SLIDE 1
1
2
Objectives
- Outlining hand hygiene requirements and
methodology at Fraser Health
- Provincial partnership for hand hygiene
- Understanding audit data
- Achieving improvement
Hand hygiene: who owns it? Jacquie Hlagi Hilary Espezel 1 - - PowerPoint PPT Presentation
Hand hygiene: who owns it? Jacquie Hlagi Hilary Espezel 1 - - PowerPoint PPT Presentation
Hand hygiene: who owns it? Jacquie Hlagi Hilary Espezel 1 Objectives Outlining hand hygiene requirements and methodology at Fraser Health Provincial partnership for hand hygiene Understanding audit data Achieving improvement 2
SLIDE 2
SLIDE 3
3
Fraser Health
- What we did for hand hygiene
- Education
- Auditing requirements
- Reports
SLIDE 4
4
What we did for hand hygiene
- Participated in the Provincial Hand Hygiene
Working group
– Subcommittees
- Education
- Data entry
– FormAudit purchased 2012 » Fax forms rather than manual data entry
SLIDE 5
5
FH Audit tool
SLIDE 6
6
FH Category codes
1 NP/RN/RPN 2 LPN 3 Care Aide
- Health Care Assistant
- Student aide
- Rehab worker
- unit clerk
- stocking aide
- PCA
- Emergency Room Aid
4 Physician 5 Student (all except Dr’s) 6 Medical Student/ Resident 7 Medical Technician
- SPD Tech
- cardio tech
- dental hygienist
- Dialysis Tech
- Perfusionist
- Medical Imaging tech
- Dental assistant
8 Respiratory Therapy 9 Lab Personnel 10 Porter/ Security 11 Housekeeping 12 Maintenance 13 Social Worker 14 Rehab Therapy
- PT
- OT
- SLP
- Recreation
Therapist
- Rehab assistant
- Physio
- Speech
therapist
- Audiology
15 Dietician 16 Volunteer 17 Food Services 18 Pharmacist
SLIDE 7
7
Provincial category codes
Nurse
NP/RN/RPN, LPN, Care Aide/Student Aide, Student (Nursing)
Physician
Physician, Medical Student/Resident
Clinical
Medical Technician, Respiratory Therapy, Lab Personnel, Porter, Social Worker, Rehab Therapy, Dietician, Pharmacist
Other
Housekeeping, Maintenance, Volunteer, Food Services
SLIDE 8
8
Education requirements
- Mandatory annual education (CCRS) for all
staff (Policy)
- Auditors
– Self learning
- User manual
- Policy/CPG
- video
– Certification of auditors
SLIDE 9
9
FH Audit requirements
Frequency
- Hand Hygiene audits are required to be performed per fiscal
period Requirements
- A complete audit requires a minimum of 25 observations and
a minimum of 5 Health Care Providers (HCPs) documented on
- ne Hand Hygiene audit form.
SLIDE 10
10
Reports
- 1. Overall Compliance
- 2. Dashboard - Site Level
- 3. Dashboard - Program Level
- 4. Dashboard - Fraser Health Acute
- 5. By Facility for Selected Programs
- 6. Compliance and Observations Trend by Facility, Program, Unit
- 7. By Program for Selected Facilities
- 8. By HCP Group and HCP
- 9. By Opportunity
- 10. Completed Audits Detail
- 11. Fiscal Period Unit Report – for Quality Boards
- 12. Fiscal Period HCP Report – for Quality Boards
SLIDE 11
11
By HC group by HC provider
SLIDE 12
Improvement
SLIDE 13
13
Improvement
- Information before Expectation
- Engaging before Mobilizing
- Beliefs before Behaviors
- Culture Change before Strategy
SLIDE 14
14
Information before Expectation
SLIDE 15
15
Information before Expectation
- Reasons for low hand hygiene
performance:
– Different interpretations of when HH is required – Environmental barriers
- Positive deviance
SLIDE 16
16
Engaging before Mobilizing
SLIDE 17
17
Engaging before Mobilizing
- Leaders first
- Understand the link between actions and
improvement
- Address barriers
SLIDE 18
18
Beliefs before Behaviors
SLIDE 19
19
Beliefs before Behaviors
- Perceived relevance to practice
- Perceived personal risk
- Burden of responsibility
- Perceived shared ownership
SLIDE 20
20
Culture Change before Strategy
SLIDE 21
21
Culture Change before Strategy
Culture of patient safety:
- Errors are inevitable
- Reliance on vigilance and perfection will fail
- All working in our culture feel safe to raise issues and
suggest solutions
Sustaining improvement:
- Changes embedded into usual practices
- Discipline-specific champions
- Meaningful and timely feedback
SLIDE 22
22