Making The 2017 Joint Commission Goals A Reality At Your Hospital

Updated: Aug 25

The Joint Commission 2017 goals provide guidelines for hospital hand hygiene. Here’s how to make these goals a reality at your hospital: 

It’s a well-known fact in the world of infection control and prevention: hand hygiene is the most important way to prevent hospital-acquired infections.

Unfortunately, many hospitals fall short, contributing to some 2 million hospital-acquired infections each year.

The Joint Commission has released a set of 2017 goals to improve patient safety through solving common problems in healthcare safety. One of the goals is to prevent hospital-acquired infections. The goal focuses specifically on hand hygiene, providing hospitals with three steps for goal-setting and improvement:

Here are 4 goals you can set to make the Joint Commission’s 2017 hand hygiene goals a reality for your hospital:

Goal 1: Increase Compliance Rate

According to a 2015 report from the Joint Commission, most hospitals have a hand hygiene compliance rate of under 50%.

In the mid-2000s, Joint Commission standards called for hospitals to have a 90% compliance rate. After a landmark 2010 study in conjunction with the American Hospital Association, they discovered that it was possible to greatly improve compliance — but 90% was a bit of a lofty goal.

The Joint Commission changed its standard to simply “improve compliance,”  but that doesn’t mean you can’t strive for perfection.

A 2014 article in Becker’s shows that hospitals across the country hit the over-90% mark within just a few years of implementing new hand hygiene programs. Cedars-Sinai Medical Center went from 70% to 95%, while Novant Health’s Thomasville Medical Center increased compliance from 49% to 99%.

While it’s important to aim high, don’t be discouraged if you don’t meet your goal within 1 year. It can take a little time, but the results are well worth the continued effort.

Massachusetts General Hospital sets high goals in its Hand Hygiene Program — and reaches them. Between 2002 and 2014, its handwashing rates after patient contact climbed from from 47% to 97% — and rates before patient contact skyrocketed from 8% to 94%.

Source: Massachusetts General Hospital (March 2014)

Goal 2: Educate Your Staff About Your Hospital’s Actual Compliance Rate

What’s one major reason for handwashing problems? Hospital staff don’t always think there’s a handwashing problem.

According to a 2013 article in Becker’s, many healthcare workers and hospitals believe their compliance is much greater than it actually is. This can stem from hospital officials failing to share rates with the staff, but it can also come from poor monitoring.

For example, in 2008, officials at North Shore University Hospital, in Manhasset, N.Y., directly observed healthcare workers’ hand hygiene habits. They reported a compliance rate of 60%. However, a switch to a more objective monitoring system revealed that the rate was actually less than 10%.

In some cases, staff may be aware of low compliance rates — but don’t believe that it affects them. They may think, “I’ve worked around sick people for so long that my immune system is great, and I don’t get sick.”

Don’t be afraid to measure your compliance rate with an objective tool. Push out those numbers at least monthly — not to criticize staff, but to remind them that there’s room for improvement. As they see the numbers rising, they might feel extra motivated to get on board with hand hygiene protocols.

Then Again, A Little Nudge To The Conscience Can Go A Long Way

Want to trigger even better compliance from your staff? Play on their protective instincts toward patients.

In one experiment, psychologists made two signs to post over hand soap dispensers in a hospital:

  • Hand hygiene prevents you from catching diseases

  • Hand hygiene prevents patients from catching diseases

The second sign produced better results: It boosted soap use by 33%, and led to a 10% increase in hospital staff washing their hands. The other sign made no change in handwashing compliance rates or soap use.

Source: Association for Psychological Science

Goal 3: Create A Workflow More Conducive To Hand Washing

When the Joint Commission conducted its 2010 study, it identified workflow as a potential barrier to hand washing.

Several hospitals included in the study found that staff members went in and out of rooms often, meaning they constantly had to wash their hands.

This affected nurses, in particular — they entered, exited, and reentered patient rooms so many times that they were often required to wash their hands almost 200 times per shift. That’s two hours of total hand washing time.

To tackle this problem, hospitals began bundling tasks and supplies. For example, staff were instructed to make sure they had all the supplies they needed before entering a room to reduce the number of times they had to exit and reenter.

Goal 4: Remember That Location Matters

This goes right along with workflow. According to a 2011 article in Becker’s, the design of a healthcare facility can make a great impact on infection control.

This was demonstrated in a 2015 study in the American Journal of Infection Control. Researchers at a Midwest hospital assigned the locations of hand sanitizer dispensers in each unit a usability score based on seven criteria:

  1. Easily visible on entry to the room

  2. Easy and unobstructed access

  3. Within an arm’s reach or less than one step away from the room’s entrance

  4. Visible from point of care

  5. Along the workflow path

  6. Within an arm’s reach or less than one step away from point of care

  7. Placed at an optimal height

After 26,707 hand hygiene compliance observations, the researchers found that high usability scores were directly and significantly linked to high compliance scores. They also found that accessibility and visibility on entrance and exit to rooms had the most significant impact.

The Joint Commission’s 2010 study had similar findings:

  • Virtua Hospital, in New Jersey, saw improved compliance when it changed the location of dispensers and repainted the walls around them to make the dispensers more visible.

  • Virtua Hospital also put every hand hygiene item (e.g., gloves, trash, hand gel) in one place, and in the same location in each room. This ensured that staff would have no trouble finding what they needed.

  • Froedtert Hospital, in Wisconsin, boosted compliance by making sure dispensers were part of the workflow. They were placed right by the entrances to patient rooms, as well as by high-touch places like next to elevators or hallway telephones.

Sink location also makes a difference, according to the 2011 Becker’s article. Sinks are often located in back corners of the room, which does not encourage physicians to wash hands.

The implementation of Vitalacy’s automated patient safety compliance technology discovered that the actual hand hygiene compliance rate of a hospital was closer to about 30 percent compared to a reported 90 perfect. This data was gathered as an initial baseline where wristbands were worn by healthcare providers without receiving any feedback. Upon activating the SmartBand feedback and reminders, the hospital noticed an increase in the compliance rate to more than 75 percent over the course of about one week.

Learn more about how Vitalacy’s Patient Safety Platform can create a stronger patient safety culture and compliance rate for Joint Commission mandates at your hospital.

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