Standardizing Environmental Cleaning Procedures and Measurement Across a 12-Hospital System

Abstract

Project: MCCG is a 637 bed, academic medical center, designated Level 1 Trauma Center and Magnet hospital for nursing excellence. Goals * Improve Hand Hygiene compliance from 34% to 65% in year one, increasing to, and sustaining at, 85% following year. Note: data benchmarks recommended by 3M Education Division consultation. * Utilize best practices products, compliance monitoring, implementation and sustainability strategies. * Assess risk factors for, and remove barriers to, Hand Hygiene non-compliance. * Assure Administrative and Governing Board priority of the PI project. Innovation * Utilization of multiple methods of monitoring: mystery shopper observations, patient interviews, product usage. * Partners In Hand Hygiene program encourages patients, families and visitors to remind all staff and visitors to wash their hands. Mystery Shopper visits patients for perception of compliance. Patients rate staff (physicians included) on compliance. * Weekly surveillance program is rigorous * Short turnaround time and transparent dissemination of data within 2 days to departments encourage immediate “job well done” or corrective action. * Professional marketing of “speak up” buttons, flyers, patient brochure, staff engagement.* * Individual unit “spin” on the campaign; examples: Staff say,ladybug if a peer or physician out of compliance. Results discussed in huddles, interdisciplinary rounds, linked to HAI results. Peer mystery shopper assigned for a day give out coupons for “well done”. Meetings with key physicians to address what would help improve hand hygiene compliance.