The MGH Hand Hygiene Program

“90/90” and Beyond

Presented by Judy Tarselli, RN and Dolores D, Suslak, MSN, CIC

Infection Control Unit Massachusetts General Hospital

for the Massachusetts Coalition for the Prevention of Medical Errors

15th Anniversary Celebration

Hand hygiene compliance vs. healthcare-associated MRSA (2002-2012)

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Before contact rates After contact rates MRSA Rate

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HA-MRSA rate: A new record low!

Posters &

PublicityCompliance surveysChampions

Feedback

Leadership involvement

Goals

Product availability

Expansion & Outreach

Education

Patient & Visitor involvement

STOP Task ForceMGH Hand Hygiene Program

Rewards

“The Last 10%”

Cultural change

“Cultural Change” (defined)

“To make hand hygiene a habit so strong

it is done without thinking…

And an expectation so strong that failure to

use it is easily noticed

and worthy of intervention.”

Cultural change

Key lessons and ongoing effortsKeep it positive! Have fun, celebrate progress, focus on facts… Not faults.

Use a multidisciplinary effort: A multifaceted, team approach works best.

Set solid but attainable goals: Short term goals, long term expectations.

Get others involved: Seek input, share the efforts and the credits!• Leaders and Champions• Professionals and Non-professionals

Identify barriers and work to overcome them• Listen to complaints, concerns, and questions – and respond• Define, categorize and quantify noncompliance – and target it

Address the persistent failures – and link them to common goals• “The Last Ten Percent”• Patient Safety

Encourage growth and lasting success• Reach out, assist, and adapt the program for others• Look for successes (even small) and celebrate them!• Support related efforts: Become allies!• Seek a cultural change*

* New: The cultural change needed for lasting success must extend beyond the walls of MGH.

What’s next?

Celebrate the past: 10th Anniversary of the rollout of the MGH HH Program in 2014Prepare for the future: Attract new people, new ideas

Continue working: MGH has an ever-changing population!Expand the effort: Add Ambulatory Care Centers; other surveillance methodsSupport related projects: “Excellence Every Day” requires a mutual effort

Reach out: Encourage improvement efforts at other hospitals and schools.Lasting success depends on a cultural change that extends beyond MGH.

There is no end… Only new beginnings.

To achieve excellence… Look around, speak up, and expect it every day.