Charter Form
Project Title: Improving Hand Hygiene Compliance to Reduce Preventable Harm
University/Organization Name: University of Portage
Health System Sponsor Name: University of Portage Medical Center (Sponsorship from Dr. Canoe)
What are we trying to accomplish?
Our aim is to improve compliance with already established hand-hygiene guidelines at the University of Portage Medical Center. Specifically, we want compliance with hand hygiene to be 80% or higher across all hospital units by April 5, 2012.
Aim statement (How good? For whom? By when? 1-2 sentences):
Problem to be addressed (Defines WHAT broadly; 2-3 sentences)
Hand hygiene is extremely important because, when done appropriately, it can reduce the spread of disease in the hospital setting. At UPMC, there is already a hand hygiene policy in place, but it is not being followed appropriately. Our goal is to ensure better compliance with the policy for the benefit of the patients.
Reason for the effort (Defines WHY; 4-5 sentences)
Due to the significance of hand hygiene in preventing disease, compliance is imperative. We want to ensure that patients are protected from the spreading of disease as much as possible. The organization will benefit from higher hand washing compliance because there will be less hospital acquired infections and complications.
Expected outcomes/benefits (Defines WHAT specifically, still not HOW; 3-4 sentences)
As a result of our project, we hope that there will be a more uniform use of hand sanitizer before and after patient encounters. Improved compliance across all staff types and a more widespread awareness by staff would lead to a decrease in hospital-acquired infections, an overall improvement in conditions for patients, and improved patient satisfaction.
How do we know that a change is an improvement?
(Identify outcome, process, and balancing measures; 4-5 sentences)
Outcome measures: Throughout the auditing process, the compliance rates will be monitored to assess our progress and success. Change will be an improvement if the percentage rises.
- % of hand washing compliance per patient encounter per week
Process measures: In addition to asking what the quantitative measure of hand washing compliance is, we will also attempt to assess reasons why hand washing might not be occurring.
- % of documented washings with proper technique
- % of encounters where providers wash their hands before seeing a patient
- % of encounters where providers wash their hands after seeing a patient
Balancing measures: We will ensure that other parts of the system are not negatively affected by this increase in compliance:
- Amount of money spent on hand sanitizer before and after the project.
- Staff satisfaction with hand hygiene process.
What changes can we make that will lead to improvement?
(Initial changes, barriers, key stakeholders; 4-5 sentences)
Initial activities: Existing UPMC hand hygiene standards require use of alcohol hand rub or soap and water any time a staff member enters or exits a patient room. For this project, we will first observe the behaviors of staff with regards to hand washing at UPMC.
Additionally, we may also observe the effect of increased availability of alcohol-based hand rub dispensers and possibly increased standardization of their location. We may also measure the effect of improving signage in the hospital. We will monitor the effectiveness of these changes using PDSA cycles.
Barriers:We may come up against limited funds, existing hospital quality infrastructure and guidelines, and provider attitude and behavior.
Key stakeholders: We will work closely with nursing and physician leadership throughout the hospital, as well as distribution, housekeeping, and operational staff. We will also include one or two patients in the process to get their perspective.