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DebMed Blog: Healthcare Hygiene Matters

It’s Not a Project; it’s the Way You Work: Committing to Culture Change

Posted by DebMed on Apr 12, 2018 11:29:38 AM

According to the Patient Safety Movement Foundation (PSMF), two of the leading patient safety challenges facing hospitals today go hand-in-hand with the Joint Commission’s newest requirements in improving hand hygiene – creating a culture of safety and reducing healthcare associated infections.

 Achieving a culture of safety in a healthcare organization requires transformational change that should be owned and led by the executive leaders of the organization. This includes taking full responsibility for major changes like zero harm and when errors are identified, by “owning” and not just supporting, the culture change within their facilities.


Safety - Text on Puzzle on the Place of Missing Pieces. Scarlett Background. Close-up. 3d Illustration.It may seem like a daunting task, but when broken down in steps such as the PSMF has done, working to create a safety culture necessary to achieve high-reliability in healthcare facilities can be boiled down to these five components (Chassin & Loeb, 2013):


  1. Trust
    • Establish top-down commitment
    • Create a culture of psychological safety and non-retaliation in reporting
    • Consider anonymous electronic reporting software
  2. Accountability
    • Practice uniform accountability and transparent disciplinary procedures no matter employee the rank – from environmental services to board members

  3. Identify Unsafe Conditions
    • Identify safety issues and report them
    • Provide feedback to those who report issues to encourage communication
    • Communicate actions taken to resolve unsafe conditions with all levels of staff

  4. Strengthen Systems
    • Implement an effective, user-friendly and non-punitive reporting system
    • Aggregate and review reports
    • Implement safety strategies

  5. Access and Continuously Improve the Safety Culture
    • Measure and analyze the culture of safety with a validated tool
    • Share the results with all levels of employees, including board members, and develop specific improvement plans
    • Consistently communicate goals and expectations
    • Maintain non-punitive, but also accountable, standards
    • Encourage honesty in reporting
    • Reduce variation in patient care delivery and processes

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A major factor in creating a culture of safety in healthcare facilities is a comprehensive review of HAI prevention practices. HAIs are serious and often times preventable if an actionable prevention plan is in place and best practices, such as hand hygiene protocols, are implemented across the organization. When these protocols are not followed, they result in avoidable infections and deaths.


Patient_Safety_Movement_logo_notag-1In order to encourage a culture of hand hygiene compliance within a healthcare facility, the PSMF recommends an overall change to the safety culture. This starts with building acceptance of the hand hygiene process change with those who will be charged with implementing and sustaining the new processes, and then establishing a method of accountability to sustain the changes.


The Joint Commission Center for Transforming Healthcare’s Targeted Solutions Tool (TST), recommends a four-step process to improve hand hygiene acceptance and compliance which is mirrored by the Actionable Patient Safety Solutions (APSS) from the PSMF:


Identify barriers and obstacles unique to the unit using interventional direct observation


Establish a multi-disciplinary team responsible for removing barriers and implementing the Hand Hygiene Protocol, including nursing, physicians, infection preventionists and administration.


Implement the training and action plan

Measure improvement using an evidence-based, validated electronic hand hygiene compliance system and give appropriate feedback to ensure successes are acknowledged and that remaining barriers and obstacles are addressed (Steed, 2016).  TST & APSS 

Provide performance feedback to unit leadership and frontline staff on a regular basis, using evidence-based behavior change feedback models

Reminders in the workplace, such as posters, brochures, leaflets, badges, stickers, can be used, provided they are consistent with the overall Hand Hygiene Protocol APSS


Dispenser - GMS signal, PurpleAdditionally, when looking for an electronic hand hygiene monitoring system, the PSMF suggests the following five “must have” criteria:


  1. The system must be capable of capturing and reporting on 100% of all hand hygiene events (soap and sanitizer)
  2. The system must be able to provide room level soap vs. sanitizer reporting in the case of C Diff.
  3. The technology must include a behavior change framework for how to use the data with front line staff to drive sustainable behavior change.
  4. The system must have validated accuracy
  5. The system must be evidence based


To learn more about electronic hand hygiene monitoring systems to improve the culture of safety at your healthcare facility, visit 

DebMed Canada  DebMed USA


[i] Chassin, M. A. R. K. R., & Loeb, J. E. R. O. D. M. (2013). High-Reliability Health Care: Getting There from Here. Milbank Quarterly, 91(3), 459–490. Wiley-Blackwell. Retrieved from https://doi.org/10.1111%2F1468-0009.12023

[i] Steed, C. (2016). Use of the Targeted Solutions Tool and Electronic Monitoring to Improve Hand Hygiene Compliance. Paper Presented at the 2016 SHEA Conference.


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Topics: tips for improving hand hygiene, Actionable Patient Safety Solutions, Patient Safety Movement, Joint commission Targeted Solutions Tool

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