Cleveland Clinic Weston Hospital was experiencing increased cases of hospital onset Methicillin Resistant Staphylococcus Aureus (MRSA) bacteremia. Studies indicated that hand hygiene practices are highly effective in reducing cross transmission of MRSA to patients from healthcare workers. This transmission of MRSA to patients is associated with high mortality and morbidity. A Quality Improvement (QI) team was developed to address gaps in the hospital’s current hand hygiene surveillance program to improve hand hygiene compliance. The QI team implemented new processes to optimize the hand hygiene surveillance program resulting in eliminating inaccuracies in surveillance, improve compliance, and reduction of MRSA bacteremia cases.
Problem: This A3 project was initiated to address an increase in hospital onset MRSA bacteremia cases. The focus was to reduce inaccuracies in the hand hygiene surveillance data and improve hand hygiene non-compliance.
Measurement: Data was gathered by completing Gemba rounds to observe current surveillance and hand hygiene practices. The team utilized process mapping and fishbone diagrams to identify potential causes to the problem. Multi-dot voting was used to prioritize which potential causes of the problem the team will countermeasure.
Analysis :The QI team utilized the 5 why method to analyze each prioritized cause to determine root causes for the gaps identified in the hand hygiene surveillance and conducting hand hygiene processes.
Implementation: The QI team implemented changes to the surveillance program by increasing sample size of the audits and setting specific criteria for sampling. Return demonstration competencies were developed for: conducting hand hygiene (clinical new hires), and surveillance auditing (new/annual). Challenges with implementation were approached with effective communication with all leaders.
Results/Discussion: Pre implementation there was a 55% surveillance data variance, post implementation the variance decreased to 10%. This indicated that the data collected was more accurate. Additionally, an 80% decrease was noted on hospital onset MRSA bacteremia cases. Utilizing the A3 performance improvement process was crucial to the project’s success.
