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Novant Health receives 2008 Ernest Amory Codman Award

Hand hygiene program achieved 98% compliance over four-year period

In 2004, Novant Health, a health system based in Winston-Salem, NC, went through a patient safety awakening after a baby contracted MRSA in the neonatal unit and died. The system saw this accident as a chance to take a second look at the hand hygiene program in place and evaluate what more could be done to prevent future MRSA outbreaks.

“With something as simple as hand washing, we were going to aggressively improve this for the betterment of the patients,” says Jim Lederer, MD, medical director for clinical improvement and infection control specialist at Novant Health.

In 2005, Novant Health embarked on a three-year plan to improve the system’s hand hygiene program. The goal was set high, at 90% compliance, which was in line with the Centers for Disease Control and Prevention’s (CDC) hand hygiene guidelines. It seemed to be a big stretch from Novant’s 49% compliance rate.

Past attempts at Novant Health had been unsuccessful and did not catch the attention of staff members. The past campaigns included poster boards with cartoon character bubbles placed throughout Novant Health to inform staff members of the consequences of not washing their hands. “We didn’t know what we could do. I am an infectious disease doctor, and we have had 10 prior attempts for hand hygiene compliance, all of which have never gone anywhere,” says Lederer.

This time around, Lederer and his team decided to take a more dramatic approach to get the attention of Novant Health staff members.

In addition, Novant Health set 90% compliance with hand hygiene techniques as its goal because of The Joint Commission’s (formerly JCAHO) expectation for hand hygiene, which requires adherence with the CDC’s guidelines as a method of preventing healthcare-acquired infections. The new hand hygiene program affected all nine facilities throughout the Novant Health system.

Hand hygiene police

The new hand hygiene program places alcohol-based hand sanitizers outside patient rooms. Employees are urged to use the dispensers as a way to cut down on infection rates.

“According to the CDC hand hygiene criteria, it is expected that every time one enters or leaves a patient’s room, that the hand sanitizer dispenser be used, says Lederer.

But how do facilities manage to keep track of whether staff member have used the dispensers?

Novant Health answered this question by hiring two monitors who travel between the nine facilities, working mainly from Monday through Friday, with the occasional weekend or holiday shift, says Lederer. The monitors rotate between the facilities and observe approximately 2,000–2,500 cases per month. Specifically, the monitors observe individual staff members and document whether they used the sanitizer. By using the monitors, Novant Health is able to generate immediate reports on positive and negative behavior.

“The monitor could come up to you and say, ‘Good job,’ or ‘You probably should have washed your hands,’ ” says Lederer. “That information would go to the staff member’s manager and is then entered into our electronic database.”

The hygiene information is also placed onto a performance card within the database that is accessible to anyone within Novant Health systems.

“The vice president of the facility would be able to see specific instances of good and bad behavior,” says Lederer. “Along with the report, the individual’s picture is also within the database and posted with the report.”

Another way Novant Health grabbed the attention of staff members was by placing posters throughout the system’s facilities. The first poster to begin the campaign was called “You Could Kill Me With Your Bare Hands.” The poster received a lot of attention from staff members and made them realize that their actions can affect their patients’ health.

Above and beyond

As with any new effort introduced within a hospital setting, it takes time for staff members to adjust to what is expected of them.

“Initially, when it was announced what we were doing and why—dealing with patient safety and quality [improvement]—everyone could rally around that idea,” says Lederer.

However, once the monitors started wandering the halls and recording cases, staff members’ reactions showed that their attitudes toward the initiative were not as accepting as they initially seemed.

“We had to send around a memo saying that these monitors were here to help us and were in the facility as educators,” says Lederer.

It took time for staff members to become more accepting of the system’s new hand hygiene program. A general consensus developed that although enforcing the use of monitors was a change from what staff members were used to, the process was for the benefit of the health and safety of patients. Some units within Novant Health began to adjust the program and extended it beyond its original foundation.

“Little by little, some units were developing their own codes and ways to involve the physicians as well. The staff members would learn of the physicians’ favorite snack or drink and would use those as rewards,” says Lederer, in reference to the nurses in the cardiovascular pre- and postoperational unit rewarding physicians for proper hand hygiene compliance.

Beyond rewarding staff members for proper hand hygiene etiquette, staff members began to monitor themselves and collect data regarding their own unit’s compliance rates. For example, if there was an alcohol dispenser that needed to be filled and caused a unit to have poor hygiene rates, staff members would document the problem and try to fix it.

“When we first introduced the hand hygiene program, the Presbyterian Huntersville facility took the program to another level and developed buttons with a campaign slogan, ‘Gel in and Gel out,’ for staff members to wear. It was just a little twist to raise awareness within the facility,” says Lederer.

Helpful hints

“Everything has to be done right in order to be successful,” says Lederer, discussing how other facilities can have great results.

Novant Health used a red light/green light display to give staff members immediate feedback on where the facility stood in terms of reaching its goal of 90% hand hygiene compliance. If the traffic light was red, the compliance rate was less than 90% and not improving. If the traffic light was yellow, the compliance rate was less than 90% but improving, and if the light was green, the compliance rate was above 90%.

“We found this really useful because it was so easy to understand and get information out that everyone was going for green,” says Lederer.

And the winner is …

With such wide acceptance of the program, Novant Health submitted an application to be considered for the 2008 Ernest Amory Codman Award Program Multiple Organization category for the facility’s hand hygiene compliance program.

“In order to be considered for this award, you have to have substantial data, and not just one term, but months and months of data,” says Lederer. “It is a great feeling to win such an award.”

Lederer credits leadership, pulling together as a team, the aggressive education marketing communication plan, and direct observation and feedback for Novant Health’s successful hand hygiene program.

“The key component is ingenuity and individual departments to take hold of themselves,” says Lederer. “With the right program, a little facility can be just as successful as a large one.”

Editor’s note: Visit to view some of the materials Novant Health developed as part of its award-winning hand hygiene campaign.