Across CMHA Sudbury/Manitoulin sites, staff aren’t consistently and frequently completing self-audits, so we aren’t able to accurately measure compliance with 4 moments of hand hygiene which is putting staff and individuals at possible risk of illness.
To increase hand hygiene self-audit completion rates from 50 percent to 90 percent by November 30, 2017.
EQIP Support to the Project:
- QI coach: Laura Daly-Trottier
- Data Coach: Alexandra Clement
Proper hand hygiene is one of the most effective ways to reduce the spread of illness. At Canadian Mental Health Association Sudbury/Manitoulin, they recognized that there was an inconsistent approach to hand hygiene across their sites, and they weren’t able to measure compliance because self-audits weren’t completed consistently.
They used run charts to look at the cold and flu rates among staff by quarter, and to look at compliance rates with the four moments of hand hygiene. They dug deeper into the challenge by using the Fishbone exercise to identify the root causes. They also used a Pareto Chart to explore the question, “How can we improve the hand hygiene process to be sure that all staff are participating in the self-audit and that we are monitoring the practice of healthy hand hygiene practices every day of the year?”
Through these tools, a number of key root causes became clear, including the fact that hand hygiene compliance messaging was tied to accreditation, and not to staff health and safety. The self-audits were done infrequently, using a paper-based tool that was not user-friendly. To add to the inconsistency, staff didn’t see the value in completing the self-audits. Finally, being across four sites adds to the inconsistencies in approach – and there are no hand hygiene site champions.
The team agreed to start by creating an online self-audit hand hygiene tool, which is being tested through a PDSA – Plan, Do, Study, Act – cycle.
Hand hygiene compliance is a common challenge in many organizations. The learnings from this project can inform and inspire others to tackle this issue as well.