1. Sanja Mirkov, BPharm, PGDipPH Clinical Quality Improvement Coordinator
NWIA Building Improvement Capability Session 3NWIA Building Improvement Capability Session 2Improvement Science in Action • April 22-24, 2009
Improvement Science in ActionNWIA Building Improvement Capability Session 3NWIA Building Improvement Capability Session 2Improvement Science in Action • April 22-24, 2009
Improvement Science Professional Development Program
The Hand Hygiene Project
Sanja Mirkov, BPharm, PGDipPH Clinical Quality Improvement Coordinator

2. The Hand Hygiene Project
Content and Aim
Aim
Establish reliable HH practices within CMH healthcare facilities
To increase correct HH practice rate from 60 to 80% by 30th June 2013
System
Stable in state of statistical control - improvement can be achieved only through a fundamental change
Guidance
Methods for developing fundamental change:
Benchmarking or learning from others – e.g. literature search
Creative thinking – provoking new ideas for change - Using change concepts
Logical thinking about the current system – e.g. workflow checklist, comparison of measurements in the Gold Audit
Constraints
1.Common ineffective approaches to improvement applied previously:
Trouble with performance – add more inspection
2. Negatively framed promotional activities in the past
3. Financial constraints for using technology

3. Strategy
A literature review identified successful interventions to inform CMH multimodal strategy with an emphasis on behavioural change
Strengthen the team (complementary skills, equal commitment, accountability, trust, respect and support)
Increase staff capability (education, training, dissemination of information) and motivation (social marketing, persuasion, modelling)
Create physical (facilities, workflow, reminders, institutional safety climate) and social environment (human networks as channels for communication and behavioural change, engagement, community organising) that influence staff capability and motivation
Identify potential quality improvement projects
Perform PDSAs
Implement successful quality improvement projects

4. Strategy The behaviour change wheel Social Networks
Capability, Opportunity, Motivation
Mitchie et al Implementation Science 2011;6:42
Social Networks
Christakis et al. PLoS ONE 5(9)
Diffusion of innovation curve
Rogers

5. Hand Hygiene Primary Drivers
Education, Training & Promotion
Facilities, Workflow and Reminders
Monitoring and Reporting
Organisational Culture Change

6. Driver Diagram

7. Measures Name of Measure
Is this an Outcome, Process or Balancing Measure?
Operational Definition (e.g., numerator & denominator)
Gold Audit on hand hygiene practice, adherence per hand hygiene moment, adherence per HCW group
Process
(Correct moments / Total moments) x 100 = compliance rate (%)
>70% National Standard
Volume of hand gel per 1,000 patient days
> 20L / 1,000 pt days WHO standard
The WHO Hand Hygiene Self-Assessment Framework
Balancing
Total Score related to Hand Hygiene Level
The rate of S aureus, MRSA, ESBL, C. Difficile associated infections
Outcome
Number of cases / 1,000 patient days

8. Change Concepts & Ideas for PDSAs
Opportunity
Idea for Testing in a PDSA
Theory and prediction about what will happen when you test this idea
Phlebotomists’ blood collection procedures
Help staff embed best evidence-based practice into their procedures. Smooth workflow. Reduce number of components. Standardisation. Staff education.
conduct training, develop alliances and cooperative relationships Test: Number of procedures reduced from 5 to 2
Gold Audit October 77%
Gold Audit March 81.8%
Critical Care Complex
Hand hygiene for most common 5 procedures: before/ after insertion of the central line, catheter, suction, NG tube, rectal tube
Reasons for M2 and M3 being missed is confusion about the procedure. Smooth workflow. Reduce number of components. Standardisation.
Gold Audit October M2= 21% M3 = 31%
Gold Audit March prediction 50%
Hand gel consumption
Use proper measure. Expect increase in consumption with increase in performance

9. Change Concepts & Ideas for PDSAs
Capability & Motivation
Idea for Testing in a PDSA
Theory and prediction about what will happen when you test this idea
Sending repetitive messages via central people in the network
(26 per year)
Content: Teaching, training video, patient stories, audit feedback, celebrations, campaigns
Develop alliances and cooperative relationships, education, training, motivation, persuasion, role modelling
1. Gold Audit Correct HH adherence rate per HCW group
2. Cumulative number of staff attended sessions over time – Behaviour adoption curve
3. Number of staff initiating own sessions - Behaviour adoption curve
Identifying the new network of hand hygiene champions
e.g. Allied Health workforce
Meetings with the central people in the network
e.g. HH Champions meeting
Develop alliances and cooperative relationships, education, training, motivation, persuasion, role modelling – celebrating successful initiatives
Hand Hygiene Staff Survey
Questions exploring reasoning, behavioural, normative and control beliefs – to be administered following the Gold Audit

10. Results of your PDSAs SAB average for 2011= 0.09

11. Profound Knowledge Worksheet
Appreciation for a System
Facilities and workflow
Reminders
Institutional safety culture
Psychology
The Behavioral change wheel (Michie et al)
Altruism, empathy, morality, solidarity
Social marketing
Liberating leadership
Positive psychology
Theory of Knowledge
Statistics
Public health
Behaviour adoption life cycle curve (Rogers curve, Christakis et al)
Human factors engineering
Teaching, simulation
Understanding Variation
Hand hygiene activity monitoring
HAI burden
Volume of hand gel

12. Process Changes and Results
Positive, consistent messaging
Engagement at a ward/unit/occupational group level
Identification and engagement of “activists-in-place”
Endogenous generation of improvement activities
Ongoing communication and feedback, education and training, persuasion, role modelling
Provision of supportive physical and social environments
Acknowledgement of staff initiatives

13. March Gold Audit Interim Report
Ward A
October 40.7%
March 73%
Ward B
October 38.5%
March 58.6%
Ward C
October 58%
March   58.2%            

14. Next Steps Developing additional resources
Broadening the base of our champions and members of the HHWG
Beginning the top-down phase of our social marketing campaign
Considering improving measurement