IHI Expedition Impacting Hand Hygiene at the Front Line Session 2

Transcription

1 Tuesday, August 13, 2013 These presenters have nothing to disclose IHI Expedition Impacting Hand Hygiene at the Front Line Session 2 Lisa Maragakis, MD, MPH Tom Talbot, MD, MPH Diane Jacobsen, MPH, CPHQ Today s Host 2 Max Cryns, Project Assistant, Institute for Healthcare Improvement (IHI), assists programming activities for hospital settings including Expeditions (2-4 month webbased educational programs), Passport memberships, and mentor hospital relations. He also supports IHI s networking and knowledge efforts. Max is currently in the Co-Operative Education Program at Northeastern University in Boston, MA, where he majors in Business Administration with concentrations in Entrepreneurship and Marketing. He enjoys professional and collegiate sports, playing basketball, music, the beach, and trivia. 1

2 WebEx Quick Reference 3 Welcome to today s session! Please use chat to All Participants for questions For technology issues only, please chat to Host WebEx Technical Support: Dial-in Info: Communicate / Join Teleconference (in menu) Raise your hand Select Chat recipient Enter Text When Chatting 4 Please send your message to All Participants 2

3 Expedition Director 5 Diane Jacobsen, MPH, CPHQ, Director, Institute for Healthcare Improvement (IHI) is currently directing the CDC/IHI Antibiotic Stewardship Initiative, NSLIJ/IHI Reducing Sepsis Mortality Collaborative. Ms Jacobsen served as IHI content lead and improvement advisor for the California Healthcare-Associated Infection Prevention Initiative (CHAIPI) and directed Expeditions on Antibiotic Stewardship, Preventing CA-UTIs, Reducing C. difficile Infections, Sepsis, Stroke Care and Patient Flow. She served as faculty for IHI s 100,000 Lives and 5 Million Lives Campaign and directed improvement collaboratives on Sepsis Mortality, Patient Flow, Surgical Complications, Reducing Hospital Mortality Rates (HSMR) and co-directed IHI's Spread Initiative She is an epidemiologist with experience in quality improvement, risk management, and infection control in specialty, academic, and community hospitals. A graduate of the University of Wisconsin, she earned her master's degree in Public Health-Epidemiology. from the University of Minnesota. Today s Agenda 6 Introductions Debrief Action Period Assignment Measurement Approaches Action Period Assignment 3

4 Schedule of Calls 7 Session 1 Call to Action for Hand Hygiene Date: Tuesday, July 30, 2:30 PM 4:00 PM ET Session 2 Measurement Approaches Date: Tuesday, August 13, 2:30 PM 3:30 PM ET Session 3 Supplies, Equipment, and the Environment Date: Tuesday, August 27, 2:30 PM 3:30 PM ET Session 4 Leadership and Culture for Hand Hygiene Date: Tuesday, September 10, 2:30 PM 3:30 PM ET Session 5 Frontline Engagement Date: Tuesday, September 24, 2:30 PM 3:30 PM ET Session 6 Marketing and Communications Campaigns Date: Tuesday, October 8, 2:30 PM 3:30 PM ET Faculty 8 Tom Talbot, MD, MPH, FSHEA, FIDSA, Associate Professor of Medicine and Preventive Medicine, Vanderbilt University School of Medicine and Chief Hospital Epidemiologist, Vanderbilt University Medical Center, conducts research on healthcare epidemiology and infection control and oversees healthcareassociated infection prevention programs. Dr. Talbot currently serves as a member of the Centers for Disease Control and Prevention s Healthcare Infection Control Practices Advisory Committee (HICPAC). 4

5 Faculty 9 Lisa Maragakis, MD, MPH is an Assistant Professor of Medicine at The Johns Hopkins University, Department of Medicine, Division of Infectious Diseases and the Hospital Epidemiologist and Director of the Department of Hospital Epidemiology and Infection Control at The Johns Hopkins Hospital. She received her medical degree and postdoctoral Infectious Diseases training at The Johns Hopkins University School of Medicine and a master s degree in public health from The Johns Hopkins University Bloomberg School of Public Health. She recently served as a Councilor on the Board of Directors of the Society for Healthcare Epidemiology of America (SHEA), as Vice-Chair of the SHEA Guidelines Committee and as the liaison representing SHEA to the Healthcare Infection Control Practices Advisory Committee at the Centers for Disease Control and Prevention. Her research interest is the epidemiology, prevention and control of healthcareacquired infections caused by antimicrobial-resistant gram negative bacilli. Debrief: Action Period Assignment 10 Complete 3 to 5 hand hygiene observations on one unit using the data collection tool provided by the Joint Commission (will be distributed on the listserv after the call) OR your organization s current data collection tool If using the Joint Commission tool, Watch Improving Care with Targeted Solutions Tool (TST) video (6 minutes) proving-care-with-the-tst/ Based on what you observed, brainstorm ideas you could test to address current barriers to hand hygiene Consider: visibility and availability of soap, visual reminders or prompts, workflow obstacles related to availability and location of supplies, pace on the unit, etc. 5

6 IHI Hand Hygiene Expedition Measurement Approaches Tom Talbot, MD, MPH Why Measure Hand Hygiene Compliance? To understand performance To use data to change behaviors To assess impact of interventions 12 6

7 How to Measure Hand Hygiene Compliance 13 Direct observation of practice Alcohol hand rub utilization Technology monitoring Healthcare-associated infection (HAI) rates Survey Results: Measurement Approaches 14 Direct observation Secret or embedded observers: 87% Unit representatives who observe own unit practice: 60% Sanitizer consumption: 14% Healthcare-associated infection (HAI) rate: 30% As a surrogate outcome Technology for electronic monitoring: 6% Including RFID 7

8 Direct Observation 15 Gold Standard Many different flavors: Audit own area vs. other Embedded vs. announced Different individuals: Employees (restricted work duty?), students, visitors Observe with correction or without? How detailed? WHO 5 moments? Duration of wash? Amount of foam used? Poll Question 16 For those that use direct observation, do you use secret shoppers/embedded observers? A. Yes B. No C. N/A my organization does not use direct observation 8

9 Direct Observation 17 PROS: Direct assessment of practice Can capture details of behavior (empty foam canisters, poor compliance with glove use) Raises awareness of observer to poor compliance CONS: Hawthorne effect Observer bias (only see compliance?) Inter-rater reliability Resource intensive Changing the Observer VUMC: Shared Responsibility 18 Every inpatient and outpatient unit/clinic committed one person as observer (often a manager) Observers assigned to different area Expected to perform 20 opportunities/month Aims: Prioritize this program Shared responsibility Lessons learned from observing one area are taken back to to home unit 9

10 Poll Question 19 For those that use direct observation, do you use patients to collect data? A. Yes B. No C. N/A my organization does not use direct observation Patients as Observers? 20 What about engaging the patient? Concern about patientprovider relationship Grodon SC JAMA 2012;307: Longtin Y Arch Intern Med

11 Alcohol Hand Rub Consumption Using changes in utilization of alcohol hand rub as marker for hand hygiene compliance rates Location Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec VUH Hand Hygeine VUH Campaign SICU Gyn Surg N? Uses foam only ED GI Endo Alcohol Hand Rub Consumption 22 PROS: Cheap Indicates usage More objective/standardized Lacks selection bias CONS: How to account for bulk purchasing No assessment of timing of hand hygiene Cannot drill down to specific group usage (e.g. nursing vs. physicians) Denominator? Less tangible 11

12 Technology Monitoring 23 Technology Monitoring 24 RFID tied to dispenser Alcohol sensors Visual alerting (vibration) 12

13 Technology Monitoring 25 PROS: Large number of observations Reduces observer bias Drill down to provider level Not biased to specific times/days CONS: Expensive Clunky May involve added procedures to workflow or equipment tracking Sensor errors Issues re: tracking personal behaviors (Big Brother) HAI Rates PROS: Tangible, credible outcome May help gain buy-in CONS: Impacted by other practices Not often available for all practice settings (e.g. clinics) 26 13

14 Deciding on Measurement 27 Gain consensus Allow for input and trial Give people some skin in the game Be pragmatic/practical Consider excluding some areas/practices in order to improve buy-in e.g. VUMC dermatology clinic/mohs surgery 28 14

15 29 Dealing with Challenges to the Measurements 30 Your measurement could be imperfect or wrong Observer interpretation Failure to account for nuances in specific practice settings E.g., trauma unit ICU door, room-to-room 15

16 Dealing with Challenges to the Measurements 31 Your measurement could be correct but poor performance could be blamed on misperceptions about the measurement E.g., emergency department status report Unintended Consequences of Measurement 32 Observer fatigue/data entry Provider behavior changes to meet measurement Using foam outside room to count for measurement AND using sink inside room 16

17 Poll Question 33 Do you collect names of those persons noted to be noncompliant with hand hygiene? A. Yes B. No If you do not collect names, have you been asked to collect names of those persons noted to be noncompliant with hand hygiene? A. Yes B. No C. N/A my organization collect names Taking Names 34 Addressing non-compliance by identifying specific persons Assumes issue is due to limited few Within spirit of just culture? All persons equally under surveillance? If responds unprofessionally to reminder different issue 17

18 Now You ve Measured. Now What? Feedback the performance Make it simple, clear, visual Peer comparison good if done with right context/intent Public display of data? 35 VUH Hand Hygiene FYTD Compliance by Unit Hand Hygiene VUH Compliance Split Compliance Fiscal by PDF Year Splitter to Date Report Monday, January 31, 2011 TVC HR/PACU Amber Page 24 of 35 Bar = Your Unit 18

19 HAND HYGIENE COMPLIANCE FY13 to Date SUMMARY: Type of Person Observed: INPATIENT * Must have at least 50 observations for current FY to be included Groups with Compliance Above Target ( 92%) Nurse Practitioners CRNA Pt Care Techs Surgical Techs Xray Techs Anesthesia Tech Nuc Med Techs Radiology Techs Groups with Compliance Between Threshold & Target (88-91%) Nursing Anesthesiologists Nutrition Svcs Phys Therapy Groups with Compliance Below Threshold (<88%) Group 1 Physicians Care Partners EVS Medical Students ED Nursing Surgeons Transport Svcs Group 2 Physicians LPNs Based on FY13 Compliance Data (July 2012 January 2013) 37 Other Concerns 38 Dealing with the Hawthorne Effect Dealing with sample size (low N) Dealing with want to show patients that I washed my hands concern Setting a goal Is 100% possible with your method or are you setting up for failure? 19

20 Questions? 39 Raise your hand Use the Chat Insights from John s Hopkins 40 At the beginning of our campaign, it was incredibly important (& somewhat difficult) to get buy-in from key stakeholders and frontline staff about our measurement methodology & it took a fair amount of time (months to a year) Unit self-monitoring was a great way to get buy-in and overcome objections about the measurement method (I.e. Skeptical staff or leaders can see for themselves that HH is not happening consistently and they become advocates for HH improvement) 20

21 Insights from John s Hopkins 41 Needed to address a variety of special circumstances for measurement clarity and consistency: e.g. Transporters pushing patients across threshold; PT assisting patients across threshold; nutrition or others carrying things across threshold; open areas with curtain dividers like the ED or PACU Staff initially wanted to be able to enter the doorway to speak to a patient without washing; we offered a "red line" box as a "safe zone" just inside the door but ultimately staff said that they did not want this for a variety of reasons Insights from John s Hopkins 42 Use the "IN and OUT" methodology of measurement Standardization of the measurement was very important (training video for observers; standard data collection forms; definitions; doubling checking observer data and methods when outliers were found) Good documentation, record keeping and open communication was essential to build trust in the measurement methodology 21

22 Questions or Comments? 43 Raise your hand Use the Chat Action Period Assignment 44 Test holding measurement rounds Identify a unit with low compliance or challenges getting buyin with hand hygiene Schedule a time to round with key leader(s) on the unit (i.e., Nurse Manager, Medical director, Hospitalist) Spend ~15 min rounding on the unit Elicit feedback about barriers to measurement Identify the obstacles to hand hygiene and identify 1 PDSA cycle Come prepared to share your insights and learning at Session 3 22

23 Expedition Communications 45 Listserv for session communications: To add colleagues, us at Pose questions, share resources, discuss barriers or successes Next Session 46 Tuesday, August 27, 2:30 PM 3:30 PM ET Session 3 Supplies, Equipment & the Environment 23