Hand Hygiene Improvement Tool Linked to Decrease in HAIs at Memorial Hermann Health System

Joint Commission Resources, Inc. recently released the January 2016 issue of The Joint Commission Journal on Quality and Patient Safety. The issue features an article by M. Michael Shabot, MD, of Memorial Hermann Health System (MHHS), and Mark R. Chassin, MD, MPP, MPH, from the Joint Commission, and their co-authors on how MHHS used the Joint Commission Center for Transforming Healthcare’s Targeted Solutions Tool® (TST®) to improve hand hygiene compliance; improvements were associated with sustained reductions in healthcare-associated infections. MHHS’s system-wide hand hygiene compliance improved to 95.6 percent in the final 12 months.
 
After pilot testing the hand hygiene TST, MHHS achieved significant improvement for each of the 150 inpatient units throughout its 12 hospitals. For 31,600 observations, MHHS’s average system-wide hand hygiene compliance improved from 58.1 percent at baseline to 84.4 percent in the “improve” phase, 94.7 percent in the first 13 months of the “control” phase, and 95.6 percent in the final 12 months. During this same time period, rates of central line-associated bloodstream infections and ventilator-associated pneumonia in adult ICUs decreased by 49 percent and 45 percent, respectively.   

As described in the article, the TST is a systematic, Web-based application founded on RPI methodologies, including Lean, Six Sigma and change management. The TST guides healthcare organizations through a step-by-step process to accurately measure actual performance, identify barriers to excellent performance and receive direction to proven solutions customized to address particular barriers. To learn more, visit http://www.centerfortransforminghealthcare.org/tst.aspx/.

Source: Joint Commission Resources, Inc.

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