Unit-Based Staff Hand Hygiene (HH) Monitors To Improve Compliance in a Comprehensive Cancer Center

ISSUE: Both the Joint Commission on Accreditation of Healthcare Organizationʹs (JCAHO) patient safety goal and the Centers for Disease Control and Preventionʹs (CDC) guidelines recommend monitoring of hand hygiene adherence and providing feedback to patient care staff. In order to advance patient safety and HH compliance, a three-pronged approach was implemented to enhance HH education, observation and measurement of HH compliance. PROJECT: Three components were implemented to improve compliance with HH practices: Education Component (Phase I) Development and implementation of a mandatory computer-based learning module on hand hygiene for all patient care staff that included HHʹs “Top Ten List” based on CDCʹs Guideline for Hand Hygiene in Health-Care Settings, 2002 Focused and targeted educational program for fellows, residents and mid-level providers including staff in invasive procedural areas Special educational HH program in Spanish for spanish-speaking staff Training of unit-based HH observers (100) using the Train-the-Trainer model Focus on HH compliance during Patient Safety Week Campaign in March 2005 Evaluation Component (Phase II) Three HH observational periods for assessment of HH compliance by trained HH monitors and infection control practitioners in all patient care areas Monthly self-assessment in patient care area units and diagnostic areas Communication and Feedback of Results Component (Phase III) Communication to staff, managers and administration regarding HH violations and compliance rates Prompt follow-up with re-education in patient care areas where HH violations rates were lower than expected. RESULTS: In Phase I, 100% of patient care staff complied with HH computer-based training. A total of 100 unit-based HH observers were trained using the Train-the-Trainer approach with education on HH basics, use of HH tool and feedback to colleagues and peers. In Phases II and III, observational periods with assessment of HH compliance were implemented by the trained HH observer of each clinical area. Data from observation periods, demonstrated an incremental improvement in HH practices with an initial baseline of 79% and an average of 91% in subsequent periods. LESSONS LEARNED: A coordinated systems approach that includes patient care staff, physicians, committees and administration is essential when initiating a process change. Providing education and feedback to staff and physicians will improve compliance. Identification of areas where additional education and feedback on HH is required and will also improve compliance.