20 hospitals with great hand hygiene programs

According to the Centers for Disease Control and Prevention, roughly one in 25 patients will contract a healthcare-associated infection. Physicians and healthcare workers, however, have the ability to reduce the number of HAIs by adhering to basic hand hygiene protocols.

Hospitals and health systems across the country have implemented hand-hygiene programs that serve to prevent the transmission of harmful pathogens and microorganisms to patients. Examples of such efforts include improving disinfecting procedures, designating hand-washing monitors and increasing education on HAIs.

The following 20 hospitals have stood out as some of the most notable hand hygiene success stories in recent years.

Baptist Health, located in Jacksonville, Fla., began using uniforms made of Vestex fabric, which is designed to help fight pathogen transmission. Baptist Health is one of the first and largest in health system to use uniforms made of Vestex. The fabric is fluid-repellent on the outside, which inhibits any splatter or spill of blood, bodily fluid or other substance from soaking through scrubs and touching the healthcare workers' skin. The fabric is also antimicrobial, preventing the growth of bacteria on the uniforms, and is breathable as it wicks away sweat on the inside. The dual approach of being both antimicrobial and fluid-repellant is unique to this specific fabric.

Cedars-Sinai in Los Angeles improved its hand hygiene performance from around 70 percent to 95 percent within the year of 2010. In 2013, the organization-wide compliance rate was at 98 percent. The hospital used several tactics to achieve these improvements. To start, hospital leaders shifted the organization's prior goal of reducing HAIs to eliminating HAIs. Leaders pointed out the hospital should be striving for zero infections, not merely to reduce the rate of infection by five or 10 percent. Medical staff and other leaders also agreed that hand hygiene compliance should be incorporated into the measure of an employee's overall performance. Subjecting healthcare workers to disciplinary action for poor hand hygiene or praise for protocol-compliant hand hygiene effectively helps shape behavior. In order to measure the rate of compliance, Cedars-Sinai opted to use trained nurse observers who used direct observation to measure compliance on a departmental and individual basis. Processes were amended throughout the initiative to ensure continued improvement.

The Six Sigma methodology factored into Exempla Lutheran Medical Center's efforts to improve hand hygiene while collaborating with the Joint Commission Center for Transforming Healthcare Project between 2008 and 2010. Prior to taking part in the project, Exempla Lutheran used posters and glow powder to educate staff on hand hygiene. Using Six Sigma, the medical center evaluated hand hygiene thoroughly — reviewing room cleaning processes, food delivery, changing a light bulb and more  —  to see how a regimen could standardize hand hygiene and eliminate waste. Weekly data on compliance was collected and a report was distributed to the entire staff every month regarding compliance, HAIs and other measures. Additionally, Exempla Lutheran used hand hygiene observers and implemented a strict hand hygiene policy with consequences for non-compliance. Staff members who don't wash their hands receive one verbal warning, followed by written warnings and finally, termination. During the program, Exempla Lutheran achieved a hand hygiene compliance rate of over 90 percent for more than five straight months and continues to work toward improving compliance.

As part of the Joint Commission Center for Transforming Healthcare Project, Froedtert Hospital in Milwaukee applied the Six Sigma methodology to hand hygiene. Between 2008 and 2010, Froedtert defined and measured hand hygiene, analyzed data, and improved processes and workflow. One change the hospital made to improve hand hygiene compliance was adding hand sanitizer dispensers to high-traffic and high-touch areas such as by patients' doors, telephones in the hallway, elevators and other areas in the unit. Froedtert also specially trained specific staff members to inspect and record observations regarding compliance. During the pilot program, the hospital observed roughly 85 percent of clinician behavior and recorded a compliance rate of approximately 80 percent. Froedtert continues to work toward achieving its goal of 100-percent hand hygiene compliance.

Johns Hopkins Hospital, located in Baltimore, achieved doubled rates of compliance with hand hygiene protocols between 2007 and 2008, and increased compliance again by 27 percent from 2008 to 2009 through the implementation of a hospital-wide communication and education campaign. The first step of the campaign in 2007, WIPES, contained five steps to help "wipe out hospital infections" that were displayed throughout the hospital on posters. The second step was to make the hospital environment optimal for practicing hand hygiene. This included putting hand hygiene sanitizer dispensers outside of each patient room and following up with educational outreach sessions to emphasize the importance of using the sanitizer. Further efforts included improved leadership engagement, and an online reporting tool that made hand hygiene compliance data readily available.

Kirklin Clinic of University of Alabama Hospital in Birmingham successfully improved hand and environmental hygiene through an improvement project that resulted in a 50-percent improvement in hand hygiene compliance. In 2007, the Kirklin Clinic of UAB Hospital implemented a comprehensive hand and environmental hygiene program. The program focused on reducing all five instances of the nosocomial transmission of pathogens, including the transmission of pathogens from a healthcare worker's hands to a surface and onto the patient. To address this last type of transmission, the Clinic implemented the use of Super Sani-Cloth germicidal disposable wipes, which were designated for disinfecting high-touch surfaces such as the exam table, the patient chair, countertops and door knobs between patient visits. For potential outbreaks, the Kirklin Clinic uses a 1:10 dilution of bleach solution. The clinic focused heavily on product availability not only for the healthcare provider team, but also the patients themselves. By making the alcohol-based hand wipes available in each exam room and in high traffic areas such as elevators, lobbies and patient entrances, hand hygiene compliance went from 41 percent to 90 percent.

MetroHealth Medical Center in Cleveland has reduced rates of hospital-acquired infections by 38 percent since 2010 due to the implementation of a vigilant hand hygiene program. A bacterial infection that spread from room to room in 2010 prompted the implementation of the hand hygiene program. The program included hiring four hand washing monitors, who monitored everyone's comings and goings and note who washed their hands after walking in and out of patient rooms. This provided hospital administration with data on hand hygiene compliance on every floor and allowed them to look for improvement opportunities. Since 2010, central line-associated bloodstream infections at MetroHealth Medical Center have decreased by 35 percent, ventilator-associated pneumonia cases reduced by 71 percent and surgical site infections dropped 64 percent, according to the report.

Mount Sinai Health, based in New York City, opted to follow the World Health Organization's recommendations for removing personal protective equipment without coming in contact with potentially infectious materials. The WHO's protocol includes many opportunities for hand hygiene. According to Mount Sinai officials, the hospital elected to adopt the WHO's protocol because there is a hand hygiene step built in for every time a healthcare worker removes a piece of PPE. Following the WHO hand hygiene protocol, healthcare workers at Mount Sinai wash their hands after removing each layer of PPE, as opposed to alternate guidelines that suggest washing hands after removing all PPE.

North Shore University Hospital in Manhasset, N.Y., has tried numerous techniques to improve hand hygiene compliance. In addition to communicating directly with physicians who hadn't met the hygiene standard and using secret shoppers to observe hand washing habits, NSUH participated in a study that involved a remote video auditing system. As part of the study, video cameras were placed in intensive care unit rooms to record behavior 24/7 and send information to third-party auditors, who determine compliance to the program standards. NSUH credit the monitoring system for its increased ICU hand hygiene compliance rate, which grew from less than 10 percent to more than 85 percent in less than four weeks and maintained that rate for three years.

In 2010, Princeton Baptist Medical Center, located in Birmingham, Ala., collaborated with Proventix, a technology company, to improve hand hygiene compliance. The hospital implemented Proventix's system, nGage, a technology that provides radio-frequency identification badges for all hospital staff and physicians. At every soap or hand sanitizer dispenser, a device registered the presence of the RFID badge whenever its wearer cleaned his or her hands. The system then tracked overall compliance with hand hygiene, as well as individual compliance. The device also had a screen that presented general or personalized messages to reinforce hand hygiene. Between Feb. 2010 when the system was implemented and August of that year, the rate of healthcare-associated infections was 22 percent lower than the same time frame in 2009.

St. Joseph Health Services, located in Providence, R.I., implemented a bundle program to reduce the rate of hospital-acquired infections. According to a study published in 2013, the hospital's bundle program, which combined hand hygiene, isolation attire and clean and disinfected equipment, helped the hospital achieve significantly higher levels of compliance with cleanliness protocol. St. Joseph's hand hygiene system within the bundle program required hospital employees to wash their hands before and after patient contact. Additionally, employees were instructed to wash their hands with either soap and water or with alcohol hand rub for 15 seconds. Lastly, a paper towel or an elbow was used to turn off the faucet. Physicians, nurses and other staff who came into contact with patients were reminded to comply with the hand hygiene component of the bundle program by promotions in posters, buttons, events and even a video that played in the cafeteria. All aspects of the bundle program led to improved compliance rates at St. Joseph’s. The hospital met its goal of 90 percent compliance with isolation attire for four consecutive months after implementing the program, and maintained similar levels for the next few years.

Norfolk, Va.-based Sentara Healthcare system vastly improved its hand hygiene compliance rates across seven hospitals from about 75 percent to 92.5 percent in 2012. Initially, hospital officials believed the rate of compliance hovered around 95 percent, but a revised audit process showed an actual rate of about 75 percent. Upon this realization, eighty-three health professionals came together to brainstorm fast and affordable ideas that could help drive up hand hygiene rates. The system hired QualPro, a Knoxville, Tenn.-based consulting form, to help test and analyze 21 interventions in 48 nursing units. Sentara implemented interventions including computer screen savers encouraging hand hygiene and Hero of the Month awards to hospital employees who achieved high compliance rates. Additional interventions were done in 32 nursing units, including white-board notes, installing red stop signs to remind healthcare workers to clean their hands and written hand hygiene quizzes for physicians and other workers who were randomly stopped by a department leader or executive. These interventions ended up proving most effective.

Novant Health's Thomasville Medical Center, located in Thomasville, N.C., increased compliance with hand hygiene protocol from 49 percent to 99 percent between 2005 and 2008. The improvement of hand hygiene behavior led to a 53 percent reduction in hospital MRSA infection rates across the healthcare system. Thomasville Medical Center implemented an internal communication campaign that included screensavers, cling stickers, billboards, yard signs and other tactics to educate hospital workers and help change hand hygiene behavior. In 2008, Novant Health and Thomasville Medical Center was named a national winner of the Ernest A. Codman Award from The Joint Commission, an award presented to organizations that demonstrate exemplary performance to achieve healthcare quality improvement.

In July 2010, UCSF Medical Center worked with UCSF Benioff Children's Hospital, an infection control team, physicians, nurses, therapists, technicians, spiritual care staff, engineers and others to create a proper hand hygiene program. Discreet, open and video-recorded monitoring collect hand hygiene compliance, and a report is created and distributed to hospital staff every day with the results of the observations. Staff members that don't comply are reminded and coached on proper hand hygiene techniques. Since implementing the program, UCSF's compliance rates have hovered around 90 percent every month, up from 75 percent when it started. In September of this year, compliance was at 94 percent. The rate of HAIs at UCSF has declined because of the hand hygiene program, including a drop in central line-associated bloodstream infections. In July, California U.S. Senator Barbara Boxer visited UCSF Medical Center to thank the staff for taking steps to save patients' lives.

In an a recent observational study published in Infection Control and Hospital Epidemiology, researchers at the University of Iowa Hospital Clinics in Iowa City found that hospital workers demonstrated higher rates of hand hygiene compliance when other healthcare workers were present. Researchers deployed a custom-built, automated hand hygiene monitoring system that served two purposes: detecting if a worker performed hand hygiene upon entering and exiting a patient's room and estimating the location of other healthcare workers with respect to the worker under observation. Over a 10-day period, a total of 47,694 hand hygiene opportunities were identified. When a worker was alone, adherence rates were just under 21 percent. When other healthcare workers were present, hand hygiene adherence increased to just under 28 percent. Additionally, observed hand hygiene compliance increased when more coworkers were present.

The goal of UNC Health Care's hand hygiene program is to help all UNC hospitals achieve at least a 90-percent compliance rate. Even though hospitals in the UNC system have been performing at an 80 to 90 percent compliance rate for the past several years, The Joint Commission requires healthcare facilities to show continuous improvement. To meet that goal, UNC recently launched the hand hygiene program called "Clean In, Clean Out." The initiative requires all UNC hospital employees, including nurses, physicians, and all of support services, to wash their hands every time they enter and exit a patient's room. To measure compliance, employees observe one another and report on their findings, the results of which are updated monthly on a database online and made available collectively, as a hospital, by individual unit and by occupational group. Observations are also recorded using paper forms and using the mobile app called iScrub. When non-compliance occurs, scripting and non-verbal reminders are given. On the other hand, rewards and incentives are given to employees with the most observations and to hospital locations and occupation groups with the highest compliance rates. The measurement period for fiscal year 2015 began on Oct. 1, 2014, and ends on May 31, 2015.

UPMC Presbyterian Hospital in Pittsburgh has increased clinical staff hand washing and sanitizing compliance to nearly 100 percent through education and accountability measures. The initiative, called Just Culture at UPMC Presbyterian, was implemented June 2012. The program includes education, videos, internal newsletter articles, posters and verbal reminders about hand hygiene. Through the program, healthcare personnel are held accountable for disregard of patient safety, including hand hygiene. Staff who don't wash their hands are warned and then progress through a structure of disciplinary actions if they continue to disregard hand hygiene. Within four months of launching the Just Culture initiative, hand hygiene compliance at the hospital improved from 70 percent to 99 percent. The hospital has maintained the high compliance rate through re-education and an overall cultural shift toward accountability.

The University of Utah Hospital, located in Salt Lake City, the mean hand hygiene compliance rate among all healthcare workers improved from 19 percent to 81 percent from 2000-2006, according to a 2014 report published in JSTOR by the Infection Control and Hospital Epidemiology group. Hand hygiene adherence was measured in 12 patient care units, including six acute-care units (322 beds), one oncology unit (25 beds) and five intensive care units (103 beds) among nurses, physicians and other healthcare staff. The hospital employed two behavioral interventions in an effort to improve hand hygiene: an initial intervention that addressed cognitive and behavioral factors that influenced hand hygiene, such as providing educational presentations about hand hygiene and one-on-one discussions with clinical staff and infection control personnel, and a second, hospital-wide intervention that aimed to modify behavior through positive reinforcement, such as handing out chocolate to healthcare workers "caught in the act" performing hand hygiene. The study found that healthcare workers rapidly accepted alcohol sanitizers in place of soap and water, with the use of sanitizer accounting for an increasing proportion of overall hand hygiene actions.

Vanderbilt University Medical Center in Nashville, Tenn. improved hand-washing rates among faculty and staff members nearly 40 percent over a five-year span. As of May, hand-washing compliance was at 97 percent, up from 58 percent in 2009. After Gerald Hickson, MD — VUMC's senior vice president of quality, safety and risk prevention and assistant vice chancellor for health affairs — witnessed multiple VUMC employees fail to wash their hands when caring for his wife, post-operation, he took immediate action. Together, Dr. Hickson and VUMC's Chief Epidemiologist Tom Talbot installed additional hand sanitizer and lotion dispensers, designated one person in each department to observe and report on hand washing habits in their unit and offered financial incentives to units whose hand hygiene habits met standards. Since VUMC implemented the innovative program, many HAIs have declined considerably, including bloodstream infections associated with central lines which decreased by 80 percent.

Wake Forest University Baptist Medical Center in Winston-Salem, N.C., also monitored hand hygiene compliance as part of the Joint Commission Center for Transforming Healthcare Project, beginning in 2008. WFUBMC implemented use of an electronic method to monitor and increase compliance for hand hygiene. The real time location system used radiofrequency identification to monitor hand hygiene compliance by tracking and recording the approach of employees wearing special electronic tags on their I.D. badges. The RTLS technology also allowed for just-in-time alerts to healthcare workers as they approach the patient-care threshold as a reminder to wash their hands. The medical center also implemented a regular schedule for refilling sanitizer dispensers and worked with dietary, radiology, phlebotomy and other unit floors to improve compliance. For five months out of a six-month period during the program, WFUBMC had no instances of HAIs.




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