Regions Hospital
St. Paul, MN
499 staffed beds
Regions Hospital is an acute-care hospital in the Twin Cities with a Level 1 trauma center, and is affiliated with the HealthPartners system.
STEEEP
Effective - Hospital staff exhibited perfect hand hygiene at a 92 percent rate in 2009.
Efficient - The hospital used existing resources for the secret shopper program, redeploying existing light duty nurses.
Safe - Proper hand hygiene compliance is the simplest, most effective way to prevent nosocomial infections.
PPE
Create a High Reliability Culture - Managers, administration and physicians were held accountable to the hand hygiene protocols.
Team Members
Christine Boese, RN
Vice President, Patient Care Services
Susan Knepler
Decision Support Analyst
Brock Nelson
CEO
Dede Ouren, RN
Manager, Infection Control Department
Paula Skarda, MD
Chief of Staff
Accountability at Every Level
The Problem
According to the Centers for Disease Control, hand hygiene is the simplest, most effective measure for preventing nosocomial infections, but hospitals are still challenged with ensuring compliance. Since 2008, the Joint Commission has required hospitals to comply with either CDC or World Health Organization guidelines for hand hygiene as part of its National Patient Safety Goals.
The Solution
Regions Hospital held educational courses to demonstrate proper hand hygiene techniques to all staff members who come into contact with patients. The infection control department developed a seven question survey based on the CDC’s standards for proper hand washing technique and compliance in a variety of settings. Light-duty nurses and other hospital staff were given the scannable survey with instructions to observe staff in situations where hand hygiene was required and return the survey to the quality department, where it was automatically recorded into the decision support system.
The results were analyzed by the decision support department by time, unit and location. Each hospital unit disseminated the results regularly and discussed strategies for compliance.
The Results
Compliance with hand hygiene protocol improved from 80.7 percent in 2007 to 86.5 percent in 2008 to 92 percent in 2009.
Background
In 2005, a Joint Commission visit to Regions Hospital resulted in a notification that a staff member under observation had not complied with proper hand hygiene protocol. The hospital’s leadership subsequently decided to ascertain the extent of compliance with accepted hand hygiene protocol throughout the facility.
“When we started out, our baseline data showed there was room for improvement,” says Christine Boese, RN, vice president for patient care services. “This is one of those behaviors that you cannot argue with.”
Following the study, the hospital held extensive educational course to demonstrate proper hand hygiene technique, including instructions to rub and scrub their hands for 20 seconds—the equivalent of singing the “ABC song” twice. Educators also demonstrated the impact of hand hygiene on bacteria, using ultraviolet-sensitive hand lotions that allowed staffers to see the effectiveness of the lotions. Each staff member was then required to sign a statement promising to comply with hand hygiene protocol.
Around the same time, the infection control department developed an observation form that focuses on hygiene prior to invasive procedures, after touching blood, after removing gloves and before entering or leaving a room. The hospital’s executive leadership authorized reassigning light-duty nurses and other employees to work on the project as “secret shoppers” charged with observing their fellow employees and monitoring their compliance with hand hygiene. The secret shoppers were also expected to tell staff members, including physicians, whether or not they were complying with protocol.
“We reinforced good behavior,” says Dede Ooren, RN, the manager of the hospital’s infection control department. If a staff member missed an opportunity to wash their hands, the observers were expected to privately tell them about their lapse, Ooren said.
Decision support analyst Susan Knepler helped develop a program that reviews the observations by shift, employee and unit. Those scores are automatically updated into the hospital’s internal scorecard as secret shoppers turn in the observation forms. Managers are then able to compare themselves to other units and determine which workers and shifts are receiving perfect care scores.
In 2008, when the Joint Commission returned to the hospital, the hospital received high marks for hand hygiene compliance, Ooren says. Ultimately, Ooren and others expect that hand hygiene will become an ingrained behavior that clinicians perform as a matter of course.
“We’re trying to get it to be automatic muscle memory, so you don’t have to think about it anymore,” Ooren says.
Principles of Performance Excellence
Create a High-Reliability Culture
In order to meet the hospital’s organizational goals, each department manager must maintain a 90 percent hand hygiene compliance rate for their subordinates. In addition, the management team’s yearly incentives are tied to performance variables that include hand washing compliance throughout the organization. The emphasis on compliance caused units to compete to meet the objectives, according to Regions Hospital CEO Brock Nelson. Administrators are also expected to wash their hands when entering and leaving patient rooms. “We set the expectation as leaders,” Nelson says. “It just comes part of the routine to foam in and foam out.”
When the observation program began, physicians initially received lower scores for compliance. Using the data developed by the decision support team, the hospital’s leadership presented the information to the doctors. “To look up at the board and see physicians with the lowest compliance was embarrassing for them,” says Paula Skarda, MD, the hospital’s chief of staff.
Since then, the hospital’s physicians made a concerted effort to improve their compliance; the latest statistics, reported in late 2009, saw physicians performing perfect hand hygiene compliance 91.6 percent of the time. “They responded,” Nelson says.
Continual Improvement
When the project started, many of the hospital’s patient rooms did not have foam hand sanitizers. While the foam dispensers were available outside the rooms, it was difficult for clinicians to quickly and easily wash their hands in the course of their duties. “We needed better access to foam cleaners,” Boese says.
Subsequently, the hospital’s executive leadership authorized the purchase of foam canisters, which were mounted to the wall of each patient room. When the hospital built a new wing, each room came with its own sink, making it possible for clinicians and others to wash their hands with soap and water at the proper opportunities. “With the design process, I remember vividly that we debated where to best put the sinks,” Nelson recalls.
