1. KEY DRIVERS FOR SUSTAINING CULTURAL
CHANGE
• Commitment from senior leadership to establish work as an organizational priority.
• Multidisciplinary team representing all units and departments.
• Use of a structured process improvement methodology.
• Ongoing communication and education for staff.
• Use of reliable data to drive decisions.
• Continued monitoring; appropriate follow up of identified opportunities.
• Public posting of unit compliance appears to have contributed to some
improvement in a short amount of time.
• We must stay the course and understand that cultural change in an organization of
our size takes time.
Changing Our Safety Culture: How Our Hand Hygiene Improvement Initiative is Leading the Way
Ellie Carter, CLS, MPH, CIC; Madeleine Hart, MA, CPHQ; Jason J. Reed, MD, Chief of Staff
ABOUT ABBOTT NORTHWESTERN
HOSPITAL
• As the largest hospital in the Twin Cities, Abbott Northwestern
Hospital is recognized nationally and locally for its exceptional
expertise and care.
• Located in the heart of Minneapolis, Abbott Northwestern Hospital
employs nearly 6,000 staff, providing services annually to more than
200,000 patients and their families from across the Twin Cities and
Upper Midwest.
CALL TO ACTION
It is a well-known mantra, stated by the World Health Organization:
Hand hygiene is the single most effective way to prevent infection.
Yet, nationwide compliance with hand hygiene in health care settings
remains abysmally low. Leading up to 2012, despite multiple efforts to
improve, Abbott Northwestern Hospital’s hand hygiene compliance
rates had reminded virtually unchanged. Opportunities existed for a
leadership-driven and accountability-based approach to improving hand
hygiene compliance. In 2012, Abbott Northwestern’s Vice President of
Medical Affairs, Dr. Dennis O’Hare, set into motion a comprehensive
physician-, performance improvement-, and infection prevention
department-led hand hygiene improvement initiative. From the outset,
this core team agreed that the backbone of our improvement program
must:
• Have full and continued support of leadership.
• Be established as an organization-wide priority.
• Utilize the tried and true tenets of Performance Improvement
methodologies.
• Ensure a culture of accountability among all levels of staff.
Without these, any improvements would not be sustainable.
UNDERSTANDING CURRENT CULTURE
Our team began with a thorough literature review to learn and
understand current best practices. This review elucidated some common
themes and contributed to planning the program components we aimed
to adopt:
• Create a multidisciplinary team, representative of the entire body of
staff.
• Take steps to understand the unique culture of our organization
(conduct focus groups of physicians, nurses, and ancillary staff).
• Conduct physician attitude and knowledge surveys.
• Develop a multi-pronged initiative to address the many facets that
contribute to the behaviors and actions underlying hand hygiene
compliance.
*Vital Smarts©
matrix
1% 3% 3%
19%
75%
1% 3%
8%
26%
62%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Always Most of the
time
Sometimes Rarely Never
How often do you approach
other physicians?
How often do you approach
non-physician staff?
BUILDING THE FOUNDATION FOR
CULTURE CHANGE
The major building blocks for supporting change include:
• Ensuring that everyone has the right tools available, at the right time,
in the right place, including product and signage.
• Clearly and regularly communicate the focus and importance of the
work.
• Ensuring understanding and demonstration of all aspects of hand
hygiene.
• Building in accountability at all levels.
ENGAGING OUR PATIENTS AND THEIR FAMILIES
FOR CHANGE
Clean Hands Kit contents:
• Expectations for hand hygiene
practices
• Talking points about holding each
other accountable
• The “Accountability Commitment”
inviting staff to sign,
acknowledging that they commit
to hold others accountable and
expect to be held accountable by
others
• “F.O.A.M.”fliers for department
posting
USING A MULTI-PRONGED APPROACH
The scope of the work required a systematic approach that would
address the numerous drivers of hand hygiene compliance. Sub groups
were formed to further delineate tasks, timelines and responsibilities
to address each essential component for ensuring success, including
data display, product standardization, signage, education, and
patient and family engagement. A detailed communication plan was
developed to ensure continuous and effective messaging.
From the very beginning, the team recognized the work would need
to address personal as well as group motivation for performing proper
hand hygiene – every patient, every time. Physician leadership and
engagement was also recognized as a key factor to success.
Accountability
Education
Communication
Structure
Ensure system
of personal
responsibility
Ensure common
knowledge base
Broadly and
frequently
Ensure the right
tools at the right
time
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Clean hands save lives.
F.O.A.M.
(for others and me)
abbottnorthwestern.com
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F.O.A.M.
(for others and me)
Abbott NorthwesterN hospitAl
Clean hands save lives.
It’s OK to ask those around you to clean their hands.
• Ask your doctors and care team to clean their
hands if they did not before caring for you.
You should also clean your hands often.
You and your visitors should clean your hands
before eating, after using the restroom, and after
touching surfaces in the hospital room.
• Use soap and water or an alcohol-based hand rub
to clean your hands.
The #1 way to prevent the
spread of infections
ABBOTT NORTHWESTERN HOSPITAL
Visual collateral
House-wide distributed posters, fliers,
electronic imaging with our team-created
slogan “F.O.A.M. (For Others And Me)”
with quarterly refreshed images.
“Ask me if my hands are clean” buttons for
staff to wear, inviting patients and other
staff to inquire about hand cleanliness.
Video collateral
F.O.A.M. (For Others And Me): produced
by and starring our own staff, this video
uses humor to introduce the concept of
accountability for hand hygiene.
Approach Coach: the term coined
by the Hand Hygiene Improvement
Team, further demonstrated different
scenarios to appropriately hold colleagues
accountable for hand hygiene.
In Your Hands: Phyllis’ Story: an interview
with a patient and her family about the
personal impact of acquiring MRSA while
admitted at our hospital.
MEASURING CHANGE
In 2012, the entire Allina Health system of hospitals adopted a standardized process for collection
of hand hygiene compliance data. An unofficial best practice described in peer reviewed literature
describes a process referred to as “third-party observers” or “secret shopper observers”. These
observations occur as covertly as possible in a department where the observer typically does
not work. This process has been demonstrated to reduce potential bias that can result when an
individual is observing their own departmental colleagues. This has become an accepted standard
for collection of hand hygiene compliance data.
Acknowledging accomplishments is an important
aspect of changing culture. Our senior leaders
personally recognize departments that achieve goal
for three consecutive months by presenting our
“Clean Hands High Five” trophy to staff.
In a bold move toward true transparency, Abbott
Northwestern Hospital’s Chief of Staff, Dr. Jason
Reed, initiated the public posting of unit-specific
hand hygiene compliance rates each month, along
with the hospital-wide physician hand hygiene
compliance rate. These posters are prominently
displayed on each unit with an accompanying
message inviting anyone to speak up if they believe
hand hygiene was missed. Dr. Reed shares his
e-mail and phone number for patients and visitors
to contact him personally with any questions or
comments.
“At Abbott Northwestern, we strive to always clean
our hands before we enter and when we exit every
patient’s hospital room. All of our caregivers and
staff partner with patients, families and visitors to
reduce the spread of infection. We need everyone’s
help. Never hesitate to ask me or anyone here:
Are your hands clean?”
Jason Reed MD, Chief of Staff
mobile: (612) 296-0284
email: Jason.Reed@allina.com
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ABBOTT NORTHWESTERN HOSPITAL
Last month’s Hand Hygiene rates:
% on station E3100/W3500
Physician hospital-wide compliance: %
Measured by percent of observations of
foaming in and out of patient room.
Compare to national average of 40-55%
Clean hands save lives.
HEALTH CARE WORKER (HCW) TYPE KEY
11 = Patient Transport (Teal)
17 = Phlebotomy
staff (Dk Teal)
1 = Physician
4 = Respiratory Therapist
(Olive Green)
6 = IV Team (Navy) 12 = Radiology (Gray)
18 = CRNA
2A = Nurse Practitioner
5A = Registered Nurse
(Navy)
7 = Care
Coordinator/SW
13 = Dietitian
19 = CST
2B = Medical Student
5B = Licensed Practical
Nurse (Purple)
8 = Pastoral Care
14 = Tray Passer
(Black/Khaki)
20 = Ophthalmic
Personnel
2C = Physician Assistant
5C = Nursing Assistant
(Teal)
9 = Physical Medicine
Staff (Royal Blue)
15 = Other Healthcare
Provider
21 = Dialysis RN
3 = Pharmacy (Maroon) 5D = RN Student
10= Environmental
Services(Dark Brown)
16 = Volunteer
22 = Op Tech
04/01/14
Observer Name
Title
Month
Year
INSTRUCTIONS: Complete a minimum of 10 random hand hygiene observations per month. If you have multiple units, complete a
sample from each area, totaling 10 audits.
Use this log to record your interactions with staff that you observe to be non-compliant. Continue to acknowledge and thank staff
that are performing proper hand hygiene, but do not include those interactions on this form.
Mail your completed forms to PI Office: MS 11137 or email cynthia.campbell@allina.com. Fields in this form can be
completed electronically. Download and save with your name/date.
Unit or Dept
HCW Type Record staff response to being coached regarding non-compliance
1
2
3
4
5
6
7
8
9
10
CLEAN HANDS SAVE LIVESHand Hygiene Practice Expectations
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Basic Hand Hygiene Expectations1. The 5 Moments for Hand Hygienea. Before each patient contact or encounterb. Before clean/aseptic procedure or taskc. After body fluid exposure riskd. After touching patient environmente. After each patient contact or encounter2. Every time upon entry or exit of a patient’s rooma. Expected even if direct patient contact is not
anticipated/did not occurb. After taking care of a patient on EntericPrecautions, hand washing with soap and
water must occur
3. Allina-wide Policy on Hand Hygiene includes
more details and can be found on the Abbott
Northwestern Hospital infection control policies
and procedures page on the AKN.
More specifics on Hand Hygiene Expectations
How do I demonstrate to our patients and my
colleagues that I am practicing proper hand hygiene?
In situations where you have both or one hand free
upon entry:
· Grab foam before entry, then rub your hands
together when your patient can see it.· Remember, when both hands are full, perform
hand hygiene once you’ve put down the item(s).
What do I do if my hands are full when entering
or exiting a patient room?If you ENTER or EXIT a room with something in
your hands (equipment, tray, etc.) clean your hands
immediately after putting down the item(s). You
should also clean your hands before you pick up
something to bring into a patient’s room.
What is considered the “threshold” of apatient’s room?
If the door threshold is crossed, hand hygiene
is expected regardless of whether the patient
or anything in the patient’s environment was
touched or not. According to the Allina Isolation
Precautions policy, this includes either passing
beyond the swing of a door OR passing over the
threshold of a sliding door.
If I cross the threshold and don’t plan to touch
anything and I didn’t touch anything in the patient
room, do I still need to foam in and out?Yes.
If I foam out of a patient room and go directly to
another patient room, do I need to foam in to that
patient’s room?
No, as long as you don’t touch anything along the
way outside the patient rooms.
continued on reverse
Our individual and collective handhygiene practices are everyone’s business.
It is critical for our safety culture and for patient reassurance that both our patients and your
colleagues are able to see hand hygiene being performed when necessary to protect all of our safety.
Accountability Kit contents:
• Tools and information on
conducting “Approach Coach”
interactions
• Refreshed expectations for hand
hygiene practices
• FAQs on what the hand hygiene
compliance observers are looking for
• Resources available for partnering
with our patients
Level 3 Achievement:
Goal met for 3 consecutive months
Action: Leaders present
“High Five” Trophy
Level 2 Achievement:
Goal met for 2 consecutive months
Action: Certificate sent to
unit/department leaders
Level 1 Achievement:
Goal met for 1 month
Action: Congratulations to Leaders
via letter
Level 3 Awareness:
Goal not met for 3 consecutive months
Action: Meeting with V.P. s to discuss
plan for improvement
Level 2 Awareness:
Goal not met for 2 consecutive months
Action: Letter request to develop
formal action plan
Level 1 Awareness:
Goal not met for 1 month
Action: Feedback to Leaders
via letter
GOAL MET GOAL NOT MET
The Accountability Model consisted of two parallel pathways for hospital departments
to follow based on achievement of our monthly hand hygiene goal or falling short
of goal.
Departments achieving goal were acknowledged by senior leadership and awarded a
trophy for sustained achievement.
Departments falling short of goal were assisted in planning a 30-60-90 Action Plan,
outlining their planned tactics to achieve goal by the completion of the 90-day period.
Modeling behavior using “Approach Coach”
Holding each other accountable for hand hygiene is imperative to our success.
However, getting staff to take the leap of faith necessary to actually approach a peer
(let alone to approach someone in a place of more authority) proved difficult to
implement. The Hand Hygiene Team decided our hospital leaders must first lead the
way and role model what exactly Approach Coach looks like by demonstrating it
in front of their own staff. Approach Coach entails acknowledging staff for proper
hand hygiene as well as subtly asking staff why hand hygiene was missed. Supervisors
all the way up through our Senior Leadership Team committed to conducting at
least 10 Approach Coach interactions per month with their staff. As of mid-2013,
more than 11,000 Approach Coach interactions have been conducted.
RESULTS
Hand Hygiene Compliance Rates and Intervention Timeline
2014 Goal = 85%
Hospital-Wide
20%
40%
60%
80%
100%
Aug-12
Sep-12
O
ct-12
N
ov-12
D
ec-12
Jan-13
Feb-13
M
ar-13
Apr-13
M
ay-13
Jun-13
Jul-13
Aug-13
Sep-13
O
ct-13
N
ov-13
D
ec-13
Jan-14
Feb-14
M
ar-14
Apr-14
M
ay-14
Jun-14
Jul-14
Aug-14
Clean Hands Kit
Accountability
Model and
Approach
Coach
Patient Story
Video
For Others
Me
Video
Focus Groups
MD
Survey
Team
Formation
Approach
Coach Expansion
August 2012 - August 2014
Announced to staff:
Public display of data
Public display of data
Accountability Kit
BUILDING A CULTURE FOR CHANGE
Messaging the change
The hospital’s Marketing and Communications department was a key partner in developing
impactful hospital-wide messaging and images.
Early on, the team acknowledged the importance of
involving our patients and visitors as essential partners.
Current research informed us that these individuals are
generally not comfortable speaking up to remind their
providers to clean their hands if they did not personally
see them do so. Multiple methods were used to invite
patients, families and visitors to partner with us to help
better serve them and ensure their safety including in-
room posters and video reminders via the hospital’s
closed-circuit TV system.
CELEBRATING CHANGE
HARDWIRING BEHAVIOR CHANGE
Providing tools for change
Toolkits were developed that include materials to support our leaders as they
embarked upon the culture change journey in their respective departments.
The Accountability Model
In 2013 the Institutes for Healthcare
Improvement (IHI) delivered a webinar
lead by two top performers in the U.S.
for improving hand hygiene – Vanderbilt
University Medical Center and The Johns
Hopkins Hospital.
The Abbott Northwestern Hospital
team modified and adopted one of the
approaches used at Vanderbilt and coined
it our “Accountability Model”.
Accountability Gap
Cultural Change Influencers
Motivation Ability
Personal 1 It’s the right thing to do
• First do no harm
• Avoid infection among patients and staff
2 Ensure people have skills
• New employee orientation education
• Infection Control section of annual
mandatory staff education
• F.O.A.M Video emphasizes personal
accountability and coaching others
Social 3 Harness peer pressure
• Voices from video “I want to be held
accountable”
• Clean Hands Kit Accountability
Commitment
• Data transparency; encourage
competition; acknowledge positive
performance
4 Find strength in numbers
• Broad use of Clean Hands Kit
• Sharing messages and materials at key
staff meetings
• Allina intranet Infection Control links to
video, Clean Hands Kit and monthly data
Structural 5 Design rewards accountability
• Leadership recognition of units/
departments
• “Clean Hands High 5”
• Follow up with lower-performing
departments/units
• Senior Management Team unit adoption
6 Change the environment
• New Foam In Foam Out signage and
standardized placement
• Increased availability of foam in public
areas
• Patient room “OK to Ask” signs and video
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Clean hands save lives.
Hand Hygiene
Accountability Commitment
From Allina Health’s “Our promise”:
We will be fearless advocates and tireless partners on your path to better health.
To protect the safety of our patients and ourselves, I commit to:
• Allowing others to hold me accountable if I forget to clean my hands
• Holding others accountable if I observe someone who may not have cleaned their hands
Our unit: ___________________________________________ Manager: __________________________________________
Signed:
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Abbott NorthwesterN hospitAl
Clean hands save lives.
Hand Hygiene Talking Points for ManagersPlease use these suggested topics and activities when discussing
hand hygiene with your staff.
hand hygiene Accountability
1. The best way for our hospital to achieve sustained improvement with
hand hygiene is to hold each other accountable for hand hygiene. We all get busy
and at times we may forget.
2. Nursing, ancillary staff, and physician representatives have given their support to this approach.
3. It does not matter who you are or who the other person is; it is not personal, it is about patient
and staff safety.
a. A suggested way to approach someone who may not have cleaned his/her hands:
• Say “Did I miss seeing you clean your hands?”• Be respectful and discrete
b. A suggested way to respond when someone asks you to clean your hands:
• Say “thank you,” then perform hand hygieneConsider role-playing with staff so they can practice accountability with each other.hand hygiene Compliance Data
1. Data on inpatient hospital units are collected using Secret Shopper observations
2. Data from elsewhere in the hospital are collected by the department’s or clinic’s own staff
3. The data are not about individual performance; they are a reflection of a team’s performance,
reported by unit and by type of health care worker4. We all play a role in our team’s performance and we can help each other do better.
hand hygiene expectations
1. The 5 Moments for Hand Hygiene (share and discuss diagram with staff)
a. Before each patient contact or encounterb. Before clean/aseptic procedure or taskc. After body fluid exposure risk
d. After touching patient environmente. After each patient contact or encounter2. Every time upon entry or exit of a patient’s rooma. Expected even if direct patient contact is not anticipated/did not occur
b. When a patient is on Enteric Precautions, hand washing with soap and water must occur
3. Allina-wide Policy on Hand Hygiene includes more details and can be found on the
Abbott Northwestern Hospital infection control policies and procedures page on the AKN.
abbottnorthwestern.com
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F.O.A.M.(for others and me)
Abbott NorthwesterN hospitAl
Clean hands save lives.
abbottnorthwestern.com
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Clean hands save lives.
Memorandum
To: Patient Care and Ancillary Department Leaders
From: The Abbott Northwestern Hand Hygiene Improvement Team
Date: Nov. 26, 2012
Subject: Hand Hygiene Improvement
Dear Patient Care and Ancillary Department Leaders:
Enclosed you will find the materials that make up the Abbott Northwestern Hand Hygiene
Improvement “Clean Hands Kit.”
Please use these communication tools in your continuing efforts to engage staff in achieving our goal:
Improve hand hygiene compliance from 61 percent to 80 percent by Dec. 31, 2012.
We hope the materials help you to inform and talk with your staff about how they can individually
contribute to improving hand hygiene. Your kit includes:
1. talking points for Managers
Some suggested topics/activities that you can use when discussing hand hygiene with your staff.
2. hand hygiene Accountability Commitment Form
This is an OPTIONAL exercise for you and your staff. Use the form to publicly commit to each
other and the hospital that you care enough about patient and staff safety to hold each other
accountable, and you expect to be held accountable. A larger, poster-sized commitment form is
available upon request. See contact information below.
3. secret shopper FAQs
The who, what, when, why and how on the Secret Shopper hand hygiene observation process.
4. “Your 5 Moments for hand hygiene”
The World Health Organization’s visual description of when hand hygiene should be performed.
This is part of the Allina Hand Hygiene Policy.
5. F.o.A.M Flier for employees
This flier is being sent to your department and all internal mail routes for posting in employee
areas. You will see more of this messaging throughout the hospital in the coming months.
6. Current hand hygiene data
Our team is hard at work preparing several more hand hygiene improvement strategies to
accompany this kit. One example is a short video that will model “the right words at the
right time.” The video uses humor and role play to help staff become more comfortable with
holding each other accountable for hand hygiene. Watch for its release next month. If you
have additional ideas on how to keep the hand hygiene improvement momentum going, please
contact Maddy Hart (ext. 3-4462) or Ellie Carter (ext. 3-4375).
Thank you for your dedication to protecting our patients and staff!
Sincerely,
The Abbott Northwestern Hand Hygiene Improvement Team
CLEAN HANDS SAVE LIVES
Approach Coach in Action
Protecting patient and staff safety
by practicing hand hygiene is everyone’s business.
Abbott Northwestern’s safety culture depends on:
· Individuals practicing proper hand hygiene, and
· Our collective hand hygiene practices as a care team.
When patients and colleagues see us cleaning our hands, they can be reassured
we are protecting everyone’s safety.
PLEASE POST
19055 0314 ©2014 ALLINA HEALTH SYSTEM. TM – A TRADEMARK OF ALLINA HEALTH SYSTEM.
CLEAN HANDS SAVE LIVES
Partners in Hand Hygiene
Accountability
How to include hand hygiene in
conversations with your patients
“OK to Ask” signage for posting in
patient rooms
· Signage available to order through
SMARTworks: #S411026
Make it a point to tell your patients that we may
need their help to remember to clean our hands
AND that it is also important for them to clean
their hands often:
· When orienting a patient to their room
· When rounding on your patients
If a patient ever does ask you to perform hand
hygiene, simply thank them for the reminder and
do it (even if you already did and they didn’t see it).
Helpful resources:“OK to Ask” patient TV information slide
“OK to Ask” 5-minute video from
CDC on hospital channel 50
19055 0314 ©2014 ALLINA HEALTH SYSTEM. TM – A TRADEMARK OF ALLINA HEALTH SYSTEM.
Design:mondofragilisnetwork
WHO acknowledges the Hôpitaux Universitaires de Genève (HUG),
in particular the members of the Infection Control Programme, for their active participation in developing this material.
October 2006, version 1.
abbottnorthwestern.com
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Clean hands save lives.
Hand Hygiene Secret Shopper FAQs
why are we using secret shoppers to collect hand hygiene data?
• It is a more accurate measurement of hand hygiene practices
(this is supported by literature)
• The Allina Quality Council has asked all Allina hospitals to measure in this
way so reporting on hand hygiene compliance is more consistent.
who are the secret shoppers?
• At Abbott Northwestern, they are pool of 60 staff consisting of:
Assistant Clinical Nurse Managers
Ancillary staff representing the departments of transport, social work, lab, PT/OT, RT,
and radiology.
• Each shopper is on a monthly rotation and collects observations according to the schedule
• Shoppers collect observations on inpatient units only (not including Mental Health Service units).
They do not observe on the unit they normally work.
what are the secret shoppers looking for?
• Opportunities for hand hygiene:
Mostly staff entering OR exiting patient rooms
An observation may include room entry, exit or both
• A variety of staff types: nurses, doctors, lab, environmental services, nutrition, transport, therapies,
and any other support staff
• If someone exits a room rubbing their hands together or drying with a paper towel, it is counted
as a “yes” for performing hand hygiene
• If someone exits a room, performs hand hygiene and goes directly into another patient room
without touching anything along the way, it is counted as a “yes” for performing hand hygiene
for both exiting and entering the next room
• If someone exits a room with something (equipment, tray, etc.) in their hands, the observer will
wait for hand hygiene to occur after the item is put down
• If observing hand hygiene on staff exiting the room of a patient on Enteric Precautions, only
washing with soap and water will counted as a “yes” for performing hand hygiene.
how are the secret shoppers doing their observations?
• They are watching for all opportunities for hand hygiene; not just for staff doing it or not doing it
• They try to be as inconspicuous as possible, so the resulting data will be as close to real-life
as possible.
abbottnorthwestern.com
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Abbott NorthwesterN hospitAl
Clean hands save lives.
Hand Hygiene
Accountability Commitment
From Allina Health’s “Our promise”:
We will be fearless advocates and tireless partners on your path to better health.
To protect the safety of our patients and ourselves, I commit to:
• Allowing others to hold me accountable if I forget to clean my hands
• Holding others accountable if I observe someone who may not have cleaned their hands
Signed: