The Road to Eliminating HAIs: Hand Hygiene Improvement at Cedars-Sinai

Hospital-acquired infections affect approximately 440,000 patients each year in the U.S., costing roughly $10 billion a year. Largely preventable, healthcare organizations across the country have long focused on reducing HAIs; yet, HAIs continue to plague our nation's hospitals.


One of the most effective ways to reduce HAIs is proper hand hygiene practices; however, many organizations fall short when it comes to hand hygiene compliance. The reasons for this failure are fairly straightforward: physicians and staff are busy, and sometimes forget or forgo hand hygiene because it can be inconvenient.

In an effort to improve hand hygiene practices across the industry, the Joint Commission Center for Transforming Healthcare in 2010 approached a number of leading healthcare organizations, asking them to join together to share and test best practices for improving hand hygiene.

Cedars-Sinai in Los Angeles was one of the organizations approached, and it quickly signed on to participate. Its hand hygiene performance at the time was around 70 percent, and the organization's top leaders felt improvement in this area was critical to the system's efforts to reduce HAIs across the organization.

"We were interested in participating because one of our performance improvement principles is to seek out methods of learning of from others," explains Thomas Priselac, president and CEO.

Cedars-Sinai's involvement certainly paid off. The organization now tracks hand hygiene on a monthly basis organization-wide, and performance is broken down by department, so the medical staff, environmental services team and all other employee groups can see how their performance is tracking. Within a year of its efforts to improve hand hygiene, the organization was able to achieve a compliance rate of 95 percent, and has sustained that level of performance for more than a year. In 2013, the organization-wide average compliance rate was 98 percent.

So how did the health system achieve these results?

Reframing improvement goals
To start, the hospital's leaders shifted the organization's prior goal of reducing HAIs to eliminating HAIs.

"For a long time, our efforts with regard to [performance metrics] were around being in the 90th percentile plus," said Mr. Priselac, explaining that we're traditionally used the 90th percentile equating to high performance.

But, Mr. Priselac and other leaders at Cedars-Sinai realized that the theoretical best performance for HAIs was "0" infections, and that should be the goal for the organization, not a 5 or 10 percent reduction in the infection rate.

"Zero is the greatest number, and we basically aimed at zero defect or 100-percent performance," he says. "When you switch to that mindset, you look at the situation differently and you pose solutions that if you're not in that mode, can be overlooked."

With this mindset, the leaders worked to garner agreement among medical and staff leaders that hand hygiene was a critically important metric for the organization, if it truly intended to eliminate HAIs, says Michael Langberg, MD, senior vice president of medical affairs and CMO.

"Many people believed HAIs were just a necessary part of being cared for in a complex environment, and we had to break through that way of thinking," he adds.

Ensuring accountablity for hand hygiene measures
Medical staff and other leaders agreed that hand hygiene was necessary to meet the organization's goals of zero infections, and hand hygiene compliance was incorporated as a performance measure. Employees or medical staff who routinely fail to follow the organization's rules for hand hygiene —"gel in and gel out" every single time you enter and leave a patient room, regardless of whether or not your touched anything or anyone — may receive disciplinary action. In the most egregious of cases, a medical staff member could lose privileges for repeated failure to follow hand hygiene protocols.

Medical staff was slower to adapt to the new performance measure than hospital employees. Efforts to gain buy-in from the physicians turned a corner after the system began distributing monthly data comparing medical staff compliance with other departments in the hospital. "The medical staff was seeing their number lag behind the rest of the organization," and the physicians ultimately adopted the measure, explains Dr. Langberg.

Finding ways to reliably measure hand hygiene performance consumed most of Cedars-Sinai's hand hygiene work. While the system examined several automated systems, including those that featured personalized RFID identifiers, leadership determined the technology would require too much time to implement and had too high an error level.

"We look forward to a time when we will be able to deploy one of those automated resources in our environment reliably," explained Dr. Langberg, but added at the time Cedars-Sinai investigated automated options, the team felt such tools "were not ready for primetime."

Instead, the organization opted to use trained nurse observers who use direct observation to measure compliance on a departmental and individual basis.

Performance improvement
Once the organization had a method to obtain reliable data on compliance, it set out to implement and test various improvement initiatives. Leaders listened to front-line workers on where sanitizer should be placed, and facilities staff ensured each patient room had a dispenser and that each dispenser was in the same place in every room. Processes were amended to ensure the dispensers were continually refilled. The fire department was even brought it to assess the safety of the volume and location of the dispensers, since hand sanitizer contains alcohol, which is highly flammable.

Dr. Langberg shared an example of a specific improvement project the hospital undertook, which he says was only made possible after its shift to eliminating infections.

During a performance improvement discussion, someone mentioned privacy curtains as a possible source of contamination. Its curtains were tested, and 30 percent of those cultured were found to contain antibiotic-resistant organisms. On top of that, the team discovered that when physicians and employees entered a room, they'd touch the privacy curtain subconsciously. That is, when asked if they'd touched the curtain, they said no, but observation revealed that a majority of had actually done so.

The infection control team searched for literature on how to care for the screens, but it didn't exist. They replaced all privacy curtains in the organization with new ones with a bacteria-resistant coating, and set protocols for how often the curtains would be laundered.

The organization could have easily opted not to pursue a fix; it would have still had infection rate performance in the high 90th percentile. But, its new focus on zero made any and all efforts to reduce infection a priority.

"If we were going to get to zero, we realized we had to eliminate this," says Dr. Langberg, even though it is impossible to know if or how eliminating the privacy curtain organisms would impact the overall HAI rate. "We'll never be able to prove it, but we really believe it played a role in the reducing organism burden in our environment, which is critical to getting to the zero infection goal."

The organization hasn't yet reached its goal of zero infections, but it is getting close.

"We don't hold ourselves accountable only for rates of infection; we hold ourselves accountable for each and every infection we have," says Dr. Langberg. "They are really far and few between, but each of them is different and each one deserves a root cause analysis."

With any improvement effort, he says, a critical element for success is a broader conceptualization of the reason for the effort. "It wasn't about hand hygiene; it was about saving lives," he says. "Hand hygiene is the intermediate piece that is ultimately accountable for lives saved."

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