Sustained Improvement of Hand Hygiene Compliance at a Large Community Teaching Hospital using Lean Six Sigma Methodology

Background: Healthcare associated infections (HAI) contribute to adverse outcomes and are a major patient safety issue.  In Canada, an estimated 220,000 HAI result in more than 8,000 deaths annually.  Improving hand hygiene (HH) may decrease the risk of HAI and related costs.  Numerous studies describe interventions to improve HH, but sustained improvement is difficult to achieve. In January 2008, NYGH partnered with 3M Canada to develop a HH compliance program based on Lean Six Sigma methodology.    

Objective: Primary objective: To demonstrate consistent and sustained improvement in HH compliance, as defined by Ontario’s four moments of HH, across all clinical inpatient units (interim target of 80%).
Secondary outcome measures: compliance by HH moment, day/night shift, staff knowledge/awareness, and alcohol-based hand rinse (ABHR) use. 

Methods: Two General Surgery units were selected to pilot and define the interventions.  Process failure points were identified. Six Sigma improvement methodologies were utilized to identify and implement improvement opportunities. A tailored control plan was developed. 
The defined pilot interventions (education module with successful post-test, awareness strategies, appropriate and accessible ABHR placement, a system to replace empty HH product, enhanced accountability, and culture change) were then spread to all inpatient clinical areas using a Vertical Value Stream (a Lean Management approach to project planning).  Tasks and timelines were clearly defined throughout the project phases.

Results:

The pilot units demonstrated improved HH compliance from 19% to 74% within eight weeks of launch. From June 2008 to November 2009 (corporate roll-out phase) over 45,000 HH observations were collected. 20 out of 20 clinical areas surpassed 70% HH compliance by week 8 of unit implementation. HH compliance improved significantly to a hospital-wide mean of 83% (range 74% - 90% by clinical unit) and has been sustained, corporate-wide, above 77% for more than 12 months. A concomitant increase in volumes of alcohol rub usage was observed. HH compliance improvements were present across healthcare worker type, shift (day-evening night), and each of the four moments of HH.

Conclusions:

A year after implementing a corporate-wide Hand Hygiene Program utilizing Lean Six Sigma methodology, rapid and sustained HH compliance improvements have been achieved from a baseline hospital mean of 30%  to a post-implementation mean 83% (range 74% - 90% by unit).