Vol. 32 No.

4 July/August 2010

61

A Lean Six Sigma Team Increases Hand Hygiene Compliance and Reduces Hospital-Acquired MRSA Infections by 51%
Clark Carboneau, Eddie Benge, Mary T. Jaco, Mary Robinson Healthcare workers unclean hands are the number one source of germ transmission and hospital-acquired infections (HAIs) (Unnecessary Deaths, 2008). It is estimated that 2 million Americans contract an HAI each year resulting in 99,000 deaths (Guideline for Hand Hygiene, 2002). These preventable infections cause more deaths than AIDS, breast cancer, and auto accidents combined (Unnecessary Deaths, 2008). The cost of treating HAIs in the U.S. ranges from US$28.4 to US$33.8 billion in 2007 US dollars (Scott, 2009). The estimated hospital costs for a Surgical Site Infection and Central line associated bloodstream infection, respectively, are US$25,546 and US$36,441 (Parekh, 2008). At Presbyterian Healthcare Services (PHS) in Albuquerque, New Mexico a Lean Six Sigma Improvement team was chartered to increase hand hygiene compliance to 90%. The project scope was twofold. First, root cause discovery and solution implementation at the two hospitals in Albuquerque. Those hospitals are 553and 129-bed acute care facilities. The second step was spreading the solutions to the other six PHS hospitals across the state. The teams efforts reduced the actual number of hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections by 51% in 12 months. Abstract: A low hand hygiene compliance rate by healthcare workers increases hospital-acquired infections to patients. At Presbyterian Healthcare Services in Albuquerque, New Mexico a Lean Six Sigma team identified the reasons for noncompliance were multifaceted. The team followed the DMAIC process and completed the methodology in 12 months. They implemented multiple solutions in the three areas: Education, Culture, and Environment. Based on methicillin-resistant Staphylococcus aureus (MRSA) mortality research the teams results included an estimated 2.5 lives saved by reducing MRSA infections by 51%. Subsequently this 51% decrease in MRSA saved the hospital US$276,500. For those readers tasked with increasing hand hygiene compliance this article will provide the knowledge and insight needed to overcome multifaceted barriers to noncompliance.

3. after exposure to a body fluid risk (and after removing gloves), 4. after patient contact, 5. after contact with a patients surroundings. Since April 2006 the PHS infection control department performs 105 hand hygiene audits per month in 21 clinical units between the two hospitals. The hand hygiene compliance rate is determined by dividing the number of acceptable hand hygiene observations by the total number of hand hygiene observations. Note: A hospitals observed hand hygiene compliance rate is an estimate of the facilities actual hand hygiene compliance. The actual hand hygiene compliance rate is unknown and unknowable. Measuring hand hygiene compliance is difficult and varies from hospital to hospital (Measuring Hand Hygiene, 2009). Other leaders in hand hygiene adherence are The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS). TJC National Patient Safety Goal (NPSG) #7 requires hospital hand hygiene to be at 90% compliance (NPSG 7, 2009). If a TJC surveyor observes three occurrences of staff noncompliance the facility is cited for failure to comply. Furthermore, beginning in October 2008 CMS no longer reimburses for the following HAIs:  catheter-associated urinary tract infections.  vascular catheter-associated infection.

Keywords
DMAIC Hand Hygiene Compliance Hand Hygiene Culture Infection Control Lean Six Sigma

Hand Hygiene Background

Two leaders in hand hygiene adherence guidelines are the Centers for Disease Control (CDC) and the World Health Organization (WHO). These organizations guidelines are complementary to each other; both detail how and when healthcare workers should clean their hands. Hand hygiene compliance is defined as hand cleaning with soap and water or use of a waterless alcohol-based hand rub. According to the WHOthere are five moments when hand hygiene compliance is required (Guidelines on Hand Hygiene, 2005): 1. before patient contact, 2. before performing an aseptic task,

Journal for Healthcare Quality Vol. 32, No. 4, pp. 6170 & 2010 National Association for Healthcare Quality

Journal for Healthcare Quality

62

Journal for Healthcare Quality

In addition, CMS no longer pays for Surgical Site Infections acquired during the following procedures:     CABG surgery; total knee, shoulder, elbow replacements; surgical spine procedures; laparoscopic gastric bypass and gastroenterostom procedures.

A Juran Institute Master Black Belt (MBB) assured each improvement tool was used appropriately during each phase. The MBB also verified that the projects solutions were correct and complete.

Define PhaseSetting the Course

The first phase of DMAIC is Define. The Define phase sets the course for the improvement team. The champion, process owner, and black belt developed the teams charter. The charter includes team membership, problem statement, project scope, timeline, project goal, and projected benefit. The project goal was to develop a peer-enforced hand hygiene culture to meet TJC NPSG of 90% hand hygiene compliance by February 2008. Developing a SIPOC provided the team an understanding of the projects major components and boundaries. SIPOC is the acronym for Supplier, Input, Process, Output, and Customer. The SIPOC includes the macro process steps and identifies all the suppliers and customers of the process, see Figure 1.

The Lean Six Sigma Team and Process

To understand the multiple issues involving hand hygiene noncompliance and statistically verify the underlying root causes the improvement team used the six-sigma improvement methodology DMAIC. DMAIC is the acronym for Define, Measure, Analyze, Improve, and Control. The Vice President of Medical Staff Affairs was the project Champion, the Director of Infection Control was the process owner, an Infection Control practitioner was the greenbelt, and a Juran Institutecertified Black Belt was the team facilitator. A cross-functional team was used with members representing Infection Control, Nursing, Laboratory, Pulmonary, Environmental Systems, Marketing, Epidemiology, Radiology, Quality, and Finance.

Figure 1. Hand Hygiene Project SIPOC

Define Hand Hygiene Compliance - SIPOC

Process Start HC worker approaches patient & or their environment

What are we trying to accomplish? Increase hand hygiene compliance to meet the TJC National Patient Safety Goal of 90% compliance for PH & PKH hospitals health care workers.

Process Stop HC worker leaves patient & or patient environment

Suppliers 1 4) Patients, family, physicians, Infection control, dietary, respiratory therapy, phlebotomist, housekeeping, PT & OT, social workers, radiology, nursing, transporters, chaplain, DMEs, pharmacy, volunteers, dialysis contractor, students, maintenance, admitting, placement coordinators, ED, ambulance service

Inputs 1) Standard operating procedure 2) Provide meds, care, diagnosis, equip. info, educ, social support, transport, cleaning 3) Provide meds, care, diagnosis, equip. info, educ, social support, transport, cleaning 4) Same as 2 & 3

Hand Hygiene Compliance process

Outputs 1) Patient& Env Contact 2) Care or services received 3) Care or services received 4) Care or services provided

Customers & Stakeholders 1) Patients, physicians, CNM Board of Directors, employees, families, TJC, CMS, PHS finance 2) Same as 1 3) Same as 1 4) Same as1

S t a r t

1) HC worker plans to touch patient or patient

3) 2) Perform hand Render care to the patient or hygiene handle something

4) Perform hand hygiene

S t o p

Vol. 32 No. 4 July/August 2010

63

The team obtained the Voice of the Customer (VOC) by asking 58 providers, staff, patients, and visitors the following two questions. 1. Why are hand hygiene practices in healthcare important? 2. What are the barriers preventing good hand hygiene in healthcare? The team grouped the VOC comments into themes and then wrote a Critical to Quality to address each customer need, see Figure 2. By the close of the Define phase the team understood the issues of hand hygiene noncompliance were more than behavioral and were in fact multifaceted.

Measure PhaseUnderstanding the Current Performance Level

The Measure phase purpose is twofold. The primary purpose is to understand the process outcome (i.e., the process Ys) current performance level. The average monthly hand hygiene compliance rate at the start of the project was 65%. The Measure phase secondary purpose is to narrow the list of potential root causes (i.e., the potential Xs, which affect the process outcome). A funnel is a good illustrator of this concept. Many root causes enter the top of the

funnel but after much filtering only a few potential root causes exit out the narrow end of the funnel. Some of the tools used by the team to filter down to a short list of root causes were a Detailed Process Flow Map, Pareto analysis, a Cause and Effect Diagram, and a Failure Modes and Effects Analysis (FMEA). The process map showed nonvalue-added (NVA) steps associated with locating sinks and the travel distance to the sinks. Another NVA step was locating a serviceable hand cleaning dispenser. The team used a cause and effect diagram to identify potential causes for these delay steps. The Pareto analysis did not demonstrate the usual 8020 rule of defects. In fact the flat Pareto showed hand hygiene compliance was stable across all clinical departments. No particular department was having more difficulty than other departments with hand hygiene compliance rather it was a system-wide problem. To close the Measure phase the team used a FMEA to rank each of the potential root causes. The result was the following short list of potential Xs ranked from the highest to lowest. To prove or disprove each item on the list would require more data analysis in the Analyze phase.

Figure 2. Hand Hygiene Critical To Quality Matrix

Critical to Quality Matrix Themes
1) The purpose of good hand hygiene compliance is to protect oneself and patients from spreading germs, bacteria, infections, and disease. 2) Healthcare workers personal hand hygiene habits are required to meet the CDC hand hygiene guidelines 3) A serviceable hand gel dispenser may be difficult to locate when needed

Critical to Quality
1) Prevent healthcare associated infections

2) Healthcare workers are accountable to be in compliance with the CDC hand hygiene guidelines 3) Healthcare workers have failsafe hand hygiene processes and easy access to hand hygiene supplies 4) Healthcare workers are provided effective education and are accountable to be in compliance with the CDC hand hygiene guidelines 5) There are reliable disinfection processes for personal equipment.

4) PH & PKH patients, visitors, physicians, & staff do not understand the CDC Hand Hygiene guidelines 5) Staff personal care equipment, e.g., stethoscopes, clipboards, accu-checks are not disinfected between patients 6) PH & PKH staff & non staff have only 2 choices for hand hygiene products, i.e., soap and water or alcohol based hand gel 7) Cleaning gurneys, stretchers, and wheelchairs is difficult 8) Stakeholders in some locations find it difficult to locate a clean sink with foot & knee controls within a close proximity to their patient.

6) There are a variety of hand hygiene products

7) There are a variety of washing equipment and processes to sanitized equipment 8) There are multiple sink locations to accommodate varying needs

64

Journal for Healthcare Quality

Failure ModeStaff did not clean their hands  staff does not know proper application of hand hygiene,  hospital lacking hand hygiene culture,  lack of personal hand hygiene products,  no dispenser in immediate area or dispenser empty or broken,  sink locations not evident when looking down hallways,  too few sinks are hands free controlled.

Analyze PhaseIdentifying the Critical Xs

The purpose of the Analyze phase is to verify the key root causes (i.e., the critical Xs). By collecting and analyzing specific data the team proved the potential Xs identified in the Measure phase were indeed the critical Xs. Once the critical Xs were known, solutions were then developed and implemented, tailored to each root cause during the Improve phase. The following is the proven list of Critical Xs:  X1: Staff hand hygiene knowledge is less than the target of 90%.  X2: Staff comfort level to enforce hand hygiene compliance is less than the target of 90%.

 X3: Target: 90% of staff agree that having personal hand hygiene products would be helpful in hand hygiene compliance.  X4: Low hand hygiene compliance due to too few gel dispensers and or too few sinks.  X5: Low hand hygiene compliance due to no signage for sink locations.  X6: Low hand hygiene compliance due to not enough sinks with hand free controls in clinical areas. The Critical Xs were grouped into three general categories: Inadequate staff hand hygiene knowledge (Staff Education), unsupportive hand hygiene culture (Hand Hygiene Culture), and facility issues particular to hand cleaning product dispensers, sinks, and signage (Environment).

Analyze PhaseStaff Education

To understand how staff education impacted hand hygiene noncompliance the team interviewed 92 healthcare workers with a seven question knowledge assessment, see Figure 3. The sample was large enough to infer onto the general hospital staff and physician population. The results showed statistical significance on three of the seven questions. In particular the results showed a

Figure 3. Hand Hygiene Staff Knowledge Assessment

Type of HCW: (Please circle one) MD/DO PA RN NA RT PT OT ES Radiology Pharmacist Social Worker Chaplain Transporter Volunteer Other 1. In which of the following situations should hand hygiene be performed? A. Before having direct contact with a patient B. Before inserting an invasive device (e.g., intravascular catheter, Foley Catheter) C. After having direct contact with a patient or with items in the immediate vicinity of the patient D. After removing gloves E. All the above for reducing the number of pathogenic bacteria on the hands of personnel? A. Washing hands with plain soap and water B. Washing hands with an antimicrobial soap and water Dietary

3. Clostridium difficile (the cause of antibiotic-associated diarrhea) is readily killed by Alcohol-based hand hygiene products __ True __ False 4. Which of the following pathogens readily survive in the environment of the patient for days to weeks? A. Clostridium difficile (the cause of antibiotic-associated diarrhea) B. Methicillin-resistant Staphylococcus aureus (MRSA) C. Vancomycin-resistant Enterococcus (VRE) D. All the above __ True __ False

___True ___ False A. 2 million patients per year acquire Healthcare Associated Infections B. 90,000 patients die per year from Healthcare Associated Infections C. $30.5 Billion in extra healthcare costs due to Healthcare Associated Infections D. All the above

Vol. 32 No. 4 July/August 2010

65

general knowledge deficit in the appropriated use of alcohol-based hand sanitizer.

Analyze PhaseHand Hygiene Culture

Understanding hand hygiene culture was a challenge the team overcame by interviewing

healthcare workers with a Culture Assessment, see Figure 4. The team asked 95 staff and physicians their comfort level when reminding each other if they witnessed an instance of hand hygiene noncompliance. Overwhelmingly the respondents stated they had no

Figure 4. Hand Hygiene Cultural Assessment

(a)
Unit/Department_______________________________ Type of Healthcare Worker (please circle one): MD/DO ES PA RN Dietary NA RT Pharmacist Volunteer PT OT Social

Radiology Chaplain

Worker Other

Transporter

Please answer the following questions using a scale of 1 to 5, with 1 being the least comfortable with the situation described in the question and 5 being the most comfortable. Please circle your answer . 1. You observe a co-worker or colleague not performing hand hygiene when they should. In general, how comfortable do you feel approaching them and asking them to perform hand hygiene? 2. In general, how comfortable do you feel approaching the following healthcare workers and asking them to perform hand hygiene when you have observed them not performing appropriate hand hygiene? 1 Physicians: Nurses : 1 2 3 4 5 2 3 4 5 1 2 3 4 5

Other ancillary staff such as Phlebotomists, Housekeeping, Physical Therapist, Respiratory Therapist, Radiology, Dietary, Chaplains, Social Workers, Transporters or Volunteers: 3. In general, how comfortable are you when asked to perform hand hygiene by a co-worker or colleague who observes you not performing hand hygiene at an appropriate time 4. In general, how comfortable are you when asked to perform hand hygiene by the following type of healthcare worker who observes you not performing hand hygiene at an appropriate time? Physicians:

Nurses :

Other ancillary staff such as Phlebotomists, Housekeeping, Physical Therapist, Respiratory Therapist, Radiology, Dietary, Chaplains, Social Workers, Transporters or Volunteers:

66

Journal for Healthcare Quality

Figure 4. Continued.
(b)
5. In general, how comfortable are you when asked to perform hand hygiene by a patient who observes you not performing hand hygiene at an appropriate time? 1 2 3 4 5

Please answer the following questions using the number of times a described situation has occurred. Please place a mark in front of your answer. 6. In the last three months, how often have you approached a co-worker, colleague, or other healthcare worker, and asked them to perform hand hygiene when you observed them in a situation in which they should have but did not? ___05 times ___610 times ___1115 times ___15+ times ___05 times ___610 times ___1115 times ___15+ times

7. In the last 3 months, how often have you been approached by a co-worker, colleague, or other healthcare worker, and asked you to perform hand hygiene when they had observed you in a situation in which you should have but did not?

Please answer the following questions using a scale of 1 to 5, with 1 being the least helpful in the situation described in the question and 5 being the most helpful. Please circle your answer 8. How helpful do you think having a personal device that dispenses alcohol-based hand rubs (such a lanyard with Calstat attached, or a Calstat dispenser that clips to the belt) would be in helping you adhere to hand hygiene requirements? 1 2 3 4 5

Please answer the following questions by choosing the response that best states how you feel about the following situations. Please place a mark in front of your answer. 9. Do you feel that Alcohol-Based Hand Rubs (i.e. Calstat) dispensers are readily available and easy to locate in your work area? 10. Which of the following handwashing sink locations do you prefer to use when caring for a patient in which you are required to wash you hands with soap and water: ___Yes ___No ___In the patients room ___In the patients bathroom ___In the hallway ___In another area not mentioned above 11. A sink was added in the newly constructed patient rooms for healthcare personnel to use to wash their hands. Do you feel comfortable using it? ___Yes ___No

12. Optional Question: Do you have any suggestions how Hand Hygiene compliance could be improved? (Please use the provided space to write your comments)

problem reminding each other about hand hygiene. A few departments stated there was some discomfort with staff reminding physicians. However, when asked how many times in the past month they actually reminded someone to clean their hands the answer was nearly zero. The team concluded this nonaction was a truer representation of hand hygiene culture than staff saying they would intervene if needed. One aspect of a safe clinical environment is staff members helping each other remember to clean their hands. The results of

the Hand Hygiene Culture Assessment were as follows:  Twelve out of 14 questions showed statistical significance.  Staff were not comfortable approaching other staff members to perform hand hygiene.  Staff were not comfortable when approached by other staff about their own hand hygiene.  Staff prefer to use hallway sinks versus the sink in the patient room.

Vol. 32 No. 4 July/August 2010

67

 Staff believe having personal hand hygiene products are helpful in improving hand hygiene compliance.

The teams solutions mirrored other facilities solutions to increase hand hygiene compliance. For example the IHI 2007 hand hygiene best practices list the following:  Place alcohol based dispensers and clean gloves near point of care.  Assigning responsibility for checking dispensers & gloves on a regular basis: not empty, dispensers are operational, dispensers provide the correct amount of product.  Evaluating the design and function of dispensers before selection.  Staff follow CDC recommendations for hand hygiene & gloves use.  Provide ongoing hand hygiene education for staff.  Initiate a multicomponent publicity campaign.  Use opinion leaders as role models and educators academic detailing.  Create a culture where reminding and encouraging each other about proper hand hygiene is the social norm.  Engage patients and families in hand hygiene efforts through tip sheets. Other facilities working to increase hand hygiene compliance suggest improvements are needed in three areas: Education, Motivation, and the System (Pittet, 2001). The team identified nearly 60 possible solutions and used a priority matrix to narrow the list to 22, see Figure 5. However, one of the highest ranked solutions was not implemented. The team identified a need to increase hand hygiene audits from 105 per month to 450 per month. There was a plan to hire a full time hand hygiene compliance monitor to assist with keeping hand hygiene vigilance and awareness high. The national economic downturn halted the addition of this new position.

Analyze PhaseEnvironmental Surveillance

The third and final root cause category the team investigated was environment issues (i.e., facility barriers to hand hygiene compliance). The team walked every clinical floor of both hospitals including the 447 patient rooms looking at sinks, signage, and hand cleaning product dispensers. The surveillance highlights were as follows:  Only nine sinks were hands free controlled.  Six sinks were inoperable.  Recessed clinical area hallway sinks did not have sink locator signs.  Thirteen alcohol-based gel dispensers were broken.  Seventeen gel dispensers were empty. There were 495 areas identified as needing soap or hand gel product dispensers.

Analyze PhaseOne Proportion Test

A one proportion test was used to determine if the percent defective of the sample could be accurately inferred unto the hospital population. The test compared the data set against a target and utilized a confidence interval to calculate a p-value. The confidence intervals for our knowledge and cultural assessments were set at 95%. p-values of .05 or less were used to determine statistical significance. The team closed the Analyze phase by proving each of the six potential Xs. Implementing solutions tailored to each of the six root causes was the task of the Improve phase.

Improve PhaseSelecting and Implementing Solutions

The Improve phase purpose is to identify and implement solutions to remedy the problem the team was chartered to solve. To assure they identified all possible solutions the team reviewed articles, presentations, Web sites, conferences, and communicated with other U.S. hospitals working to improve hand hygiene compliance. One healthcare system in particular, Novant Health in Charlotte, NC, has implemented improvements to hand hygiene compliance to maintain a rate of 90% or higher for at least 14 months.

Control PhaseSustaining the Gains

Implemented solutions in the Improve phase require a plan to sustain their improved performance level. A control plan allows the process owner to monitor performance with reaction trigger thresholds and defined remedial actions if thresholds are reached. The Infection Control staff continues to perform their monthly hand hygiene audits. In addition the organization has implemented a Safety Coach program to keep hand hygiene awareness and surveillance high. There are now 100 safety coaches

68

Journal for Healthcare Quality

Figure 5. Hand Hygiene Solutions

Education
1) Use staff & visitor posters for education 2) Involved CEO, VPs, & Medical Staff as role models in videos 3) Utilize CDC education for annual staff competency 4) Provided 10 weeks of staff and physician hand hygiene education 5) Involve patients in their care by clean hands message in pt. rooms 6) Include bilingual hand hygiene clean hands message with patient admissions packet

Culture & Awareness

7) Use patient stories to help educate staff Safety Coaches 8) Use trusted role models in each unit Safety Coaches 9) Added hand hygiene image & message to all computer screen savers 10) Initiated a Clean Hands Club to recruit staff & physicians into the hand hygiene culture 11) Developed a hand hygiene employee script to be used for intervention with non-compliant staff 12) Developed a script for staff to announce hand hygiene to their patients 13) Includes Wet Nap with each patient meal 14) Rotate staff photos on Presbyterian computer network promoting hand hygiene

Environment
15) Installed 94 hallway sink locator signs 16) Installed large bilingual soap, lotion, & gel labels on dispensers 17) Develop new hand hygiene policy 18) Added the inspection of dispensers & sinks to housekeeping checklist 19) Retrofitted 364 clinical sinks to hands free controls 20) Implemented report card process providing hand hygiene performance to units 21) Stock personal size hand sanitizer 22) Added additional 495 gel dispensers in clinical & non-clinical areas

Figure 6. Hand Hygiene Overall Compliance Run Chart (Mar 17Feb 09)
100 90 80 70 60 50 40 30 M A M J J A S O N D J F M A M J J A S O N D J F Month

Compliance Rate

Vol. 32 No. 4 July/August 2010

69

Figure 7. Hand Hygiene Message to Patients

throughout the health care system watching and mentoring staff on proper hand hygiene technique and compliance.

Hand Hygiene Team Benefits

The hand hygiene team increased compliance on average nearly 20%, see Figure 6. The hand hygiene teams finance department representative, called the money belt used PHS HAI data to calculate the financial benefit. The date range was from August 1, 2006 to September 30, 2007. During this time 292 patients were coded as having a HAI. A cost comparison was made with a cohort of patients with the same primary diagnosis but without a HAI. Average length of stay for patients without infections was 7 days. The average length of stay for patients with infections was 26 days. An additional average cost of US$16,665 per case was attributed to the patients with HAIs. However, because most HAIs are currently reimbursed by Medicare reducing the number of infections reduces the hospitals revenue. To adjust for this the money belt recommended

using half of the HAI cost of US$8333 for any benefit analysis of the teams work. The number of hospital-acquired MRSA cases during the 12-month baseline period was 80 and 40 were invasive. The comparison 12-month period had a 51% decrease in MRSA to 39 cases with 26 being invasive. Mortality rate associated with invasive MRSA is 17.7% (Klevens, Morrison, & Nadle, 2007). The estimated number of lives saved by the hand hygiene team was 2.5 lives. The overall prevention of 41 MRSA infections resulted in a gross savings of US$354,276 with a net hard dollar savings of US$276,500. Note: The cost of increasing hand sanitizer use by 30% equaled US$40,000 in 12 months.

Conclusion
Hand hygiene compliance by healthcare workers is an ongoing challenge. In the future an engineering solution is needed to mistake proof this problem. At the present time increasing compliance requires a multifaceted

70

Journal for Healthcare Quality

approach in three areas; ongoing staff and physician education, developing a supportive culture, and environmental improvements to the hospital facilities. Following this hand hygiene teams lean six sigma journey is not intended to be an evidence-based approach for all hospitals. However, there are common themes of this teams root causes identified and their implemented solutions with other facilities working to increase hand hygiene compliance, see Figure 7.

Parekh, A. (2008). HHS efforts to reduce hospital acquired infections. Health care Infection Control Practices Advisory Committee. Pittet, D. (2001). Improving adherence to hand hygiene practice: A multidisciplinary approach. Emerging Infectious Diseases, 7, 234240. Unnecessary Deaths: The Human and Financial Costs of Hospital Infections. (2008). Retrieved May 30, 2009, from www.hospitalinfection.org/ridbooklet.pdf

Authors Biographies
Clark Carboneau, Deming Scholar, MBA, BS, ASQ Certified Quality Manager/Organizational Excellence. Juran Certified Lean Six Sigma Black Belt. Currently a Lean Six Sigma Black Belt with Presbyterian Healthcare Services, Albuquerque, NM. Eddie Benge, MD, is a Rheumatologist and for the last 8 years has been Vice President of Medical Staff Affairs at Presbyterian Hospital in Albuquerque, NM. He works with the 1,400 member medical staff and in the areas of Patient Safety and Clinical Quality. Mary T. Jaco, RN, MSN, MBA, MPA, CIC, is an Infection Control Practitioner at Presbyterian Healthcare ServicesCentral New Mexico Region in Albuquerque, NM. Mary Robinson, RN, BSN, MPA, is currently the director of Quality and Performance Improvement at Presbyterian Healthcare ServicesCentral New Mexico Region in Albuquerque, NM. For more information on this article, contact Clark Carboneau at ccarbonea@phs.org.

References
The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. (2009). Retrieved May 30, 2009, from www.cdc.gov/ ncidod/dhqp/pdf/Scott_CostPaper.pdf Guideline for Hand Hygiene in Healthcare Settings. (2002). Retrieved May 30, 2009, from www.cdc.gov/ Handhygiene/ Guidelines on Hand Hygiene in Health Care. (2005). Retrieved May 30, 2009, from www.who.int/patientsafe ty/events/05/HH_en.pdf Klevens, R. M., Morrison, M. A., & Nadle, J. (2007). Invasive methicillin-resistant Staphylococcus aureus. JAMA, 298, 17631771. Measuring Hand Hygiene Adherence: Overcoming the Challenges. (2009). Retrieved April 30, 2009, from www. jointcommission.org/patientsafety/infectioncontrol/hh_ monograph.htm National Patient Safety Goals 07.01.01. (2009). The Joint Commission.