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

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

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

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

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

Driver Diagram

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

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

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

Results of your PDSAs SAB average for 2011= 0.09

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

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

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%            

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