Presented By:

Summer Pike RN, CIC

Infection Control Preventionist
A Member of the Quality Department
of Mercy Health Partners, Muskegon
Mentored By: Dr. Remington Sprague,
Vice President & Chief Medical Officer
Presenting
TO WASH OR NOT
TO WASH. THERE
IS NO QUESTION.
Among healthcare workers in the United States,
hand hygiene adherence is less than 50 percent.
WHO Guidelines on Hand Hygiene in Health Care
15%
32%
17%
9%
22%
67%
63%
89%
23%
59%
0%
20%
40%
60%
80%
100%
Medical Staff Nurse Staff Technical
Staff
Ancillary Staff Total
ED Hand Hygiene - April 2012
Entering Room Compliance Exiting Room Compliance
72%
28%
0%
50%
100%
YES NO
3.) Are you comfortable reminding a co-work (any
co-worker; lab, nurse physician, tech, etc.) to
wash their hands when you have seen that they
haven't?
20%
63%
10%
7%
0%
20%
40%
60%
80%
100%
0% 25% 75% 100%
4.) How often do you remind a co-worker (any co-
worker; lab, nurse physician, tech, etc.) to wash
their hands when you have seen that they haven't?
CULTURE &
PERCEPTION

Targeted Change Direction
% or
Amount
By This
Date
HH compliance in
the Hackley ED.
Increase
50%
(from baseline)
12/2012
Culture (Survey
question 3 & 4)
Increase
50%
(from baseline)
12/2012
BEFORE AFTER
Patient
Stickers
Staff Mouse
Pads
Patient/Visitor
Brochure
Staff
Visual
Reminder

72% of staff surveyed said they are comfortable
reminding a co-worker to wash their hands when they
see they havent, BUT in a later question 83% of staff
surveyed stated that they only remind someone 25% of
the time or less.
14%
69%
100%
33%
44%
54%
79%
100%
75%
74%
0%
20%
40%
60%
80%
100%
Medical Staff Nursing Staff Technical
Staff
Ancillary Staff Total
ED Hand Hygiene - October 2012
Entering Room Compliance Exiting Room Compliance
Increased Hand Hygiene
Compliance by 100%
(from baseline)
resulting in
72% of the staff who were
not washing, are now.

14%
69%
100%
33%
44%
54%
79%
100%
75%
74%
0%
20%
40%
60%
80%
100%
Medical Staff Nursing Staff Technical
Staff
Ancillary Staff Total
ED Hand Hygiene - October 2012
Entering Room Compliance Exiting Room Compliance
Increase of Hand Hygiene
Compliance by 25%
(from baseline)
resulting in
44% of the staff who were
not washing, are now.
It takes an engaged team that will maintain a continuous
focus on the importance of the plan, its process, and the
overall goal to successfully implement a project.
Failure will ultimately lead you to success, as it is only
when you re-assess your failure that you are able to
discover your success.
Process improvement plans can take an extreme amount
of time which only solidifies the importance of doing it right
the first time.

Engage others outside
your department to gain
support and varied
perspectives.

Keep communication
flowing with continuous
updates throughout the
committee,
transparency.

Schedule continuous
meetings with the team in
the beginning to help
keep the commitment
and program refreshed.
We are what we
repeatedly do.
Excellence,
then is not an act,
but a habit. - Aristotle
A hero of quality and safety
has to be able both to
discover opportunities for
improvement and to
implement the system
changes necessary for the
improvement. - Joe Swedish