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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.
Shared governance is an organizational innovation that legitimizes healthcare professionals' decision-making control over their practice while extending their influence to administrative areas previously controlled by managers.1 This model, for CCHS purposes, consists of five systemwide councils with unit-based councils operating under their guidance: education, evidence-based nursing practice, quality and safety, professional nursing, and coordinating.
The quality and safety council is responsible for improved compliance with current National Patient Safety Goals and other safe practice initiatives, reduction of hospital-acquired infections, improvement in pain management, improvement in patient satisfaction, and reduction of potential and actual patient harm by using nursing sensitive clinical excellence indicators.2
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.
Nurses on 4D identified areas for improvement in hand hygiene compliance. Early indications of deficits in this area were identified through monitoring performed by council members (hand hygiene observations) and anonymous reporting from systemwide means (secret observers trained to assess unit hand hygiene practices).3 Other healthcare systems use this method for hand hygiene reporting and have had success in identifying real baseline data versus estimates.4 December 2009 results revealed 71% unit compliance with the hand hygiene protocol.
All healthcare providers are responsible for upholding a standard of care that instructs first "to do no harm."5 Poor hand hygiene is one of the most preventable sources of patient harm. Performing proper hand hygiene is important at all levels in healthcare delivery, but it's crucial at the bedside where contact is guaranteed. We acknowledged our poor compliance, and the implications for this negligence prompted the council to take action.
Practicing proper hand hygiene is themost effective way to prevent healthcare-acquired infections.6 Despite advances in infection control and hospital epidemiology, the hand hygiene message isn't consistently translated into clinical practice, and healthcare workers' adherence to recommended hand hygiene practices is unacceptably low.7 Compliance is estimated at lessthan 50% as a national average across hospitals.8 CCHS's overall hand hygiene compliance rate in December 2009 was 75%.
Proper hand hygiene is crucial for patient safety. Studies have shown that at least one-third of all hospital infections are preventable.9 A substantial proportion of infections result from cross-contamination, and transmission of microorganisms from the hands of healthcare workers and is recognized as the main route of transmission.10
Many factors contribute to poor hand hygiene compliance. In several studies about hand hygiene, perceived barriers for lack of hand hygiene included skin irritation, inaccessible supplies, insufficient staffing, high workload, and intensity of job-related activities.11 The most evident barriers identified on 4D were skin irritation and high workload/insufficient time, according to 58% of the RNs on 4D.
As hand hygiene compliance continues to be a significant problem, hospitals must be responsible for improving compliance and ensuring delivery of safe, effective patient care. Because of the complexity involved in the process of change, single interventions often fail, so employing a multimodal, multidisciplinary strategy is essential.12
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.)
The video and catchy song quickly became a favorite among staff on 4D and other units. After much positive feedback, the video debuted on CCHS's intranet and played during Nurses Week festivities as a staff-driven initiative. The more the video played, the more momentum it gained. Before long, it wasn't unusual to hear staff singing it aloud during the workday. Most important, it cast a spotlight on proper hand hygiene techniques and compliance with this standard. The unit's fun and informative video inspired staff to pay closer attention to practicing hand hygiene according to infection prevention recommendations.13
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.
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.
1. Barden AM, Quinn MT, Donahue M, Fitzpatrick JJ. Shared governance and empowerment in registered nurses working in a hospital setting. Nurs Adm Q. 2011;35(3):212-218. [Context Link]
2. Joint Commission Requirement. Approved: 2010 National Patient Safety Goals. http://www.allhealth.org/BriefingMaterials/JointCommission-Oct2009-2010NationalP. [Context Link]
3. Strategies for Nurse Managers. Secret shoppers help improve hand hygiene. http://www.strategiesfornursemanagers.com/ce_detail/228830.cfm. [Context Link]
4. Hospitals in Pursuit of Excellence. Hand Hygiene Project: best practices from hospitals participating in The Joint Commission Center for Transforming Healthcare Project. http://www.hret.org/hand-hygiene/index.shtml. [Context Link]
5. Seo MJ. Advance for Nurses. Hand hygiene compliance: a multidisciplinary and proactive approach. http://nursing.advanceweb.com/Infection-Control-Center/IC-Articles/Hand-Hygiene-. [Context Link]
6. Marra AR, Guastelli LR, Pereira de Araujo CM, et al. Positive deviance: a new strategy for improving hand hygiene compliance. Infect Control Hosp Epidemiol. 2012;30(1):12-20. [Context Link]
7. HICprevent. Reality check: Joint Commission lowers hand hygiene standard. http://hicprevent.blogs.ahcmedia.com/2011/04/15/reality-check-tjc-lowers-hand-hy. [Context Link]
8. Cummings KL, Anderson DJ, Kaye KS. Hand hygiene noncompliance and the cost of hospital-aquired methicillin-resistant Staphylococcus aureus infection. Infect Control Hosp Epidemiol. 2012;31(4):357-364. [Context Link]
9. Umscheid CA, Mitchell MD, Doshi JA, et al. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011;32(2):101-114. [Context Link]
10. Martin-Madrazo C, Soto-Diaz S, Canada-Dorado A, et al. Cluster randomized trial to evaluate the effect of a multimodal hand hygiene improvement strategy in primary care. Infect Control Hosp Epidemiol. 2012;33(7):681-688. [Context Link]
11. McLaughlin AC, Walsh F. Self-reported reasons for hand hygiene in 3 groups of health care workers. Am J Infect Control. 2012;40(7):653-658. [Context Link]
12. Pincock T, Bernstein P, Warthman S, Holst E. Bundling hand hygiene interventions and measurement to decrease health care-associated infections. Am J Infect Control. 2012;40(4 Suppl 1):S18-S27. [Context Link]
13. CDC. Hand hygiene basics. http://www.cdc.gov/handhygiene/Basics.html. [Context Link]
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