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Sustaining and Spreading Improvement in Hand Hygiene Improvement from January 2015 Front Office to Front Line Volume 41 Number 1 Sustaining and Spreading Improvement in Hand Hygiene Compliance Features Infection Prevention and Control ■■ Editorial: Toward More Reliable Processes in Health Care “If other quality and safety ■■ Improving Hand Hygiene at Eight Hospitals in the United States by problems exhibit the same characteristics as hand Targeting Specific Causes of Noncompliance hygiene noncompliance, ■■ Beyond the Collaborative: Spreading Effective Improvement in attempting to address them Hand Hygiene Compliance everywhere with exactly the same set of interventions is Performance Improvement likely to fail because the key ■■ Using Lean Management to Reduce Blood Culture Contamination causes of the problem will differ from place to place.” Teamwork and Communication ■■ — Beyond the Collaborative: Implementation of a Standardized Postanesthesia Care Handoff Spreading Effective Improvement in Increases Information Transfer Without Increasing Handoff Duration Hand Hygiene Compliance (p. 24) Department Field Notes ■■ Inviting Families to Participate in Care: A Family Involvement Menu www.jcrinc.com The Joint Commission Journal on Quality and Patient Safety Infection Prevention and Control Editorial: Toward More Reliable Processes in Health Care Peter Pronovost, MD, PhD alk into most manufacturing plants that are performing Yet the important message is that RPI can improve patient care Wwell, perhaps winning the Malcolm Baldrige Award,1 and and should be applied broadly in health care. Lean and Six Sigma, you will find robust leadership and management systems focused for example, are too often considered a work process tool rather on customer needs. Good leaders establish a bedrock of values, a than as a management system. Yet the Toyota production system clear moral compass, and a compelling vision and inspire others to was based on two key principles: respect for people and continued embrace that vision. Good managers declare goals and measures improvement.4 When Toyota encountered quality problems in the and ensure that both of these cascade through each level of the or- last decade, its leaders learned that they needed to add a key val- ganization, with designated processes and persons accountable for ue—humility.5 them. Workers know the behaviors needed to achieve the goals, Health care would benefit from refocusing on the following and management is visible in their work area and posts perfor- principles: I am humble and curious; I respect, appreciate and help mance on key behaviors. others; and I am accountable to continuously improve myself, my Health care has not yet widely embraced these management organization, and my community.6 The Joint Commission Center practices. Despite considerable clinical research to identify essen- for Transforming Healthcare has provided the tools and has pushed tial behaviors and practices, health care processes are unreliable, for us further toward becoming high reliability organizations.7 which there are several reasons. First, we are still heavily practicing These two articles offer hope that health care can benefit from the “art” of medicine, reflecting a failure to determine when art is more disciplined use of RPI—Lean, Six Sigma, and change man- needed and when more disciplined science should be practiced. agement. To make it stick and spread, we will need managers and Second, at most organizations, clinicians are not trained in the leaders to champion this approach as the way to manage and lead tools and methods of Lean, Six Sigma, and change management— their organizations. In the struggle to find the balance between art which Chassin and colleagues, in their two articles in this issue of and science, patients would be better served if more emphasis was The Joint Commission Journal on Quality and Patient Safety,2,3 refer placed on management science. J to collectively as Robust Process Improvement® (RPI®). Third, our accountability systems are grossly underdeveloped, and low com- Peter Pronovost, MD, PhD, is Senior Vice President for Patient pliance with evidence-based practices is too often tolerated. Safety and Quality, and Director, Armstrong Institute for Patient Safe- Thanks to The Joint Commission Center for Transforming ty and Quality, Johns Hopkins Medicine, Baltimore; Professor of An- Healthcare, all of this seems to be changing in health care. Its first esthesiology and Critical Care Medicine, Surgery, and Health Policy and Management, Johns Hopkins University; and a member of The project addressed hand hygiene, one of the most effective behav- Joint Commission Journal on Quality and Patient Safety’s Editorial iors to prevent health care–associated infections, for which com- Advisory Board. pliance lies at less than 50% at most hospitals. The first article de- scribes how eight hospitals used RPI to achieve a 70.5% relative improvement in the units that implemented a five-step Six Sigma References 2 1. Schaefer C. Baldrige Award Recipients (blog category). Blogrige–the official project (Define, Measure, Analyze, Improve, Control). A notable Baldrige blog. The National Institute of Standards and Technology. Accessed component of the project was the Center’s approach to identifying Dec. 3, 2014. http://nistbaldrige.blogs.govdelivery.com/category/baldrige- barriers to hand washing. Too often we assume that knowledge award-recipients/. is the only barrier and education the sole intervention. Yet other 2. Chassin MR, Mayer C, Nether K. Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance. Jt Comm J common barriers are agreement (clinicians do not agree with the Qual Patient Saf. 2015;41(1):4-12. evidence), ambiguity (what we are asking is unclear), and ability 3. Chassin MR, et al. Beyond the collaborative: spreading effective improvement (systems make it impossible). This project identified local barriers, in hand hygiene compliance. Jt Comm J Qual Patient Saf. 2015;41(1):13-25. unique to each unit, and then sought local solutions. 4. Liker JK. The Toyota Way: 14 Management Principles from the World’s Greatest 3 Manufacturer. New York City: McGraw-Hill, 2004. The intervention then spread, as reported in the second article. 5. Taylor A. How Toyota lost its way. Fortune. Jul 10, 2010. Accessed Dec In the first three years, data were collected from 174 organizations, 5, 2014. http://archive.fortune.com/2010/07/12/news/international/toyota_ which implemented 769 projects, with each unit serving as a proj- recall_crisis_full_version.fortune/index.htm. ect. The average hand hygiene compliance improved from 57.9% 6. Armstrong Institute for Patient Safety and Quality. Mission, Vision and Values. Accessed Dec 4, 2014. http://www.hopkinsmedicine.org/armstrong_ to 83.5% in a diverse sample of units. Despite the use of RPI, the institute/about/mission_vision_values.html. study design could have been more robust. For example, control 7. Chassin MR, Loeb JM. High-reliability health care: getting there from here. units were not selected. Milbank Q. 2013;91(3):459-490. January 2015 Volume 41 Number 1 3 Copyright 2015 The Joint Commission The Joint Commission Journal on Quality and Patient Safety Infection Prevention and Control Improving Hand Hygiene at Eight Hospitals in the United States by Targeting Specific Causes of Noncompliance Mark R. Chassin, MD, FACP, MPP, MPH; Carrie Mayer, MBA; Klaus Nether, MT (ASCP) SV, MMI n the 1840s, Semmelweis demonstrated the efficacy of hand Article-at-a-Glance Ihygiene in dramatically reducing maternal deaths in hospitals from puerperal fever.1 Ever since, the goal of achieving and sus- Background: Hospitals and infection prevention special- taining high rates of compliance with hand hygiene protocols ists have attempted to achieve high levels of compliance with has generally eluded hospitals. For example, in a systematic re- hand hygiene protocols for many decades. Despite these ef- view of 96 studies from around the world, Erasmus et al. report- forts, measured performance is disappointingly low. ed a median hand hygiene compliance rate of 40% in hospital Methods: The Joint Commission Center for Transform- units of all kinds.2 In 2005 the World Health Organization an- ing Healthcare convened teams of experts in performance nounced the launch of its first Global Patient Safety Challenge, improvement and infectious disease from eight hospitals for which was focused on improving hand hygiene.3 its hand hygiene quality improvement project, which was The Joint Commission Center for Transforming Healthcare conducted from December 2008 through September 2010. (the Center) was created in 2008 to apply the tools and meth- Together, they used Lean, Six Sigma, and change manage- ods of Lean, Six Sigma, and change management to address the ment methods to measure the magnitude of hand hygiene most difficult safety and quality problems facing health care. noncompliance, assess specific causes of hand hygiene fail- These tools, to which we refer collectively as Robust Process ures, develop and test interventions targeted to specific caus- Improvement® (RPI®), have long been effectively employed in es, and sustain improved levels of performance. business4,5 and, more recently, in health care. Two reviews doc- Results: At baseline, hand hygiene compliance averaged ument the extent to which the use of Lean and Six Sigma tools 47.5% across all eight hospitals. Initial data revealed 41 dif- are spreading in health care.6,7 Although rigorous evaluations of ferent
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