Improving Hand Hygiene Practice with Six Sigma

HealthEast Care System
St. Paul, Minnesota, USA

Boyd Wilson, MS, CIC, System Director, Infection Control and Epidemiology
Kathy Miller, RN, CIC, Infection Control Specialist
Becky Wong, RN, Clinical Director, Critical Care
Rosie Emmons, RN, Performance Improvement Specialist
Karen MacDonald, MS, RN, CPHQ, Associate Administrator, Care Management
Martin Paul, Vice President, Quality and Risk Management
Katie Foran, Six Sigma Black Belt, 3M Health Care
Gary Kupferschmidt, Six Sigma Green Belt, 3M Health Care
Cheryl Pederson, RN, Six Sigma Green Belt, 3M Health Care


To increase compliance with hand hygiene practice to 80 percent or a statistically significant improvement from baseline.


  • Number of hand hygiene actions taken per 100 hand hygiene opportunities encountered (%)
  • Volume of hand sanitizer used per 1,000 patient days



  • Updated hand hygiene policy to reflect current CDC Guidelines and HealthEast expected practice
  • Developed a theme around creating champions of excellent hand hygiene as a patient safety initiative             
  •  A “CHAMPS” logo was designed with acronym standing for “Clean Hands Are Making Patients Safer”
  • Used “CHAMPS” logo golf towels as a recognition award for personnel who had become champions
  • Identified and educated infection control liaisons/staff champions on the unit
  • Identified and educated physician champions on the unit
  • Engaged staff, physicians, and administration by developing a hand hygiene pledge banner that was signed by all hospital and unit leaders/champions and posted on the unit
  • Developed hand hygiene champion posters depicting staff and physicians who work on the unit
  • Provided targeted training during staff meetings and unit reports
  • Updated site and unit orientation to include a more engaging hand hygiene message
  • Provided evidence-based education with a physician champion during quarterly critical care education
  • Developed a learning packet with pre- and post-test assessment
  • Developed a computer module addressing hand hygiene best practices and supporting rationale
  • Provided monthly theme posters for awareness and weekly fact/fiction informational flyers
  • Created a screen saver hand hygiene message on all unit computer monitors and changed it periodically
  • Collected environmental and personnel cultures as a part of an education/awareness initiative
  • Implemented games with prizes including a question of the week
  • Implemented a “if you touch this, clean your hands” awareness using Post-It note reminders
  • Conducted an environmental assessment with staff and physicians for location/accessibility of hand hygiene supports and implemented a master plan for best locations on the unit as well as on portable equipment
  • Created a housekeeping hand hygiene support verification as part of daily cleaning checklist
  • Trialed and implemented a new sanitizing soap on the unit that was then implemented throughout the hospital
  • Provided pocket size hand sanitizer to staff and physicians
  • Developed a patient/visitor hand hygiene brochure and education/awareness plan to include the admission packet and the family lounges
  • Posted a message on the white board in each room, “It’s OK to Ask,” reminding patients and visitors of the importance of hand hygiene and encouraged them to remind health care personnel




Summary of Results / Lessons Learned / Next Steps
In partnership with 3M Health Care, we initiated a Six Sigma hand hygiene improvement project in a 20-bed medical-surgical intensive care unit and improved practice compliance from 36 percent to 70 percent (p<.001) with corresponding statistically significant increase in volume of hand sanitizer used. This was accomplished through the implementation of a comprehensive program that focused on changing the unit culture by addressing staff awareness/knowledge, staff decision making, supply convenience/availability, and empowering staff as well as patients and families to remind health care personnel about the hygiene procedures.
The Six Sigma approach ties together improvement methods directly with identified process failures. This analysis results in enhanced identification of specific improvement opportunities and supports development of a tailored control plan to sustain gains in compliance. The work done in this project is being replicated in all critical care units in other HealthEast hospitals as well as other units in the project hospital.
  • Identify visible physician and nursing leadership on the unit, as this is critical to success
  • Develop a strong project steering team and maintain regular status meetings
  • Secure administrative support and keep them actively aware and up-to-date
  • Include clinical and non-clinical support areas in the education and communications
  • Ensure the policy and environment support expected practice
  • Provide routine feedback of results to help motivate and maintain awareness
  • Repeat the education; keep it simple and fresh
  • Incorporate education into orientation and annual competency
  • Use visual reminders to help maintain awareness and clarify the need for hand hygiene
  • Conduct a demonstration or activity to personalize the issue (“make it real”); this helps to shift perspectives
  • Promote successes (milestones) along the road to improvement
  • Expect some bumps in the road
  • Have a sense of humor
  • Be patient
  • Be persistent

Contact Information
Boyd Wilson, System Director, Infection Control and Epidemiology
HealthEast St. Joseph’s Hospital
[Storyboard presentation at IHI's National Forum, December 2005]
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