Launching a Hospital-Wide Hand Hygiene Education and Competency Program To Meet JCAHO Safety Goal #7

Abstract

ISSUE: The new hand hygiene recommendations are the first in a series of patient safety campaigns to educate healthcare personnel. Hand and nail hygiene was chosen to start the series as a key safety goal to reduce hospital-acquired infections and prevent the spread of multidrug-resistant bacteria. How to monitor caregivers hand and nail habits was an issue. PROJECT: A Hand Hygiene Task Force was developed to critique the education program and to develop a monitoring tool and competency on hand and nail hygiene. A PowerPoint presentation was developed that included key points on patient safety goals, use of waterless hand antiseptic, glove and lotion usage, artificial and natural nails. Sessions were mandatory for all direct caregivers. A monitoring tool was developed by the task force and incorporated into the competency program. RESULTS: Education sessions were completed in 1 month. Raffling hand kit prizes improved attendance rates. Managers were asked to complete a monitoring tool on direct caregivers on their units. Ten observations per month or 30 per quarter are the recommendations. Results are tallied by Infection Control and Standards and then reported quarterly to the hospital Leadership Committee. An Individual Competency assessment plan was also developed in critical elements. This was incorporated into the hospital competency plan. Managers could choose hand and nail hygiene as one of the patient safety goals for competency by individual/group discussion or observation. LESSONS LEARNED: The patient safety act is an important initiative in healthcare. We are able to measure the outcomes of our education process and include individual remediation similar to the other patient safety goals in the hospital competency plan.