An organizational perspective on hand hygiene: a model for building to success Carol VanDeusen Lukas, EdD Center for Organization, Leadership and Management Research Department of Veterans Affairs April 10, 2008

Background Project in the Department of Veterans Affairs resulting from collaboration of: Directors and Chief Medical Officers of three Veterans Integrated Health Care Systems Center for Organization, Leadership and Management Research Lessons from Robert Wood Johnson Pursuing Perfection (P2) shaped project approach

Project aim To improve hand-hygiene compliance using a three-pronged model to strengthen the organization’s ability to implement evidence-based clinical practices

Organizational model for improving evidence-based clinical practices Improved evidence- based clinical practices Active top leadership commitment Links to senior management structures and processes Organizational infrastructure Clinical process redesign

Clinical process redesign … Actively engages middle & front-line staff around priority clinical issue Works toward desired hand-hygiene performance through system redesign to build new practices into daily work Builds skills, motivation and culture to support and sustain quality improvement Experience with systematic quality improvement and redesign teams Confidence to tackle other problems

Redesign key actors, venues: Infection control professionals Hand-hygiene champions Multi-disciplinary redesign teams Collaborative, interdisciplinary work, including MDs Systematic problem analysis, data collection, tests of change Shared learning groups

Redesign activities: Education and awareness – what needs to be done Product selection and placement – make it easy to do Social marketing – create imperative to change Monitoring and feedback – feedback on how doing

Active top leadership commitment... Sets priorities for the organization Establishes hand-hygiene as high priority Sets high expectations for performance Communicates commitment & goals Demonstrates personal commitment through use of own time To quality in general To hand hygiene in particular

Leadership commitment actions: Set public goal for breakthrough performance in hand hygiene Model good hand-hygiene Talk with patients and staff about hand hygiene on leadership rounds Discuss hand-hygiene at employee forums Attend performance improvement or other quality committees

Management structures & processes… Align redesign efforts with organization’s strategies and priorities (top to bottom) Actively support redesign with needed resources Create accountability through measures, reporting and monitoring progress Integrate activities across organizational boundaries (facilities, workgroups, functions) Facilitate cooperation and problem resolution Spread learning and reinforce culture

Management structure & process actions: Identify cabinet champion or executive sponsor to work with redesign efforts Monitor hand-hygiene performance at leadership meetings Hold low-performing areas accountable for improvement Leverage cooperation across professions and departments Provide resources to recognize and reward success

High-level performance builds from all three elements: a VA example High-performing academic medical center with wide experience in systematic quality improvement Well-established redesign team for hand-hygiene with strong leadership commitment and management processes and support Hand-hygiene compliance ~80%

Urgency takes to a new level: VA example continued Hand hygiene cited as problem in Joint Commission Survey 30 days to reach 90% Blitz built on strong base Redesign team coordinated education, awareness, generation of new ideas from all areas Data collection increased Middle-managers held accountable Chief of staff very active in holding physicians accountable Reached, then exceeded 90%

Sustaining improvement Aim to move from special project needing extensive attention to routine business, built into culture But need periodic monitoring to sustain; hold accountable and take action if performance drops off