1. The MGH Hand Hygiene Program “90/90” and Beyond Presented by Judy Tarselli, RN and Dolores D, Suslak, MSN, CIC Infection Control Unit Massachusetts General Hospital for the Massachusetts Coalition for the Prevention of Medical Errors 15 th Anniversary Celebration

2. Hand hygiene compliance vs. healthcare-associated MRSA (2002-2012) 0.23 94% 92% HA-MRSA rate: A new record low!

3. Posters & Publicity Compliance surveysChampions Feedback Leadership involvement Goals Product availability Expansion & Outreach Education Patient & Visitor involvement STOP Task Force MGH Hand Hygiene Program Rewards “The Last 10%” Cultural change

4. “Cultural Change” (defined) “To make hand hygiene a habit so strong it is done without thinking… And an expectation so strong that failure to use it is easily noticed and worthy of intervention.” Cultural change

5. Key lessons and ongoing efforts Keep it positive! Have fun, celebrate progress, focus on facts… Not faults. Use a multidisciplinary effort: A multifaceted, team approach works best. Set solid but attainable goals: Short term goals, long term expectations. Get others involved: Seek input, share the efforts and the credits! Leaders and Champions Professionals and Non-professionals Identify barriers and work to overcome them Listen to complaints, concerns, and questions – and respond Define, categorize and quantify noncompliance – and target it Address the persistent failures – and link them to common goals “The Last Ten Percent” Patient Safety Encourage growth and lasting success Reach out, assist, and adapt the program for others Look for successes (even small) and celebrate them! Support related efforts: Become allies! Seek a cultural change* * New: The cultural change needed for lasting success must extend beyond the walls of MGH.

6. What’s next? Celebrate the past : 10th Anniversary of the rollout of the MGH HH Program in 2014 Prepare for the future : Attract new people, new ideas Continue working : MGH has an ever-changing population! Expand the effort : Add Ambulatory Care Centers; other surveillance methods Support related projects : “Excellence Every Day” requires a mutual effort Reach out : Encourage improvement efforts at other hospitals and schools. Lasting success depends on a cultural change that extends beyond MGH. There is no end… Only new beginnings.

7. To achieve excellence… Look around, speak up, and expect it every day.