New Joint Commission Project Tackles Handwashing Missteps


The Joint Commission recently launched the Center for Transforming Healthcare, an entity that involves teaming with hospitals and health systems nationwide to measure and practice methods that aim to stop breakdowns in patient care, such as wrong-site surgery and improper communication. The first stop? Handwashing.

The answers to unacceptable and infrequent handwashing seem simple and yet have proved illusive at many institutions. To gain more accurate data and to explore the efficacy of potential solutions to the handwashing problem, the Center for Transforming Healthcare sent task members to eight volunteer hospitals and health systems. The project started in December of 2008. The participating centers include: Cedars-Sinai Health System, Los Angeles; Exempla Lutheran Medical Center, Wheat Ridge, Colo.; Froedtert Hospital, Milwaukee, Wis.; Johns Hopkins Hospital and Health System, Baltimore; Memorial Hermann Health Care System, Houston; Trinity Health, Novi, Mich.; Virtua, Marlton, N.J.; and Wake Forest University Baptist Medical Center, Winston-Salem, N.C.

“Demanding that healthcare workers try harder is not the answer,” said Mark Chassin, MD, MPP, MPH, president of the Joint Commission, in a news release.”These healthcare organizations have the courage to step forward to tackle the problem of handwashing by digging deep to find out where the breakdowns take place so we can create targeted solutions that will work now and keep working in the future. A comprehensive approach is the only solution to preventing bad patient outcomes.”

The Joint Commission’s Robust Process Improvement (RPI)™ toolkit includes a variety of methodologies—Lean Six Sigma and change management principles and methodologies, says Anne Marie Benedicto, MPH, MPP, vice president of operations for the Joint Commission Center for Transforming Healthcare.

“The idea is to use a proven systematic approach to analyze specific breakdowns in care, discover the underlying causes, and develop targeted solutions that solve complex problems while building support and acceptance among staff and leadership that are critical to sustaining the solutions created,” Benedicto continues. “That’s what RPI is all about.”

The Joint Commission claims that the following factors are the main root of anemic handwashing practices:

•Ineffective placement of dispensers or sinks

•Hand hygiene compliance data are not collected or reported accurately or frequently

•Lack of accountability and just-in-time coaching

•Safety culture does not stress hand hygiene at all levels

•Ineffective or insufficient education

•Hands full

•Wearing gloves interferes with process

•Perception that hand hygiene is not needed if wearing gloves

•Healthcare workers forget


While the Joint Commission supports the use of efficacious process-improvement methodologies, it doesn’t require a specific methodology. The solutions are meant to be simple and customizable.

“The goal of translating the Center’s work is to make the solutions free of jargon and easy-to-use by clinicians and quality professionals al-ready on staff at healthcare organizations,” Benedicto says. “This means hospitals don’t have to adopt Lean Six Sigma, hire Black Belts or retain consultants in order to implement the solutions identified by the Center.”

Accurate measurement of handwashing is a key starting point. The eight participating hospitals, using the Center’s measurement methods consistently, found on average that caregivers washed their hands less than 50 percent of the times in which they should have washed their hands. That’s a lot of missed opportunities. It was also somewhat of a surprise, says Benedicto. The organizations did not expect such low compliance.

“It really brings home the fact that random observation is an unreliable measure of compliance,” she continues. “The high compliance rate that many hospitals are reporting is probably not accurate. That is why we recommended that hospitals take a different approach to get a realistic assessment of actual performance in real time: use trained and certified independent observers to monitor hand hygiene; take measurements 24/7, at all times of the day, every day of the week.”

Detailed information about the root causes and identified solutions is available on the Center’s Web site ( And in mid-2010, organizations that are accredited by the Joint Commission will be able to access a customized set of solutions.

The aforementioned Web site lists solutions to problems in the following manner:

Cause: Ineffective placement of dispensers or sinks

Solution: Provide easy access to hand hygiene equipment and dispensers

Cause: Hand hygiene compliance data are not collected or reported accurately or frequently


• Data provide a framework for a systematic approach for improvement

•Utilize a sound measurement system to determine the real score in real time

•Scrutinize and question the data

•Measure the specific, high-impact causes of hand hygiene failures in your facility and target solutions to those causes

The personnel of the pilot units selected by the participating hospitals knew they were being observed, Benedicto says. However, they did not always know who the observers were.

“These hospitals did use ‘secret shoppers,’ though, to measure hand hygiene compliance,” she continues. “They also used other valid measurement systems to collect compliance rates, and the statistical process control charts validated the stability of the measurement system. But it was interesting that biases were discovered in virtually all non-secret shopper observations. This led to reliance on secret shoppers until technology solutions were initiated. Beta testing is still being conducted on the technology solutions.”

While most of the participants were hospitals, that doesn’t mean the solutions tested there are only appropriate in that setting. A majority of solutions will translate to other settings, including small and rural hospitals, Benedicto asserts.

“We believe—but will confirm with future work—that the solutions developed by the participating hospitals will be effective for the same causes when they appear in other hospitals,” she says. “For example, if a small hospital finds that some of its caregivers don’t wash their hands prior to entering a patient room because their hands are full, that hospital will likely find that the same solution developed by a participating hospital (e.g., the installation of a simple shelf near a hand gel dispenser) will work for them.”

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