Sheryl Harnas, System Director of Infection Prevention at Arnot Health in upstate New York, talks with Qualaris about her system-wide hand hygiene initiative that was launched early in 2015.
Q: There are three hospitals in the Arnot Health system with over 650 beds total. Why did you decide to launch the hand hygiene project in all three hospitals simultaneously rather than begin with a small pilot and expand the project over time?
A: I feel strongly that if you’re going to attack hand hygiene, then you have to do it everywhere. I don’t want to focus in one place and not another; I would be concerned that it sends the wrong message about hand hygiene. In addition, all three of our hospitals need to feel involved in our big projects, it helps to keep them engaged and working together as a system. With that in mind, we decided to go big and make hand hygiene a focus for improvement in all three hospitals and in every unit.
Q: Can you describe your project plan at a high level?
A: We took several months at the end of 2014 to plan the project. First we contacted every unit leader and asked them to identify two people in their units who would collect observation audits. Next, we focused on the launch itself in January 2015 by scheduling a big meeting that brought all of the unit leaders and identified data collectors together to talk about our project goals and provide training on QualarisAudit. We allowed everyone to use the month of February to “play” with QualarisAudit to get comfortable with entering data and looking at results in the system. Then on March 1 we started collecting “real” hand hygiene observations and planned to take three months to collect baseline data. Our goal is to collect 20 observations per unit per month. We’ve spent the last three months encouraging units to collect the appropriate amount of data and we’ve been looking very closely at the validity of the data being collected. In June we will start kicking into gear to reward excellence in compliance and work on improvements.
Q: Did everything go according to plan? What has worked well and what challenges have you faced?
A: At the highest level, everything has gone according to plan. Remember, we launched this project less than five months ago; so even though I wish things were moving faster, when I look back I’m pretty pleased with the progress we’ve made in such a short time. We’ve done a few things that have worked really well to support our plan. One was to coordinate this project with the launch of a new hand sanitizer. This gave us a “jump” in visibility because of the new product and dispensers. We also coordinated regular meetings with our Preventing Infection Liaison Leaders (PILLS) from each unit who have been enormously supportive and helpful with coordination and engagement across the system. And the best part of the project was having a tool like QualarisAudit that saves us time and helps to easily communicate our results and progress. But we’ve also had our challenges, and perhaps the biggest is how difficult it is to maintain visibility and priority status in a system where there is enormous pressure to focus on many new and important initiatives. I really need center stage for this project, but we are sharing the limelight with other priority projects and that makes it harder to keep everyone focused on what needs to be done to accomplish our goals.
Q: If you could give advice to a colleague who is planning a system-wide project like this, what would you say?
QualarisAudit is a great tool. It’s perfectly reasonable to attempt a large project at any organization with this tool because you can communicate with the entire leadership across the system and they can login and see exactly what’s going on at any point. I would never have approached this project without QualarisAudit.
You must work hard ahead of time to get complete buy-in from everyone before you start. If you’ve got a system effort, and it’s across the board, then every director and every employee must know the expectations and be in the game working together. It has to be a corporate initiative.
Don’t expect results too quickly. We are five months into the project and our big win to date is that we are seeing hand hygiene compliance for what it really is. We used to collect paper audits that always said the units were 100% compliant, which we knew wasn’t true. After being trained on QualarisAudit and learning the expectations for collecting data, the measurements are far more realistic. Now we can move forward from here with our eyes open.
Q: Thank you for sharing your experience with us Sheryl. Do you have any final thoughts to add?
A: Yes. If they take my QualarisAudit tool away, it’s all over! A project of this scope and scale would be impossible any other way. What’s so amazing about it is that it’s real-time and anybody can log in and look at results. The more that people can access it and look at results, the better things will get.