A Quality Assurance Project to Track Compliance with Autoclave Maintenance and Use of Biological Indicators in Outpatient Physician Offices

Abstract

percent). In 2004, a targeted assessment of HCWs compliance with HH was conducted in our facility identifying a similar compliance rate to the nation. In order to improve compliance, the HH Program was created comprising of the Hand Hygiene Compliance Team. Project: Our Program was based on the Institute of Healthcare Improvement (IHI) “How to Guide: Improving Hand Hygiene.” The four IHI components to improve compliance were implemented: 1) education of staff was conducted through employee training and multi-component publicity campaigns, 2) improvement of HH technique using several methods, 3) increase availability of alcoholbased hand rubs(ABHRs) throughout the facility, 4) HH observations performed using Center for Disease Control and Prevention (CDC) guidelines. Results: 1) Education of staff was conducted through orientation, annual training and section specific training. Twomulti-component campaigns were implemented-first one in 2006, and the second in 2008. Campaigns included: HH posters, life size figure of facility leader, HH pamphlets, quarterly HH articles, HH trophy, incentives for patients/staff and HH surveys for the second campaign. Survey results (2009-2011) reveal that staff awareness of the campaign increased with each year and was above 90% and patient awareness was above 80%. 2) Correct techniques for using an ABHR and handwashing were discussed during educational sessions, 2 videotape Presentations, and using fluorescent dye-based training methods. 3) Pocket-size ABHRswere distributed and a survey of the facility was conducted to maximize the availability of ABHR wall units in patient care areas. 4) HH compliance checklist was created for use by trained observers. Targeted areas were surveyedmonthly with a minimum of 30 opportunities for HH observed, immediate feedback given, and compliance rates reported to leadership. Results: 24,840 observations were performed from 2006 to 2011, with the most observations done in 2006 (5,369) and the least in 2011 (2,991). The facility goal was set at 90% compliance rate and was reached in the latter part of 2008.The lowest overall compliance rate was 77% in 2006/2007, and the highest compliance rate was 94% in 2011. Physicians/Respiratory Therapy technicians improved the most.