Using the six sigma process to implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 intensive care units

Abstract

Background: 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.

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

Design: Six Sigma Project with pre-post design.

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

Measurements: 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.

Results: 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.

Conclusions: 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.

FIGURE 1

Summary of Centers for Disease Control and Prevention hand hygiene recommendations required by Joint Commission on Accreditation of Healthcare Organizations.

FIGURE 2

Hand hygiene interventions developed through Six Sigma process.

FIGURE 3

Control chart showing baseline and final grams of alcohol-based hand rub used per 100 part-days per month for Medical Intensive Care unit-1, Surgical Intensive Care Unit (SICU)-1, and SICU-2. Control bars are set at 2 standard deviation intervals.

FIGURE 4

Observed hand hygiene compliance, by practice measured in observation tool. Observed practices were as follows (Fig. 2 and Appendix for additional information): (1) Before clean and aseptic procedures, including medication prep and prior to prep, gown and glove for sterile procedures. (2) After contact with blood, body fluids, secretions or excretions, mucous membranes, nonintact skin. (3) After handling objects and devices such as soiled linen, trash, equipment. (4) After removing gloves or other PPE used for contact with body substances. (5) Before patient contact. (6) After patient contact upon exiting patient's room. (7) Upon entering patient's room before equipment contact. (8) After equipment contact upon exiting patient's room. PPE, personal protective equipment.