Hand hygiene: who owns it? Jacquie Hlagi Hilary Espezel 1 - PowerPoint PPT Presentation

Hand hygiene: who owns it? Jacquie Hlagi Hilary Espezel 1

Objectives • Outlining hand hygiene requirements and methodology at Fraser Health • Provincial partnership for hand hygiene • Understanding audit data • Achieving improvement 2

Fraser Health • What we did for hand hygiene • Education • Auditing requirements • Reports 3

What we did for hand hygiene • Participated in the Provincial Hand Hygiene Working group – Subcommittees • Education • Data entry – FormAudit purchased 2012 » Fax forms rather than manual data entry 4

FH Audit tool 5

FH Category codes 1 NP/RN/RPN 2 LPN 3 Care Aide 4 Physician • Health Care Assistant • Student aide • Rehab worker • unit clerk • stocking aide • PCA • Emergency Room Aid 5 Student (all 6 Medical Student/ 7 Medical Technician 8 Respiratory Therapy except Dr’s) Resident • SPD Tech • cardio tech • dental hygienist • Dialysis Tech • Perfusionist • Medical Imaging tech • Dental assistant 9 Lab Personnel 10 Porter/ Security 11 Housekeeping 12 Maintenance 13 Social Worker 14 Rehab Therapy 15 Dietician 16 Volunteer • PT • OT 17 Food Services • SLP • Recreation 18 Pharmacist Therapist • Rehab assistant • Physio • Speech therapist • Audiology 6

Provincial category codes Nurse NP/RN/RPN, LPN, Care Aide/Student Aide, Student (Nursing) Physician Physician, Medical Student/Resident Medical Technician, Respiratory Therapy, Lab Personnel, Porter, Social Worker, Rehab Clinical Therapy, Dietician, Pharmacist Other Housekeeping, Maintenance, Volunteer, Food Services 7

Education requirements • Mandatory annual education (CCRS) for all staff (Policy) • Auditors – Self learning • User manual • Policy/CPG • video – Certification of auditors 8

FH Audit requirements Frequency • Hand Hygiene audits are required to be performed per fiscal period Requirements • A complete audit requires a minimum of 25 observations and a minimum of 5 Health Care Providers (HCPs) documented on one Hand Hygiene audit form. 9

Reports 1. Overall Compliance 2. Dashboard - Site Level 3. Dashboard - Program Level 4. Dashboard - Fraser Health Acute 5. By Facility for Selected Programs 6. Compliance and Observations Trend by Facility, Program, Unit 7. By Program for Selected Facilities 8. By HCP Group and HCP 9. By Opportunity 10. Completed Audits Detail 11. Fiscal Period Unit Report – for Quality Boards 12. Fiscal Period HCP Report – for Quality Boards 10

By HC group by HC provider 11

Improvement

Improvement • Information before Expectation • Engaging before Mobilizing • Beliefs before Behaviors • Culture Change before Strategy 13

Information before Expectation 14

Information before Expectation • Reasons for low hand hygiene performance: – Different interpretations of when HH is required – Environmental barriers • Positive deviance 15

Engaging before Mobilizing 16

Engaging before Mobilizing • Leaders first • Understand the link between actions and improvement • Address barriers 17

Beliefs before Behaviors 18

Beliefs before Behaviors • Perceived relevance to practice • Perceived personal risk • Burden of responsibility • Perceived shared ownership 19

Culture Change before Strategy 20

Culture Change before Strategy Culture of patient safety: • Errors are inevitable • Reliance on vigilance and perfection will fail • All working in our culture feel safe to raise issues and suggest solutions Sustaining improvement: • Changes embedded into usual practices • Discipline-specific champions • Meaningful and timely feedback 21

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