CHRISTIANA CARE Health System (CCHS) introduced a shared decision-making model in 2003 to encourage direct care nurses to participate in shared governance over practice. This article describes how nursing staff at CCHS used shared governance plus a little creativity to significantly improve compliance with hand hygiene and reduce infection rates.

Accepting accountability

Each unit at CCHS is responsible for organizing a quality and safety council to discuss unit strategies to provide planned, systematic, and collaborative approaches in overseeing and directing quality and safety initiatives related to nursing processes, functions, and services provided. One of the 2010 to 2011 goals for 4D, a 35-bed surgical step-down unit, was to decrease infection rates by improving hand hygiene compliance. With the spirit of a shared vision, the council developed a plan to implement interventions and evaluate progress and outcomes for hand hygiene practices.

Poor compliance with hand hygiene

Phase I of this project included data acquisition and measurement reports. In December 2009, 4D received a score of 71% in hand hygiene compliance, even lower than the overall system score of 75%. The quality and safety council immediately targeted this unsatisfactory result as an area needing improvement. The members decided that unit compliance should be at least 90%.

Phase II of the project included a call for improving hand hygiene on the unit, which was heard in monthly staff meetings and newsletters, promoted through bulletin board awareness, in e-mails, and on visual cues in the nursing districts. A hand hygiene game, aptly named "hot hands," was introduced on the unit. The charge nurse for each shift would give out red, laminated hands to any staff members witnessed not performing proper hand hygiene. The staff member with the most "hot hands" during a shift was most noncompliant with the standard.

By April 2010, hand hygiene compliance on 4D increased to 79%, far short of the 90% goal but now higher than the system's overall score of 78%. To achieve 90% compliance, the council had to think outside the box. So, as part of phase III, they suggested creating a unique jingle about the importance of proper hand hygiene practices. The idea received overwhelming support from leadership; the unit's nurse manager and the infection prevention department provided financial backing and staff was granted workshop time to assist with the project. A council member wrote lyrics about proper hand hygiene techniques and infection prevention, which were set to contemporary music. The jingle was recorded at a local studio, a concept for a music video was developed, videographers filmed the music video on site, and "Get Your Clean On" was born in early May 2010. (See the music video on the Nursing2012 iPad app.)

Evaluating the effect the project had on hand hygiene compliance and infection rates at the unit level revealed positive results. From July 2009 to June 2010, hand hygiene compliance was 73%, with a total of 12 Clostridium difficile infections; the C. difficile infection rate per 1,000 patient days was 1.23. Data from July 2010 to May 2011 revealed 98% hand hygiene compliance. The total number of C. difficile infections was 6, and the rate of C. difficile infections was 0.61 infections per 1,000 patient days. Overall system compliance was 80% in July 2010 and 82% in May 2011. These data suggest that increased hand hygiene compliance yielded a decrease in hospital-acquired infections.

A clean community outreach

Nurturing a workplace where creativity and innovation drive the staff to strive for excellence in nursing measures has positive effects on the care provided to patients. Since the video's debut, the members of the 4D quality and safety council have developed a hand hygiene instructional program for school-aged children in the community. "4D Clean Team" t-shirts and hand sanitizers are given out during programs in local elementary schools. So far the group has visited three schools and 260 children, spreading their message through the video, education, and games about hand hygiene. In addition, the group has successfully sponsored and coordinated a contest (using all of the units under surgical services) within the escort services department at CCHS to help its hand hygiene rates. The contest aimed at rewarding escort personnel who conducted appropriate hand hygiene on any of the surgical units within the hospital. The staff on the units would provide the escort with a laminated commendation, which was signed and dated by the unit staff administering it and its recipient. At the end of 2 months, first, second, and third places were identified by a count of the commendations. Escort services had hand hygiene compliance nearing 70% in December 2010; after the contest ended in March 2011, Escort Services' hand hygiene scores increased to 88%.

4D's success has proven to us at CCHS that infusing fun into quality and safety practices can be the impetus needed for sustained change.

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