compliance.
To intervene when hand hygiene non-compliance is observed and coach staff on proper compliance.
Data collected
Hand hygiene compliance data is used for establishing the baseline Hand Hygiene performance
Data collection will begin after the baseline data has been collected and the compliance data shared with staff.
Secret shoppers”: anonymous observers collected data on physical barriers of non-compliance without influencing the observed behaviors.
JIT coaches capture non-observable cultural barriers by interviewing health care providers after an observed instance of non-compliance.
Who
Using staff in a position where they can secretly observe staff while performing their regular job duties and not seem out of place during their time on the unit.Example: housekeeping and lab staff, chaplains, volunteers.
Approach staff when defects (non-compliance) occur and have staff to explain how the defect occurred since some defects cannot be observed (i.e., distractions, skin irritation). Example: unit managers, charge nurses, infection control practitioners, executives/leadership, and quality coaches or unit-based educators.
“We fully attribute to the Center for Transforming Healthcare’s hand hygiene [tools] the final drop in HAI rates to zero or near-zero system-wide. After implementing CTH hand hygiene, our hospitals began to report zeros as their most common monthly CLABSI and VAP result. Our mothers were right after all! Feel free to quote me. This actually saves lives.”
Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass, 1996.
Why Test?
Increase the belief that the change will result in improvement
Predict how much improvement can be expected from the change
Learn how to adapt the change to conditions in the local environment
Evaluate costs and side-effects of the change
Minimize resistance upon implementation
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Plan• Compose aim
•Pose questions/predictions
•Create action plan to carry
out cycle (who, what, when,
where)
•Plan for data collection
DoStudy
Act
• Carry out the test and
collect data
•Document what occurred
•Begin analysis of data
• Complete data analysis
•Compare to predictions
•Summarize learning
• Decide changes to make
•Arrange next cycle
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Testing on a Small Scale
RULE OF ONE: Conduct the test on one unit, with one staff member or physician and one patient
Conduct the test over a short time period
Test the change on a small group of volunteers
Develop a plan to simulate the change in some way
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Repeated Use of the PDSA Cycle
Hunches
Theories
Ideas
Changes That
Result in
Improvement
A P
S D
A P
S D
Very Small Scale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
Sequential building of
knowledge under a
wide range of
conditions Spread
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Questions?82
Raise your hand
Use the Chat
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Action Period Assignment
Complete 3 to 5 hand hygiene observations on one unit using the data collection tool provided by the Joint Commission (will be distributed on the listserv after the call) OR your organization’s current data collection tool– If using the Joint Commission tool, Watch “Improving Care with
Targeted Solutions Tool (TST)” video (6 minutes) http://www.centerfortransforminghealthcare.org/multimedia/improving-care-with-the-tst/
Based on what you observed, brainstorm ideas you could test to address current barriers to hand hygiene– Consider: visibility and availability of soap, visual reminders or
prompts, workflow obstacles related to availability and location of supplies, pace on the unit, etc.
Come prepared to share your experience at Session 2.