1. H AND H YGIENE Everyone is already at 100%, so why are we talking about this?!

3. Hand Hygiene “Advanced Math”

4. Hand Hygiene Guru

6. T HE J OINT C OMMISSION National Patient Safety Goal (NPSG.07.01.01) Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. Elements of Performance 1. Implement a program that follows categories IA, IB, and IC of either the current Centers for Disease Control and Prevention (CDC) or the current World Health Organization (WHO) hand hygiene guidelines. (See also IC.01.04.01, EP 5) 2. Set goals for improving compliance with hand hygiene guidelines. (2. See also IC.03.01.01, EP 3) 3. Improve compliance with hand hygiene guidelines based on established goals.

7. P ROGRAM I NFRASTRUCTURE System Change Training and Education Evaluation and Feedback Reminders in the Workplace Institutional Safety Climate Multimodal hand hygiene improvement strategy CDC-WHO Partnership to Assess HH Infrastructure at Healthcare Facilities http://www.cdc.gov/handhygiene/

8. J OINT C OMMISSION C ENTER FOR T RANSFORMING H EALTHCARE Targeted Solutions Tool™ (TST) is an innovative application that guides health care organizations through a step-by-step process to accurately measure their organization’s actual performance, identify their barriers to excellent performance, and direct them to proven solutions that are customized to address their particular barriers H abit A ctive Feedback N o One Excused D ata Driven S ystems http://www.centerfortransforminghealthcare.org/tst.aspx

9. H AND H YGIENE BUNDLE 1. Establish ongoing monitoring and feedback on infection rates 2. Establish administrative leadership and support 3. Establish a multidisciplinary design and response team 4. Provide on-going education and training for staff, patients, families and visitors 5. Ensure hand hygiene resources are accessible facility wide and at the point of care 6. Reinforce hand hygiene behavior and accountability 7. Provide reminders throughout the health care setting 8. Establish on-going monitoring and feedback of hand hygiene compliance AJIC. Vol.40, No.4, Supplement 1. May 2012.

10. P OLICY AND P ROCEDURE Expectations Products Procedures Program Description

11. P RODUCT P LACEMENT

12. C OMMUNICATION : E DUCATION /R EMINDING Healthcare Workers Family/Visitors Patients

13. M ONITORING Joint Commission Monograph Measuring Hand Hygiene Adherence: Overcoming the Challenges (2009) iScrub

14. F EEDBACK Patient Survey Data Observation Data Real Time Engagement

16. T ECHNOLOGY FOR R EMINDING, M ONITORING AND C OMPLIANCE

17. A N OLDIE, BUT A G OODIE ?!

18. C ULTURE OF S AFETY ( HIGH R ELIABILITY O RGANIZATIONS ) Shared value/beliefs about safety in organization Always anticipating precarious events Informed employees and medical staff Culture of reporting Learning culture “Just culture” Blame-free environment Team work environment Culture of continuous improvement Empowering families to participate Informed and activated patient Source: Safe Design