1. 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

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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%

13. 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%

14. 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