Mentor Registry Home
Use this table to quickly find a mentor for the improvement of hand hygiene with demographics similar to your own, or use 'ctrl+f' in your web browser to search for specific key words on this page.
Heart Hospital Baylor Plano, The – Plano, TX
Availability Status: Available to answer requests
Licensed Beds: 116
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: August 2007
Mentor Contact Name: Brenda Helms RN, BSN, MBA/HCM, CIC
Mentor Contact Email: brenda.helms@baylorhealth.edu
Mentor Contact Phone: 469-814-3525![]( "Call: 469-814-3525")
Additional Information:
When the Heart Hospital of Baylor Plano first started our hand hygiene campaign in August of 2007, the compliance with availability of supplies was 85%. Environmental Services is responsible for maintaining the soap and paper towels and stocking of alcohol foam. They check all supplies as each room is cleaned daily. Since Environmental Services has been responsible, compliance with the availability of soap/water, paper towels and alcohol gel for hand hygiene has been consistently 100%.
With monthly observations of caregivers, including MD, RN and Techs, compliance has been as low as 72.22 and as high as 100% since July of 2008. When the hand hygiene campaign was started, compliance had been as low as 65%. The last quarter has been >93% with 320-543 observations each month. We have a large number of observations due to the large number of volunteers who document observations each month. We have at least 2 people from every department who turn in monthly audits. One unit, as part of their action plan, has the charge nurse for each shift complete 10 observations.
We look at our infection rates (VAP, CLABSI, CAUTI) each month compared to the hand hygiene compliance rates to see if there is a correlation between the two. The one month that our compliance rate was 79%, our infection rates increased.
Keys to our hospital’s success:
• Facility administration/health care system administration support
• Accountability: We designed and implemented the "You Bugged Me" program where anyone who sees someone (including physicians) not washing their hands can give them a card. Once a person gets three cards, they have to present a hand hygiene in-service for the staff. If they receive five, they have to do a research project. If they get seven, they have to present the research to the Best Care Committee. If they receive ten, they have to meet with the CEO and CNO of the facility. (We have not yet had anyone get more than two cards.) Every time a card is given, the Infection Preventionist is notified so they track numbers and provide one-on-one education. The cards can also be given to employees who always wash their hands as positive reinforcement and they get rewards the more they collect such as movie tickets, etc.
• Use of a hand hygiene education kit: This kit includes a product designed to glow when exposed to a black light to educate all departments about proper hand hygiene during staff meetings. We named hand hygiene champions for each department and one for the physicians that act as secret shoppers and also provide ongoing education with the kit.
Strategies for periodic monitoring of staff hand hygiene compliance:
We have secret shoppers who monitor hand hygiene each month in different areas. We strive for at least 10 observations from every department. The audit tool also allows for entering the name of the employees who are monitored. We calculate compliance rates overall, by department, by job description and individually. These results are posted on our communication boards in all departments alongside our infection rates for the month.
We urge our patients to remind their nurses and physicians to wash their hands if they forget. This engages and empowers the patients to take part in their care and their safety. We have signs posted in every patient room to remind visitors and staff to wash their hands.
Our hand hygiene initiative has cost relatively little. The education kit was less than $200. The time spent for education is done during normal working hours, so there is not an extra labor cost. We made copies in-house of signs provided by our health care system. Our infection rates have been low so we have not had a huge financial impact resulting from infections.
Download their hand hygiene presentation slides.
Mentor designation - 5/4/10
* * *
Mission Hospital – Asheville, NC
Availability Status:
Available to answer requestsLicensed Beds:
673Teaching / Non-Teaching Status:
TeachingSetting:
UrbanStart Date of Intervention Work:
July 2006Mentor Contact Name:
Paula Blankenship, Infection Control Specialist
Mentor Contact Phone:
828-213-5467![]( "Call: 828-213-5467")
Additional Information:
Mission Hospital has a Hand Hygiene team chaired by a physician, who is an infectious disease specialist. In 2006 the committee expanded the auditing of hand hygiene from just the ICUs to staff across the hospital. The Infection Prevention Specialist developed the observer training curriculum and offers one training session per month for the "secret and known observers." The Infection Prevention Specialists oversee the audit process and distribute data to department leaders. Monthly reports are posted on the hospital internal web site for all staff to see.
Hand Hygiene Compliance:
Baseline - July 2006 68%
3rd Qtr. 2006 73%
4th Qtr. 76%
2007 82%
2008 92%
2009 95%
2010 96%
2011 96%
2012 95%
Hand hygiene compliance at baseline in July 2006 was 68%. Compliance steadily increased through 2007 until we reached the goal of 90% compliance in March 2008 and have sustained a rate greater than 90% since then. The compliance rate then continued to increase from 92% in 2008 to 95% in 2009, 96% in 2010 and 2011 and 95% in 2012.
All patient rooms are single rooms and have alcohol hand rub mounted on the wall. In 2007, alcohol hand rub dispensers were placed in the hallways at the entrance to each room. Public corridors and lobbies also have these alcohol hand rub bottles. We have found that the alcohol product drips from the dispensers and stains the walls and floors so we began installing an improved dispenser with a drip plate in 2011.
Secret observers were asked to submit at least 20 observations per month and some were able to record more than the required number.
1st Qtr 2010 compliance rate was 94% with 16,766 observations
2nd Qtr 2010 had a rate of 95% with 18,512 observations
3rd Qtr 2010 had a rate of 96% with 16,866 observations
4th Qtr 2010 had a rate of 96% with 17,170 observations
1st Qtr 2011 had a rate of 96% with 15,587 observations
In 2011 we asked observers to do fewer observations and we started a new program for Patient Hand Hygiene Observations. A nurse or clerk on the nursing unit or in the clinic gives the patient a form and instructs them to record if the health care worker performs hand hygiene before and/or after their care. To make it easier for the patient, the forms list the most commonly recognized occupations: doctor, nurse, Lab , XRay, PT, Transport. The forms are returned to the nurse and observations are entered into a database. Preliminary results from these audits are comparable to those of the non-patient "secret observers."
Mission Hospital implemented the following strategies to improve and monitor hand hygiene compliance:
• Implemented a monitoring program that included both secret and known observers. The observers watch staff performing hand hygiene and enter the data into a computer system for tracking purposes. The secret observers do not intervene with the staff at the point of observations and the known observers intervene with the staff who do not perform appropriate hand hygiene.
• Implemented a monitoring program to assess compliance with the policy that prohibits artificial fingernails for clinical staff. Audits were conducted in 2009 and 2011 with the findings of 100% compliance for staff with direct patient care (N=2457); 134 audits of medical staff with 100% compliance with 120 audits of physician extenders with 100% compliance.
• 2007 Installed antiseptic handrub dispensers outside patient rooms in each department, and in public corridors and entrances.
• Began a process for monitoring the amount of antiseptic handrub purchased per patient day. Utilization of antiseptic handrub has increased from 0.87 ounces per patient day in January 2006 to 1.98 ounces per patient day in June 2009.
• Posted “wash in” and “wash out” stickers on all patient room doors.
• Posted static cling stickers reminding staff to “wash germs off here” on mirrors above sinks in all patient rooms and in bathrooms.
• Implemented the use of “computer screen savers” to remind staff to use appropriate hand hygiene.
• Asked staff to sign a pledge stating the promise to perform hand hygiene. The pledge was then posted in the department.
• 11x18 posters with Hand Hygiene messages distributed bimonthly (8 in all)
• Several times a year Infection Prevention gives small bottles of alcohol hand rub to employees and volunteers at hospital sponsored fairs.
• At the 2009 employee fair custom made "fortune cookies" with hand hygiene messages inside were distributed.
• "Secret observers" and “known observers” monitor staff in their assigned work area for compliance with hand hygiene. The observers then enter the data into a computer tracking system.
Staff complete an annual computer module on hand hygiene.
Monthly reports of hand hygiene compliance by department and occupation are run by the Infection Preventionist and posted on hospital internal website. The Hand Hygiene committee reviews the data and identifies departments with compliance below threshold (90%) who are expected to complete an action plan identifying strategies to improve compliance. Data is reported to several committees. Data related to physician compliance with hand hygiene is reported to the Chief of Staff.
Outcome data to help measure the impact of efforts to improve hand hygiene:
We began our MRSA PCR screening program in high risk units at the same time we began the hand hygiene campaign in 2006. We attribute the success of the MRSA program both to the PCR screening in high risk units and to the increase in hand hygiene compliance. The MRSA NIM rate has steadily declined each year.
MRSA NIM (Nosocomial Infection Marker) Rate per Total Hospital Admissions:
2008 - 0.33%
2009 - 0.34%
2010 - 0.30%
2011 - 0.28%
2012 - 0.23%
In 2009, we created new isolation signs specifically for patients with C. difficile infections to remind staff to wash hands with soap and water instead of using alcohol-based hand rub, since evidence has shown this to be more effective. The hospital experienced a small decline in rate shown in 2008 through 2009 and since the testing methodology remained constant during 2009, it is believed that the decrease observed was a true decrease. In February 2010 the Microbiology Lab implemented a PCR test for C. difficile. With this change, the hospital established a new baseline rate of 0.45% in 2010 and has seen a small increase each year since then. The Infection Prevention Specialists continue to monitor the rate and in 2012 instituted changes to the isolation practices for patients with C. difficile. Beginning in August 2012 all patients who test positive for C. difficile (whether they are continent or not) are placed in contact precautions for the duration of their hospitalization.
C. difficile NIM (Nosocomial Infection Marker) Rate per Total Patient Admissions:
2008 - 0.34%
2009 - 0.27%
2010 - 0.45% ( Feb 2010 implementation of C. difficile PCR test)
2011 - 0.47%
2012 - 0.49%
Keys to Success:
Support from Administration is key in the success of the program. Financial support allowed us to purchase the data management program, posters, stickers, kiosks, promotional items to distribute to staff and reinforce the importance of hand hygiene. Support from Information Technology and Marketing is essential to develop the creative signs and screen savers that are changed frequently.
The secret observations and patient observations are are done anytime-nights, weekends, and weekdays.
Managers monitor presence of artificial fingernails which are not permitted to be worn by any staff who touch patients or prepare food. Managers do visual surveys of employee hands and employees are required to remove the artificial nails if any are found.
In 2009 large free standing kiosks with alochol hand rub dispensers were placed in the lobbies. The kiosk has hand hygiene reminder posters appropriate to the season. Fall and winter signs remind visitors of hand hygiene and flu season while others have "cute germs" and a hand hygiene message. Visitors use the alcohol hand rub at these kiosks.
Mentor designation - 5/16/10
Information updated - 4/2/2013
* * *
St. Joseph Mercy Hospital – Ann Arbor, MI
Availability Status: Available to answer requests
Licensed Beds: 537
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: July 2009
Mentor Contact Name: Robert MacDonnell, Performance Improvement Leader & Six Sigma Black Belt
Mentor Contact Email: macdoner@trinity-health.org
Mentor Contact Phone: 734-712-5370![]( "Call: 734-712-5370")
Additional Information:
All rooms are private and 100% of the rooms have gloves of appropriate sizes, as well as sinks, bacteriocidal hand soap, paper towels, and alcohol-based hand rub (ABHR) dispensers. In addition to ABHR dispensers in the patient rooms, there are ABHR dispensers outside each room door (affixed to the wall) to provide additional access/ availability of the products and to act as visual cues to remind staff to engage in hand hygiene before and after entering/leaving patient rooms.
Overall compliance with hand hygiene (HH) by health care workers (HCW) improved from a mean of 68% to 89% and was sustained for a period of 12 months, on the patient care unit studied. See additional data here.
(NOTE: This study was done in conjunction with the Joint Commission's Center for the Transformation of Healthcare which included our organization and six other hospitals and health care systems nationwide.)
The improvements at our organization are attributable to:
1. Encouraging unit staff to modify their HH practices from hand washing, to the use of alcohol-based hand rubs (ABHR) where appropriate, to reduce skin irritation. Skin irritation was found to be a major barrier to consistently high HH compliance in our organization.
% ABHR use:
Baseline (Jan-Aug 2009) After Interventions (Sep-Dec 2009)
Nurses 60% Nurses 76%
Patient Care Techs 43% Patient Care Techs 63%
2. Promoting a better understanding of the WHO 5 Moments for HH among HCW, especially before patient contact (BPC), After Patient Contact (APC); and After Contact w/ pt. Surroundings (ACS)
Baseline - Nurse After Interventions - Nurse
Jan-Aug 2009 Sep-Dec 2009
BPC 70% BPC 84%
APC 100% APC 100%
ACS 67% ACS 83%
Baseline - Patient Care Techs After Interventions - Patient Care Techs
Jan-Aug 2009 Sep-Dec 2009
BPC 38% BPC 68%
APC 79% APC 100%
ACS 67% ACS 87%
3. Placement of ABHR dispensers outside patient room doors to improve availability/accessibilityand to promote visual cueing.
4. Providing individual feedback to HCW to raise awareness of their own HH compliance.
5. Promoting a greater awareness of the lifespan of bacteria and viruses on environmental objects and surfaces.
After the study unit data was validated as sustainable over a 6 month period (July-Dec 2009), the interventions were rolled out hospital-wide beginning in January 2010 with the following results:
Hospital-wide Baseline Data:
Jun 2009 407/516= 78.9%
Jul 2009 356/441= 80.7%
Aug 2009 51/557= 81.0%
Sep 2009 488/589= 82.9%
Oct 2009 407/470= 86.6%
Nov 2009 460/525= 87.6%
Dec 2009 486/606= 80.2%
Hospital-wide Post-intervention data:
Jan 2010 565/662=85.3%
Feb 2010 431/509= 84.7%
Mar 2010 501/561= 89.3%
Apr 2010 491/562= 87.4%
May 2010 434/490= 88.6%
Jun 2010 446/496= 89.9%
Jul 2010 476/539= 88.3%
Aug 2010 383/413= 92.7%
Sep 2010 460/517= 89.0%
Oct 2010 507/540= 93.9%
Nov 2010 381/419= 90.9%
Dec 2010 386/423= 91.3%
Jan 2011 - Dec 2012 consistently sustained above 90% organization wide
See more data on hand hygiene compliance here.
Keys to our hospital’s success:
1. Encouraging unit staff to modify their HH practices from hand washing to the use of alcohol-based hand rubs (ABHR) where appropriate, to reduce skin irritation.
2. Promoting a better understanding of the WHO 5 Moments for HH among HCW.
3. Placement of ABHR dispensers outside patient room doors to improve availability/accessibilityand to promote visual cueing.
4. Providing individual feedback to HCW to raise awareness of their own HH compliance.
5. Promoting a greater awareness of the lifespan of bacteria and viruses on environmental objects and surfaces.
Strategies for periodic monitoring of staff hand hygiene compliance:
We use the gold standard of direct observation of physicians and staff by trained observers to document compliance with HH, including: the WHO 5 Moments of HH; types of HH products used; HCW role; and shift. This data is collected daily on each patient care unit and aggregated monthly for reporting purposes.Tools and materials from St. Joseph Mercy Hospital:
St. Joseph Mercy HH Monitoring Tool
St. Joseph Mercy Health System Clean Hands Save Lives flyer
St. Joseph Mercy Health System posterboard
St. Joseph Mercy Health System educational slides for house officers
Mentor designation - 3/9/2011
Information Updated - 3/15/2013
* * *
Virtua - Marlton, NJ
Availability Status: Available to answer requests
Licensed Beds: 1073
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: July 2009
Mentor Contact Name: Carol Mullin , VP of Clinical Quality & Performance Management
Mentor Contact Email: cmullin@virtua.org
Mentor Contact Phone: 856-355-0070![]( "Call: 856-355-0070")
Additional Information:
Pilot floors: 100% standardization of gel, soap and gloves locations.
Virtua roll out to all sites:
Started 12/10 due to vendor contract renewal and change is dispenser type.
Virtua Policy:
In preparation for the conversion of hand hygiene alcohol-based dispenser and new hand hygiene signage, Virtua Clean Hands Council provided direction and criteria for the consistency and standardization of hand wash gel dispensers and mandatory signage over the dispensers throughout the divisions.
Hand Wash Dispenser Accessibility:
All divisions and sites will do a SWAT assessment on each patient care area to identify current locations of dispensers and their compliance with the Department of Health guidelines. Identify where dispensers are not in compliance and and new locations identified for installation. Gel dispensers need to meet the Clean Hand Council recommendations on minimum dispensers per patient room and location.
Recommendations of dispenser location in patient care areas:
Access to a dispenser should be available:
upon entering and exiting a patient area/room
in double rooms, on the wall between the foot of patient beds
Exceptions:
Behavioral/Psychiatric Units: Providers will have access to gel/foam only in controlled areas. Gel holders will also be available for providers to carry.
Home care providers will carry gel on their person or it will be supplied in the field bag.
LTC: TBD
Other common areas:
Recommendations to provide clear access and visibility to visitors, staff and physicians. Example: Outside stair wells, elevators, physician lounges, floor lounges, inside and outside cafeterias, lobby areas, and waiting rooms.
We are collecting the glove compliance data, but not separating it out. If they do not follow accepted guidelines for gloves, it is considered a defect. Moving forward we will be reporting non-compliance with hand hygiene, including glove compliance to managers to implement improvement plan.
Joint Commission Pilot Results: Pilot floors(ICU, 2N, 4nw and 4ne): 2009 baseline 28% Pilot completion 61% YTD 66%
Virtua-wide Hand Hygiene compliance 2010 roll out:
Baseline data: 55%
3rdQ 2010: 53%
4th Q 2010: 64%
Virtua saw a 24.5% increase in compliance from the 3rd quarter to 4th quarter.
During the Joint Commission project, all eight hospitals could not conclude that hand hygiene alone had a direct impact on the reduction of HAI. Health systems have published that changing the safety culture over time proved to correlate with reduction in their HAI. Virtua plans to continue to look at trending of HAI with our improvement of hand hygiene compliance.
Keys to success:
In Pilot: July 2009 - The solutions were piloted to see the impact on increasing hand hygiene compliance. Below are the solutions:
Data Collection: Training and gauging of all independent observers. Data samples were statistically significant.
Provided education to all health care providers (HCP) by first assessing their knowledge and then educating based on their need.
Utilizing the ancillary staff meetings to understand staff work flow and obtain staff input to better incorporate hand hygiene in their process. Example: Food service workers added gel dispeners to top of food tray cart - results were a 80% increase in compliance.
Posters, buttons, education sessions at all unit meetings
Rewards and recognition program to incentive (short term)
Pilot units utilized daily three minute huddles to communicate compliance rates and brainstorm solutions.
SWAT analysis on dispenser location and access was completed with the staff input on all units( as documented above)
“Just in time” coaching was initiated by using managers, champions, and APN to reinforce expected behavior
The pilot results showed an overall 118% improvement. Virtua took this success and challenged the entire system to adopt these practices and set a goal for 90% for Virtua health (Joint Commission benchmark).
In September 2010, Phase I began with education of all staff and physicians. (It is now an annual competency and part of orientation.) Standardizing location and upgrade of soap and gel dispensers which included new signage to make more visible for staff and patient/families. A video showing Dr. Dwyer addressing the importance of HH, directed to patients and family in raising their awarness and their participation in this effort. The video is shown in patient room apon admission through our Get Well Network.
During National Hand Hygiene week, Virtua invited the staff and physicians to support hand hygiene practices to protect our patients, our selves and peers through a signing of a large banner displayed at each division and off site areas, as a sign of their commitment. It was announced by leadership with support of physicians that hand hygiene was a job expectation for all staff and physicians, non-compliance would result in job performance issues.
Phase I has seen a 24.5% increase in hand hygiene compliance system wide. We measure compliance at our divisions, as well as our home care, LTC, ambulatory rehab centers and Virtua medical practices
Phase II will begin Feb. 2011, with a Speak Up for hand hygiene campaign. Selective champions who are known for their hand hygiene and patient safety efforts will be our first line advocates to reinforce expected behavior, both positive and negative. This phase is enforcing accountability of all health care providers at Virtua.
Strategies for periodic monitoring of staff hand hygiene compliance:
F. Virtua Response:
All independent observers are trained and gauged using a tool to insure standard collection of hand hygiene compliance. All division collected baseline compliance (1 week/all units/24 hr collection).
Virtua has learned that decreasing the number of independent observers decreases the potential for bias. We are implementing key observers who will collect observations at the divisions and input into our database, providing us with a more efficient process, and ability to provide managers with timely observation data to share with their staff monthly.
Data collection SOP:
Observations per month per division are based on this formula to obtain a statistically significant sample. Formula: n=defect% (1-defect %) x (1.96/.05) squared= sample size
Number of units: all patient care units, ex. ED, Surgical suite (OR,PACU, Prep area), Inpatient units, ICU, Peds, MCH units, L&D, BHU
Calculated % observations on day, night and weekend shifts. The shift % was based on HCP staffing numbers.
Health Care Provider (HCP) % observations: Utilized a tool that was developed during pilot which calculated % of type of HCP entering and exiting a patient area. Joint Commission has this tool on CTHC portal
Moving toward Outpatient area we will be rolling out a survey tool that is filled out by patient real time. Currently using in our Primary care offices(Virtua owned)
(We are a beta test site for a new product which enables us to collect data 24/7. This is still in testing phase and results will be reported later this year.)
At every Virtua facility, there is a one clear message to our community and employees: "Clean Hands are Caring Hands" and we provide an explanation of why it's so important. The message can be found at every lobby, every hallway and every patient unit at all Virtua sites. Signs over dispensers are used to remind everyone to hand wash and this is reinforced to patients /families.
Mentor designation - 4/15/11