Hand hygiene TST helps hospitals reduce HAI rates

In the January issue of The Joint Commission Journal on Quality and Patient Safety (JQPS), M. Michael Shabot, MD, FACS, FCCM, FACMI, system chief medical officer, Memorial Hermann Health System (MHHS), Houston, TX, and Mark R. Chassin, MD, MPP, MPH, president and chief executive officer, The Joint Commission, describe how MHHS used the Joint Commission Center for Transforming Healthcare’s Targeted Solutions Tool (TST) to improve hand hygiene compliance. This initiative resulted in sustained reductions in health care-associated infections (HAIs).*

The TST is an application that guides health care institutions through a step-by-step process to accurately measure performance, identify barriers, and identify proven solutions that are customized to address specific roadblocks to high reliability.

MHHS project

MHHS comprises 12 hospitals, 200 ambulatory care centers, 24,000 staff members, and 5,000 physicians. According to the article, in 2006 MHHS started down the road to becoming a high reliability organization (HRO)—defined as an organization that, despite the potential for high risk given the type of procedures performed at these facilities, maintains high levels of quality and safety over long periods of time with few adverse events. The overall goal is to achieve zero harm for patients. In 2007, MHHS started Robust Process Improvement projects to reduce HAI rates, specifically improving compliance with hand hygiene standards.

MHHS and seven other health care institutions voluntarily participated in the Joint Commission Center for Transforming Healthcare’s inaugural TST pilot test in 2009 on the hand hygiene issue. Together, the organizations identified effective and reliable methods to record hand hygiene compliance data, find root causes for noncompliance, and determine solutions to address those issues. Following this pilot, the participating institutions and the center created the TST.

Four MHHS hospitals participated in various stages of that initial project—all of which achieved significant improvement in hand hygiene compliance in the process. MHHS’ The Woodlands Hospital, for example, increased compliance from 27 percent to 80 percent in the test phase.

After seeing the results from the initial project, MHHS implemented the TST in all 12 of its hospitals—approximately 3,225 total beds—in September 2010. According to the JQPS article, MHHS implemented the TST in 150 inpatient units from October 2010 through December 2014. Based on 31,600 observations, the results were as follows:

  • From October 2010 through May 2011, the hand hygiene compliance baseline rate averaged 58.1 percent.
  • In the improvement phase—June 2011 through November 2012—compliance averaged 84.4 percent.
  • In the first 13 months of the control phase—spread out from December 2012 through December 2014—compliance averaged 94.7 percent. In the final 12 months, compliance averaged 95.6 percent.

Drs. Shabot and Chassin concluded that MHHS “substantially improved hand hygiene compliance,” and the health system was able to sustain those results for 25 months after implementation.* In addition, adult intensive care unit rates of central line-associated bloodstream infections and ventilator-associated pneumonia decreased by 49 percent and 45 percent, respectively.

Other TST projects

The TST to improve hand hygiene compliance projects have varied in duration from six to 12 weeks. A team of three to seven people is recommended for the project, and support from management is necessary for its successful implementation. The project team may need to spend approximately four hours a week collecting and inputting compliance data, attending meetings, or implementing solutions.

The TST project, if carried out properly, will improve and sustain an institution’s hand hygiene compliance, as well as reduce health care-associated infections. To learn more about the TST, visit the Joint Commission Center for Transforming Healthcare website.


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

*Shabot MM, Chassin MR, France AC, et al. Using the Targeted Solutions Tool to improve hand hygiene compliance is associated with decreased health care-associated infections. The Joint Commission Journal on Quality and Patient Safety. 2016;42(1):6-16. Available at: www.jointcommission.org/assets/1/18/JQPS0116_01_Shabot.pdf. Accessed February 26, 2016.

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