Fixes looks at solutions to social problems and why they work.
Why can’t hospitals get health care workers to wash their hands?


The New York Times, April 26, 2011, by Tina Rosenberg  —  Hospitals in the United States enjoy access to running water. Virtually all of them have alcohol-rub dispensers, hundreds of them, in the hallways. Using one takes a few seconds. Yet health care workers fail to wash hands a good percentage of the times they should. Doctors are particularly bad.

A health care worker’s hands are the main route infections take to move from one patient to another. One recent study of several intensive care units — where the patients most vulnerable to infection reside — showed that hands were washed on only one quarter of the necessary occasions.

It’s not that hospitals are ignoring the problem — indeed, they are implementing all kinds of strategies to promote hand-washing. Nevertheless, it is rare to find a hospital that has been able to keep the hand-washing rate above 50 percent.

Readers of Fixes know our skepticism about relying on things that beep in health care. In general, the American health care system depends too much on technology and not enough on human connection. But in the case of hand-washing, the opposite may be true. Improving hand-washing rates is not simple – if it were, we wouldn’t have a problem. It requires many steps that take into account human foibles. But for measuring compliance — one of the most important and difficult steps — we may have been relying too much on people to do a machine’s job. There is a new technological fix available that — when accompanied by other changes — may be key to reducing dangerous infections.

Why is this even a problem at all? There cannot be a single trained health care worker, anywhere in the world, who is unaware of the importance of hand-washing. Yet 2 million patients in America acquire an infection in the hospital every year — about one in 20 patients — and 100,000 people die of them. This is the fourth leading cause of death in America. Few families don’t have some horror story that started with a hospital-acquired infection. And hand-washing rates in other wealthy countries are not much different.

Hospital-acquired infections cost the American health care system between $30 and $40 billion annually. Simple division puts the rough average cost of treating of a hospital-acquired infection at $15,000 to $20,000. One study that gathered data from other studies found the average cost of treating an infection with MRSA, a staph bacteria resistant to many antibiotics, is $47,000.

There are several reasons, however, that hospital hand-washing rates may be about to improve. One reason is that hospitals have a strong financial incentive to reduce infections. In 2008, hospitals were told that Medicare would no longer reimburse them for the cost of treating preventable hospital-acquired conditions it calls “never events,” which includes many kinds of hospital-acquired infections. The new health care reform bill instructs states to do the same with Medicaid. Many insurance companies also now refuse to pay for never events. This tends to concentrate the minds of hospital executives.

Another powerful incentive to prevent infection is the rise of superbugs, like MRSA, that are increasingly resistant to our arsenal of antibiotics. Infections are getting more and more deadly. No one is more aware of this than the people most in contact with these bugs. Hand-washing is not only protective for patients.

Patients are also more knowledgeable about hospital infections and more empowered. Hospitals are increasingly required to report their incidence of hospital-acquired infections, and those results will be posted online. Patients can use this information to help them choose a hospital.

Many people have studied why hand-washing rates are so dismal. On Friday I will write about the reasons, and what has helped — although not enough — to fix the problems. The most important reason is probably that health care workers are so busy; stressed-out people with too much to do often forget to wash their hands, or it just gets skipped.

Using alcohol rub takes only a few seconds, but many nurses should be doing this dozens of times a day — in some intensive care wards, 100 times a day for each patient.

It will be very difficult to improve compliance unless hospitals can tell who is and isn’t cleaning hands, and in what circumstances. Individual doctors and nurses need to know their own hand-washing rates.

“Data really helps us work backwards,” said Katherine Ellingson, an epidemiologist at the Centers for Disease Control in the Division of Healthcare Quality Promotion. “If hospitals can identify wards that have problems or wards that are doing very well, they can learn where the gaps are or how people have found a way to get adherence up. And when people have data, they pay attention. The CEO may pay attention. The health workers themselves will pay attention if you provide data on their performance.”

Until now, hospitals have had two ways to measure hand-washing. One is by monitoring how often each soap or alcohol gel dispenser needs to be refilled. By tracking how much product a unit uses, you can get a rough idea of how much hand-washing is going on. The limits here are obvious: there is no way to tell who is washing hands and when.

The method currently considered the gold standard is using human observers: nurses or other health care workers who roam halls and patient rooms with a clipboard, recording who does and doesn’t wash hands. Sometimes they’re like secret shoppers and sometimes they’re announced.

This system, too, is woeful. Spending health care workers’ time in observing is expensive. And they can monitor only a small sample of health care workers. A recent study at the University of Iowa to test whether observers should stand still or move around found that moving more was better, but the real news was this: “All observation schedules capture at best 3.5% and at worst 1.2% of all daily opportunities” for handwashing.

When the monitors are announced, it’s bound to inflate compliance, in part because their presence reminds workers to wash hands. Their data may be entered into a computer and analyzed only weeks or months later. It isn’t enough. Hospitals need accurate information about who is and isn’t washing hands, and they need to be able to remind people to do so in real time.

Enter technology. In the last year or two, several new ways to promote hand-washing – all things that beep – have made their debut: HyGreen, BioVigil, Patient Care Technology System’s Amelior 360 and Proventix’s nGage are some of them, but there are others. Some are spinoffs of systems widely used to track hospital equipment (this is how hospitals can find a wheelchair when it is needed). All employ new technology that can detect alcohol — which in hospitals is a component not only of rubbing gel but also soap.

They work like this: every health care worker wears an electronic badge. When she washes her hands or uses alcohol rub, a sensor at the sink or dispenser or her own badge smells the alcohol and registers that she has washed her hands. Another sensor near the patient detects when her badge enters a room or the perimeter around a patient that the hospital sets. If that badge shows that her hands were recently washed, it displays a green light or something else the patient can see. If she hasn’t washed, her hands, the badge says so and emits a signal to remind her to do so. The sensor also sends this information to a central data base. Information about the hand-washing practices of a particular unit, shift or individual is instantly available.

Do they work? It is early yet — these systems are largely in the pilot phase or in use in only a handful of hospitals. But several different studies have shown that they greatly improve hand-washing compliance. There is some evidence that the systems are associated with a drop in infections. Proventix claims its nGage system saw a 22 percent drop in infection in the units where it was used in a seven-month trial, while elsewhere in the hospital the drop during that time was only 4 percent.

Miami Children’s Hospital said that during the time it used the HyGreen system in its oncology unit, the unit had a whopping 89 percent drop in infections. Deise Granado-Villar, chief medical officer, said that the gains have been maintained eight months later. These studies should be read cautiously; they are very small – Granado-Villar would not say how many infections were being counted – and not peer–reviewed.

The drawback to these systems is that they are much more expensive than other measures hospitals have tried. This is the “hand hygiene-industrial complex,” as Philip Polgreen, an infectious-disease specialist at the University of Iowa Carver College of Medicine, calls it. These systems are brand new and their price is likely to drop substantially, but right now they are expensive — Amelior, for example, costs $1,500 to $2,000 per hospital bed to install. Most offer hospitals the option to buy a system or lease it.

Hospital-acquired infections are so expensive, however, that a system that proves effective will pay for itself in the first year. “It paid for itself with the avoidance of one infection,” Granado-Villar said of the HyGreen system. “It cost $50,000 to implement, which can be the cost of one infection today.” An article in the journal Infection Control and Hospital Epidemiology found that if a hospital improved hand-washing rates by 5 percent, it would save $1,000 per bed each year in averted MRSA infections alone – and MRSA infections make up only 8 percent of all hospital-acquired infections.

More From Fixes

The technological approach is expensive enough that hospitals struggling with raising hand-washing rates will likely first want to make sure they are getting other things right — creating a culture of accountability, redesigning hand hygiene systems to make hand-washing easy and automatic, and other strategies. These improvements are necessary whether or not hospitals add the technological piece. “I come back to: what do you pair it with?” said Lisa McGiffert, campaign director for Consumer Union’s Safe Patient Project. “When you implement something like this technology you also have to do some culture change.”

On Friday, I’ll look at how some hospitals are changing hand-washing culture, and what we can learn from an absurdly simple idea that has already brought a deadly type of hospital infection down to near zero in Michigan.


Readers’ Comments

Peter Mojica
Charlotte, NC
April 26th, 2011
7:34 am

Tina, this is a great article. Shedding light on hand-hygiene compliance and the pros and cons to various solutions is becoming a life-saving effort. What I would add to the conversation is that when it comes to health and safety it is NOT a new phenomenon, that the overwhelming majority of people (clinicians as well as patients) actually reject things that make them safe. It sort of defies common sense, especially in matters of life and death. But, as you stated – if everyone washed their hands we would not be having this dialog – and HAI’s would not be the 4th leading cause of death in America. Do you know that many patients will not utter these simple words – “excuse me, Dr. Smith but you didn’t wash your hands” due to fear of alienating the care giver. And Nurse Jones may avoid hand-washing because it’s too time consuming or may cause dry skin. There is a practical and logical science to understanding the behaviors associated with these risk factors that cause people to reject things that make them safe. I see it as part of my role to as the CTO of one of the companies you mentioned to understand the social behavior of how to overcome what people inherently fear – so that the patient has no longer fears or better yet ever needs to utter those simple words to his or her Doctor and creating an environment where ‘doing the right thing’ – or being “compliant” is part of the fabric of each and every health-care worker, and weaves its way up and down the entire organization is much more than producing medical devices or software. Compliance for hand-washing should not be measured or counted by Secret Shoppers, Watchers, or even systems. The true measure of compliance is what the health-care worker does when no one is looking.
Peter Mojica
CTO/CIO bioVIGIL Systems




Westerner in NYC

New York, NY

April 26th, 2011

7:35 am

Nurses and other hospital workers are not the only ones broadcasting MRSA and other infections.

A frequent visitor to our elderly friend hospitalized with MRSA and other infections balked at being gowned-and-gloved. He refused to don the gown and gloves. The nursing staff alerted the hospital’s Infectious Disease Officer who rushed down to the patient’s room to instruct the visitor on what he should be doing. That didn’t work. After holding our elderly, MRSA-infected friend’s hand, the gentleman visitor would often reach into his back pocket with the same gloved hand that had touched the patient, pull out his cloth handkerchief, blow his nose on it and then replace the soiled–and probably MRSA-coated handkerchief–back into his pocket. Other visitors to the same patient just refused to don gowns and gloves–even when it was explained to them that it was for their safety.

Another problem is scrubs and white coats worn by medical personnel, nursing staff and other hospital workers, especially the cleaners. They wear their “scrubs” and other uniforms around infected patients in the hospital and then leave the hospital often getting onto crowded buses and trains. Doesn’t this spread infections? I know healthcare workers are exhausted after long days and double shifts, but wearing clothing and shoes that have been exposed to blood, bodily fluids, infections and MRSA is dangerous to the public.





April 26th, 2011

7:35 am

Patients and their family members should remind doctors and other caregivers to wash their hands. More people should be cared for at home, rather than going into a hospital. Patients should not have to wait in waiting rooms to see doctors. They should wait outside in their cars, and be fetched with a cell-phone call.





April 26th, 2011

7:35 am

I was, very recently, a patient at NYC Memorial Sloan Kettering Cancer Centers’ Surgical Day Hospital. I was extremely pleased to see everyone involved in my care, pre and post treatment, washed their hands or used an alcohol rub before they touched me. One nurse was in and out of my room, but washed every time she came back in. Every treatment area had hand sinks, and bedside sanitizing dispensers, facilitating frequent use.

Using the Six Sigma Process to Implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 Intensive Care Units



Noel E Eldridge, MS,1 Susan S Woods, BS, MBA,2 Robert S Bonello, MD,3 Kay Clutter, RN, BSN, MBA,3 LeAnn Ellingson, BSN, RN, CIC,3 Mary Ann Harris, RN, BSN, CIC,4 Barbara K Livingston, RN, BSN, MPH, CIC,5 James P Bagian, MD, PE,1 Linda H Danko, RN, MSN,6 Edward J Dunn, MD, MPH, MBA, MPA,1 Renee L Parlier, BSN, MPA,7 Cheryl Pederson, RN, BA,2 Kim J Reichling, MBA,8 Gary A Roselle, MD,6 and Steven M Wright, PhD9

1Department of Veterans Affairs, Veterans Health Administration, National Center for Patient Safety, Washington, DC, USA






The Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health Care Settings was issued in 2002. In 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established complying with the CDC Guideline as a National Patient Safety Goal for 2004. This goal has been maintained through 2006. The CDC’s emphasis on the use of alcohol-based hand rubs (ABHRs) rather than soap and water was an opportunity to improve compliance, but the Guideline contained over 40 specific recommendations to implement.


To use the Six Sigma process to examine hand hygiene practices and increase compliance with the CDC hand hygiene recommendations required by JCAHO.


Six Sigma Project with pre-post design.


Physicians, nurses, and other staff working in 4 intensive care units at 3 hospitals.


Observed compliance with 10 required hand hygiene practices, mass of ABHR used per month per 100 patient-days, and staff attitudes and perceptions regarding hand hygiene reported by questionnaire.


Observed compliance increased from 47% to 80%, based on over 4,000 total observations. The mass of ABHR used per 100 patient-days in 3 intensive care units (ICUs) increased by 97%, 94%, and 70%; increases were sustained for 9 months. Self-reported compliance using the questionnaire did not change. Staff reported increased use of ABHR and increased satisfaction with hand hygiene practices and products.


The Six Sigma process was effective for organizing the knowledge, opinions, and actions of a group of professionals to implement the CDC’s evidence-based hand hygiene practices in 4 ICUs. Several tools were developed for widespread use.

Keywords: hand hygiene, alcohol-based hand rub, JCAHO National Patient Safety Goals, Six Sigma, intensive care units


Hand decontamination has been shown to reduce the spread of infectious agents for more than 150 years.1 The Institute of Medicine has identified nosocomial infections as the most common complication for hospital inpatients,2 and hands are the most common mode of transmission for many important nosocomial pathogens such as methicillin-resistant Staphylococcus aureus (MRSA).3,4 The 1991 Harvard Practice Study on adverse events in health care5 indicated that surgical site infections were the second most frequent type of adverse event for inpatients, constituting 13% of adverse events. This study did not include other hospital-acquired infections such as urinary tract infections or central line infections. A subsequent study by the Centers for Disease Control and Prevention (CDC) of 1992 to 1996 data6 indicated that surgical site infections constituted only 17% of all hospital-acquired infections. This suggests that only 1 in 6 hospital-acquired infections were counted in the Harvard Practice Study, and that hospital-acquired infections are almost certainly the most frequent adverse event for inpatients.

In 2002, the CDC issued a new Guideline for Hand Hygiene in Health Care Settings,7 which elucidated many points related to hospital-acquired infection. The 2 most basic findings were: (1) the hands of health care workers are regularly contaminated with pathogenic microorganisms; and (2) the hands of health care workers are a major route of transmission of pathogens throughout the hospital environment and from the body of one patient to another. These findings were already well known, but the primary recommendation was new: alcohol-based hand rub (ABHR) should be used for “routinely decontaminating hands.” The 2002 CDC Guideline noted that ABHRs are faster and easier to use than soap and water, more effective at killing most microorganisms, and are less likely to cause dermatitis. Recent studies have shown that use of ABHRs results in fewer infections. Using products other than soap is not new; the original hand decontamination process established by Semmelweis in the 1850s used a decontaminating rinse with chlorinated lime rather than soap.


In total, the 2002 CDC Guideline provided over 40 recommendations, with 4 categories for the level of evidence and for 8 different aspects of practice. In 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) added “comply with current CDC hand hygiene guidelines” to its list of National Patient Safety Goals for 2004. Although this goal was clear, how to achieve it in hospitals was not.

In 2003, the 3M Company approached the Department of Veterans Affairs (VA) and Veterans Health Administration (VHA) about conducting a joint project using the Six Sigma methodology. After discussions, VHA and 3M signed a memorandum of agreement to work together to develop methods to comply with JCAHO’s required hand hygiene practices. We report on the implementation and results of this agreement.



The lead representative for VA was the National Center for Patient Safety. The first challenge was to understand which of the over 40 CDC recommendations were required by JCAHO. Discussions revealed that JCAHO would require CDC Category IA, IB, and IC recommendations, and VA staff composed a 1-page summary of the required CDC recommendations.  It contains 19 consolidated recommendations on 4 topics and was used to simplify the CDC Guideline, and specify what to address using the Six Sigma process.


The Six Sigma process focuses on identifying critical points where changes should be made, making those changes, and ensuring that the changes are established as permanent practice.12,13 The version of the Six Sigma process developed and implemented by 3M has 5 steps, Define, Measure, Analyze, Improve, and Control, which are referred to as the acronym DMAIC.

In the Define step, a “project charter” is developed that explicitly defines the problem or opportunity using a standard 1-page format that is agreed upon by all participants. This ensures that everyone understands what is to be addressed.

The Measure step includes development of a “process map” that describes the way that things currently occur, a “cause and effect matrix” linking actions and missed actions to good and bad outcomes, and quantitative measurement of the baseline performance parameter(s) to develop the “initial capability,” i.e., initial performance level(s).

In the Analyze step, “Failure Modes and Effects Analysis (FMEA)” is performed, and the data collected previously in the Measure step is analyzed using appropriate statistical methods (“multi-vari studies”) to determine/confirm sources of variation and opportunities to improve.

The Improve step involves adjusting processes and implementing improvements that address, fix, and/or prevent problems. After implementation of the improvements, data are collected again and the improvements may be refined.

The final Control step (1) codifies the improvements into a “Control Plan” that describes the interventions, who is responsible for each, and how and when they will be monitored and/or measured; and (2) sustains the gains by assuring continued adherence to the Control Plan to maintain improved performance and results. The points of the Control Plan, translated out of the Six Sigma format and into a checklist format, are seen in the list of interventions  more detailed version in the Appendix, and online at VA web site).

The Six Sigma process was used to organize and focus efforts to implement JCAHO’s hand hygiene goal in 4 intensive care units (ICUs) at 3 VA medical centers. These ICUs are coded as Medical ICU-1 (MICU-1), Surgical ICU-1 (SICU-1), ICU-2, and ICU-3. MICU-1 and SICU-1 are in a Midwestern city, in a large hospital affiliated with a university medical school; MICU-1 is a “closed” ICU staffed by full-time intensivist physicians. Surgical ICU-1, ICU-2, and ICU-3 are “open” ICUs not staffed by full-time intensivists. Intensive care unit-2 is in a Southern city, in a small hospital not affiliated with a medical school. Intensive care unit-3 is in a Midwestern city, in a medium-sized hospital affiliated with a medical school.

3M provided Six Sigma training to VA staff, and assigned 2 team members and a program manager (a “Six Sigma Black Belt”) to the project. Weekly teleconferences with representatives from the hospitals, 3M, and VA Central Office took place over a 6-month period. Control charts were used to track the monthly grams of ABHR used per 100 patient-days, providing monthly performance data and reducing reliance on observation data, which are time consuming to collect, inherently intermittent, and have more potential for unintentional bias.

To track the mass of ABHR used, the number of containers of ABHR replaced at each ICU was recorded monthly by staff responsible for this duty as part of the project. This was challenging because it required scrupulous measurement of something not previously controlled, monitored, or measured. Each container held 198 g of ABHR, and ICU staff already recorded monthly patient-days of care provided in each ICU, so grams of ABHR used per 100 patient-days was easy to compute. Working with foam, gel, and liquid products, and based on a combination of information from manufacturers, the CDC Guideline, and empirical tests with the products, it was determined that an appropriate usage quantity of ABHR was approximately 1.4 g. A template for recording and calculating this data is shown in the Appendix.

To collect data on observed hand hygiene practices, a tool was developed to allow observers to record caregiver compliance with 10 required hand hygiene practices (see Appendix). Intensive care unit (ICU) staff used the tool to monitor the practices of their colleagues without notification as to when the observations would take place. A special instruction sheet was developed to accompany the tool and standardize its use. Data were collected over several days at different times by persons who would typically be in the ICU, i.e., ICU staff rather than Infection Control Staff. The observation method and tool allowed the recording of several hand hygiene opportunities during a single patient encounter. The objective was to record at least 400 opportunities per ICU. This sample size was sufficient to show statistically significant changes as small as 10%. Staff professions or titles were noted, but names were not. There were many categories of staff recorded, but these were later recategorized as MD, RN, or “Other.”

A questionnaire was developed to record ICU staff attitudes and perceptions (Appendix). This questionnaire contained a Hand Assessment Scale15 and questions developed during the Six Sigma process. The questionnaire was used before and after interventions. The questionnaires provided insights into staff attitudes as well as data for a Six Sigma “counterbalance.” The idea for a counterbalance is to measure a parameter that might get worse as the desired parameters get better. In this study, staff satisfaction with hand hygiene practices was the counterbalance. We did not want to increase observed compliance, or the use of ABHR, at the cost of making ICU staff dissatisfied. We believed that improvements were unlikely to be sustainable if the ICU staff were unhappy about the improvement mechanisms.


Reviewing hand hygiene processes systematically, it became clear that widespread and easy access to hand hygiene products such as ABHR, antimicrobial soap, and sterile and nonsterile gloves, must be provided before anything else. First, ABHRs must be available at the bedside and/or the entryway to all patient rooms, and antimicrobial soap at all sinks. In discussions, it became clear that health care workers had not established the frequently repeated hand hygiene practices required by JCAHO as part of their routine, and that they did not feel comfortable reminding each other to decontaminate their hands. Also, health care workers did not know the specific recommendations in the CDC Guideline, and many believed that they were practicing hand hygiene at an unrealistically high rate. The latter point has been previously reported. This meant that health care workers did not fully comprehend the need to increase hand hygiene practices. The most challenging improvement identified to improve staff hand hygiene practices was for patients and visitors to remind staff to decontaminate their hands, and for patients and visitors to also decontaminate their hands.

Of note, a major educational effort was not identified as a critical aspect of the intervention by the Six Sigma process. Education-oriented items focused only on updating and reorienting existing educational training materials and providing new posters presenting new information or perspectives.  The posters developed during the project and redesigned subsequently are online at a VA web site. There were no special training sessions, and no exams based on the CDC Guideline. Other educational interventions were relatively simple: a 1-page summary document and updating preexisting Power Point presentations. An 8-minute video on hand hygiene was also provided to each ICU and shown at an ordinary staff meeting.



Results are presented on (1) the mass of ABHR used per 100 patient-days, the observed rate of compliance with hand hygiene practices and (3) the responses to items on the hand hygiene questionnaire before and after the interventions


Each ICU started interventions at a different time and MICU-1 and SICU-1 were tracking the containers of ABHR used per patient-day prior to the project (Fig. 3). Intensive care unit-2 started tracking later. Intensive care unit-3 tracked ABHR use, but partway through the project they discovered that the containers being counted included containers used in areas other than the ICU, so these data were not included in the study. Alcohol-based hand rub use nearly doubled at MICU-1 and SICU-1 (P<.001 for both pre-post comparisons), and increased by 70% at ICU-2 over the period of the study. Data on observed hand hygiene practices are based on the overall percent “yes” responses to observed hand hygiene opportunities noted using the Observation Tool.   All 4 ICUs showed statistically significant increases in observed compliance with hand hygiene practices, with relative improvement ranging from a 55% to 95%. All 3 provider groups (RNs, MDs, and others) demonstrated statistically significant improvements, with nurses starting and ending with the highest observed rate of compliance (53% and 82%, respectively). Of the 10 practices measured with the Observation Tool, those with the lowest average baseline and final compliance were numbers 5 and 6: “before patient contact” and “after patient contact upon exiting the room”   The practices with the highest average baseline and final compliance were numbers 2 and 7: “after contact with blood, body fluids, secretions or excretions, mucous membranes, nonintact skin” and “upon entering the room before equipment contact.” Observation of practices 9 and 10 was added near the end of the project and the results of those questions are not shown.


Baseline and final responses to the hand hygiene questionnaire were similar for almost all questions (Table 2; Appendix). The measure selected as a Six Sigma counterbalance, staff satisfaction, increased slightly, a satisfactory result as the goal was to maintain a baseline level of staff satisfaction while ABHR use and observed compliance improved. Also, the reported use of ABHRs increased significantly. Data shows the responses to “When you don’t disinfect your hands (use soap or an alcohol hand rub to kill microbes) when you should, what is the reason why?” The reduction in the “too busy” response, and the increase in the “forget” response suggest that postintervention noncompliance was increasingly accidental rather than intentional. The mean estimated rate of self-compliance with hand hygiene practices (87%) was virtually unchanged. However, the distribution of responses changed; the final data contained fewer unrealistic self-responses of 99% to 100% and an increase in the more realistic response of 90% to 95% (Appendix).




We demonstrated that VA personnel working with a 3M project manager to employ the Six Sigma process were able to develop and implement effective interventions that improved hand hygiene practices. The Six Sigma process proved to be an effective tool for organizing the knowledge, opinions, and actions of health care professionals on an important clinical issue that has been historically intractable.

Many studies have reported that from 5% to 15% of inpatients acquire an infection while in the hospital6,1821 or that about 2 million infections occur annually.6,22 One study established an excess mortality because of nosocomial infection of 44% in ICU patients.23 Despite the long-established, widespread, and injurious problem of hospital-acquired infections, numerous studies have shown that health care workers do not regularly perform hand hygiene practices consistent with the policies established by their professional groups, employers, etc.7,16,24 There is perhaps no aspect of inpatient care where the divergence between evidence and practice is so pervasive, damaging, long established, and well known.

Our observed 80% compliance after interventions was comparable with the most successful reports in the literature and superior to most published studies attempting to improve hand hygiene compliance.7 Furthermore, we observed statistically significant and sustained increases in the mass of ABHRs used in the observed ICUs per 100 patient-days, consistent with the compliance that we also observed. We validated monthly monitoring of ABHR use per 100 patient-days as a timesaving proxy for observed compliance with required hand hygiene practices. Data from the staff questionnaire indicated that improved compliance did not result in diminished staff satisfaction. Our finding that mean self-reported rate of compliance with hand hygiene practices was unchanged suggests that self-reported rates should not be used to indicate actual compliance rates, trends, or other changes in hand hygiene practices.

The Six Sigma process is different from the “Plan, Do, Study, Act” (PDSA) cycle used in many clinical quality improvement efforts. One important difference was evident in this study. The first 3 Six Sigma steps, “Define, Measure, and Analyze,” focus on studying the problem in depth using various prescribed methods and acquiring high-quality baseline data before doing anything else. These steps may make the Six Sigma process especially appropriate for patient safety improvement initiatives because they address a common problem in patient safety: the lack of reliable baseline data on the current or preexisting status.

Additional aspects of the Six Sigma process that were important to the success of our study included the focus on identifying the subset of potential interventions that will be especially effective, using control charts to separate normal variation from real performance changes, and using a control plan to “maintain the gains” achieved. The project generated several tools for widespread use in VA and elsewhere: a 1-page summary of the JCAHO-required CDC recommendations (which continue to be required through at least 2006), an observation tool, a staff questionnaire, a summary checklist of hand hygiene interventions, and a series of posters designed to remind staff of required hand hygiene practices and encourage compliance.


We thank Carol Meeter and Chris Hughes of 3M for help with planning data collection and data analysis, and staff at the 4 VA Medical Center Intensive Care Units for enthusiastic participation and help with data collection.





Hospital Checklists Save Lives

Simple measures such as hand washing and disinfecting skin make a difference

April 26, 2011



Simple things like hand washing and disinfecting the skin before a tube is inserted by needle into a patient’s vein, help reduce hospital infections.

A new program to reduce hospital infections with relatively simple and inexpensive quality control measures is saving lives, according to a new study.

Hospitals can be dangerous places. We go there to get well, but sometimes people get sicker or even die because of infections they contract in the hospital.

Johns Hopkins University Medical School professor Peter Pronovost pioneered the use of hospital checklists to reduce infections.

He and his colleagues started with a list of about 90 recommendations from the U.S. Centers for Disease Control and Prevention, “and we elected to say, well, I can’t do 90 things as a practicing [doctor]. Let me cull it out and pick the five most important things on that guideline and make sure we do those.”

They focused their program on reducing infections in the central line, the tube inserted by needle into a patient’s vein to deliver medications and for other purposes. Central lines are a common source of serious infection in hospital intensive care units.

The checklist includes simple things like hand washing and disinfecting the skin before the central line is inserted. It has previously been shown to reduce the infection rate to near zero.

But did a lower infection rate translate to a lower death rate?

To find out, Pronovost and his colleagues compared hospital deaths in the state of Michigan, where the checklist program was in use, with nearby states that weren’t in the program.

“What we found was that the mortality of patients in Michigan went down by 10 percent more than if they were in the 11 surrounding states.”

While the quality improvement program may be built around a simple checklist, Pronovost stresses that it really is about changing how medical staff work together so that, for example, doctors listen to nurses, not just the other way around.

“A big part of our program was this culture change, because when doctors were using the checklist, 25 percent of the time they forgot [one of the items], so we asked the nurses to work with the doctors. And if the nurses saw the doctors not comply with the checklist, they can make the doctors go back and fix the mistake.”

Pronovost says the quality improvement program is cost-effective and well-suited to resource-poor hospitals and clinics. “We’ve done it in Peru and we’ve just started a program in Pakistan and we’re looking to put it into Africa. So it absolutely works.”

PATIENTS IN PERIL?: Careful hand-washing shown to save lives



John Amis/AP

Simple handwashing procedures by health care professionals can cut the risk of bloodstream infections in hospitals. A researcher has developed a five-step checklist for reducing such infections.

By Jodie Jackson Jr. Columbia Daily Tribune


To see hospitals participating in the “On the CUSP” program, go to

That simple, time-honored command mothers give to their children is one of the earliest lessons of manners and hygiene.

Now, health care regulators and patient-safety advocates are giving that command to hospitals and health care providers with a sense of urgency. Good hand-cleansing policies and enforcement are among the most simple steps to reducing or eliminating infections — and saving lives.

The Centers for Disease Control and Prevention estimates as many as one-third of the 99,000 people who die each year as the result of a hospital-acquired infection were struck with a bloodstream infection.

Health workers who make contact with patients should apply antibacterial gel “immediately before and after touching the patient,” national infection control specialist Marcia Patrick said.

“Patients or family members should say, ‘Please clean your hands,’ ” if a health care worker approaches a patient without doing so, Patrick said. “But they shouldn’t have to say that.”

Examples of poor hand hygiene were cited in a recent report on infection control and sterile processing deficiencies at University Hospital. Patrick called the handwashing observations and a nurse’s statement that dirty floors were not an infection control concern “inexcusable.”

Incidents cited in the Centers for Medicare and Medicaid Services report were observed Nov. 4. The incidents included:

  • “RN entered patient’s room without cleansing her hands. The RN removed the patient’s intravenous lock (IV) without wearing gloves. The RN left the room without cleansing his/her hands. The RN went into another patient’s room and opened a drawer getting a flashlight and brought it back to patient’s room.”
  • “RN entered room without cleansing hands, put on non-sterile gloves; checked patient’s ID bracelet on the ankle; wrote on the patient’s medical chart; opened a refrigerator door and poured liquid into a cup and gave it to the patient. Left the patient’s room without cleansing her hands.”

Patrick, a board member of the Association for Professionals in Infection Control and Epidemiology, is the director of infection prevention and control for a four-hospital system in Tacoma, Wash. That system has a stringent hand-cleansing policy enforced from the hospital’s top administrator.

Any unit that achieves less than 100 percent compliance gets a personal call from the CEO, “and that’s not a call you want to get as a manager,” she said.

MU Health Care officials said yesterday in an electronic newsletter to employees that the CMS report “only includes those observations when staff members do not comply to the letter of a regulation. The report does not include observations when staff complied nor does it give perspective on what a small percentage the times of non-compliance represent.”

Many patient-safety advocates suggest infections were once considered a normal risk of being in the hospital. But that attitude apparently is changing. The growing list of hospitals that dramatically lowered their infection rates by implementing rigid hand hygiene policies indicates the “average” infection rates were anything but “normal.”

Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services, called on hospitals in 2009 to reduce central line-associated bloodstream infections by 75 percent over the next three years. Thomas Frieden, director of the CDC, has listed hospital-acquired infections as one of the seven “winnable battles” for public health organizations.

Peter Pronovost, a patient-safety researcher and physician at Johns Hopkins School of Medicine, has developed a five-step checklist that targets eliminating bloodstream infections related to the use of catheters and central lines.

He refers to elimination of those infections as “the polio campaign for the 21st century.”

A national initiative to combat such infections is using a Comprehensive Unit-based Safety Program supported by a number of health care-monitoring and patient-safety advocate organizations.

“On the CUSP: Stop BSIs” adopts Pronovost’s checklist, first implemented in 127 intensive care units in Michigan hospitals in 2003. The pilot project targeted central line-associated bloodstream infections and ventilator-associated pneumonia. After 18 months, those ICUs had a median central line-associated bloodstream infection rate of zero. The project saved an estimated 1,500 lives and $200 million. Advocates of the campaign say those rates have been sustained for five years.

The five steps to inserting central lines or catheters are:

  1. Wash hands to prevent bacteria from the caregiver’s hands from entering the catheter directly or getting into the vein through the opening on the skin.
  2. Disinfect the patient’s skin.
  3. Use barrier precautions — such as masks, gowns and gloves — to prevent bacterial contamination when the catheter is put in.
  4. Avoid placing the catheter in the groin area, which is inherently difficult to keep clean.
  5. Remove unnecessary catheters. The risk of infection increases the longer the catheter is in place.

Pronovost insisted the CUSP program could have “the potential to save more lives than virtually any other medical discovery of the last quarter-century.”

CUSP advocates suggest patients and their families should take the checklist with them to the hospital and insist all health care providers ­follow the steps.

“On the CUSP” came to Missouri in 2010, with 15 hospitals — all in the Kansas City area — signing on. The program will expand to more Missouri hospitals in the coming months, but none of Columbia’s three hospitals plans to participate. Those hospitals say they already have stricter hand hygiene programs.

University Hospital, for instance, had several representatives on advisory boards for the Missouri Center for Patient Safety, which coordinates the statewide “On the CUSP” effort. MU Health officials helped the Center for Patient Safety establish several safety priorities, said Jo Ann Wait, MU Health’s director of public relations.

She said University Hospital has been using the same strategies outlined in CUSP to improve infection rates for the past five years.

“Because these efforts have lowered our infection rates to rates below the national average, we chose not to participate in the statewide collaborative,” Wait said, “but to focus our ongoing improvement efforts in other areas.”

In an internal electronic newsletter for employees, MU Health officials yesterday stated state health inspectors returned to the hospital Jan. 18 and found “instances when we did not follow proper hand hygiene.”

“No hospital in the country achieves a 100 percent hand hygiene rate,” the newsletter stated. “Our most recent compliance rate is at 89 percent.”

Stephen Gaither, public affairs director for Truman Memorial Veterans’ Hospital, said all Veterans Administration health facilities have adopted Institute for Healthcare Improvement infection control standards and other programs “more robust than the CUSP program.”

Boone Hospital Center extensively educates staff about critical safety procedures, including hand sanitation, media relations specialist Jacob Luecke said.

Each hospital uses a “secret shopper” method of monitoring hand hygiene policies. Luecke said Boone Hospital recorded some 3,000 hand hygiene observations in 2010. “Anyone spotted not sanitizing his or her hands before and after entering a patient room is given immediate correction and is reported to their manager for follow-up education,” he said.

Patrick said hospitals need to add an additional step — to publicly report their hand sanitation compliance rates along with infection rates.

All hospitals report data on select infections and other statistics to CMS. That information is reported on several websites, including

MU Health announced last week it is making plans to post its health and safety statistics online. Boone Hospital also lists some of the information on its website.



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