Hand hygiene CQI strategies

May 28, 2015

by Dr. BH Manlapat presented

during the 21st PHICS Annual

Convention, 27-28 May 2015

REGULATORY MANDATE

DEPARTMENT OF HEALTH

AO 2006-0002Establishment of the Continuous Quality

Improvement (CQI) Program

and Committee in DOH Hospitals

PHILIPPINE HEALTH INSURANCE

CORPORATION

The Philhealth Benchbook

by Dr. BH Manlapat presented during the 21st PHICS Annual


DEPARTMENT OF HEALTH

ADMINISTRATIVE ORDER 2006-

0002Establishment of the Continuous Quality

Improvement (CQI) Program

and Committee in DOH Hospitals




Congruent with the requirements of hospital licensure and the intent of Department

Order Nos. 310-J s. 2001 and 172-C s. 2003 on “The Creation of the DOH Steering

Committee and Technical Working Group for the Establishment of CQI Program for the

Health Regulation Cluster and DOH Hospitals” and its amendment respectively, to

consistently deliver and continuously improve the quality of health care to our people,

there is a need to institutionalize and establish the Continuing Quality Improvement.

ADMINISTRATIVE ORDER

No.2006-0002by Dr. BH Manlapat presented



PHILHEALTH BENCHBOOK

RA 7875 Section 1 National Health

Insurance Act of 1995

Section 2 Guiding Principles

IRR Title V Section 50 – Accreditation and

Quality Assurance of the NHIPby Dr. BH Manlapat presented



Continuous Quality Improvement in the Hospital




In view of this, starting January 1, 2007, Philhealth shall require all

hospitals applying for accreditation, to have a Continuous Quality

Improvement (CQI) Program as described in Part III of the Philhealth

Benchbook. Likewise, accredited government hospitals are advised to

refer to DOH Administrative Order No. 2006-0002 for additional guidance.

PHILHEALTH CIRCULAR

No. 12 S-2006




SOURCE: PHIC Benchbook, 2004




PROBLEM SOLVING METHODOLOGY

PROBLEM IDENTIFICATION & PROBLEM PRIORITIZATION

UNDERSTANDING THE PRESENT SYSTEM

ANALYSIS of the ROOT CAUSES

SELECTION OF BEST ALTERNATIVE SOLUTIONS

PROJECT PRESENTATION

SOLUTION IMPLEMENTATION

Project Evaluation

STANDARDIZATION

SELF-EVALUATION & FUTURE PLANNING

Plan

Do

Check

Action

Quality Circle Practitioners Association of the Phils.







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Problem Identification and

Problem Identification

• Statement of the Problem

• Hand hygiene compliance in Manila Doctors Hospital in 2012 was at 60%. In 2013, however, compliance decreased to almost 50%. This prompted the Infection Prevention and Control Office to implement strategies that could increase hand hygiene compliance to 70%.




Intervention

• Using the Pareto Principle, the 3 areas

that assessed as key areas needed to

addressed are:

• Damaged Skin,

• No role models on Hand Hygiene

• Visual Reminders.

•by Dr. BH Manlapat presented



Best Alternative Solution• Implementation of link nurses system

which will monitor and encourage healthcare workers to be compliant.

• Handrub tolerability testing survey was done to address irritation issues.

• Visual reminders were also placed.

• The lack of hand hygiene facilities was also addressed by instillation of more hand rubs. by Dr. BH Manlapat presented



Evaluation of Results

• The Office required all units to have an

assigned Infection Control Link Nurse

which serves as our monitor/role model/

buddy system to monitor healthcare

workers to do hand hygiene. This was

started in August 2014.





• A pilot area was selected wherein the link

nurses was empowered and trained to be

a Hand Hygiene Advocate. Her role is to

monitor compliance, encourage other

nurses / residents to call any healthcare

personnel that do not comply.





• Within the 6-month period, hand hygiene

compliance in the ICU has increased for

healthcare workers from 20% to 77%.

Furthermore, healthcare associated

infection rate (HAI) decreased from 16% in

January 2013 to 8% in December 2014.




Results of Pilot Study

Post-intervention

Pre-Intervention

Aug - Sep 2014

Oct - Dec 2014

HH Compliance 20% 60% 77%




Radar Chart




Conclusions

• Improvement can be achieved through a

multimodal interdisciplinary approach

which involves appropriate facilities for

proper hand hygiene, monitoring and

feedback of hand hygiene compliance and

promoting an institutional culture of patient

safety.by Dr. BH Manlapat presented



Intervention







HAND%20HYGIENE%20FORM.jpg

HAND%20HYGIENE%20FORM.jpg

Link Nurses Trainingby Dr. BH Manlapat presented



2014 Compliance rate per moment

M1 C 29/142 18%

NC 113

M2 C 22/5 39%

NC 34

M3 C 23/37 62%

NC 14

M4 C 36/112 32%

NC 76

M5 C 23/101 23%

NC 78

Total Compliance 133/448

30% Overall compliance Rate on hand hygiene




Monitoring and

Evaluation




5 Components of the WHO multimodal hand

hygiene improvement strategy




The step wise approach

Facility

PreparednessBaseline evaluation Implementation

Follow-up

Evaluation

Review and

Planning




References:• As part of their ongoing commitment to reduce

HCAI, WHO Patient Safety has developed this

revised Guide to Implementation and a series

of tools to support health-care workers in

establishing and sustaining good hand hygiene

practices by health-care workers and reducing

HCAI at health-care facilities worldwide. This is

part of the long-term SAVE LIVES: Clean Your

Hands initiative.




Required Organizational Practices

(ROPs)

• are evidence-based practices addressing

high-priority areas that are central to

quality and safety.

• Accreditation Canada International defines

an ROP as an essential practice that client

organizations must have in place to

enhance patient/client safety and minimize

risk.




Thank you




Hand hygiene CQI strategies

Healthcare

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