Healthcare Hygiene magazine December 2019 | Page 35

hand hygiene
By Paul Alper
A Self-Assessment Tool: How Do Your Units Compare?
In
last month’s column (see page 34 in the November 2019 issue), I presented an evidence-based checklist for how
to drive improvement with what you have; that is, regardless of how you are training, educating, measuring
and giving feedback, the checklist provides a framework for driving improvement that has been shown to work when
implemented with solid discipline.
This month, we will take that a step forward and provide a self-assessment tool for unit managers to use for the
purpose of getting a solid baseline of where they stand today and then conducting routine self-assessment updates to
measure improvement. Also included is a scoring guide so that infection preventionists (IPs) can compare their units and
use the scoring to identify those units that need the most immediate coaching and feedback.
A HAND HYGIENE SELF-ASSESSMENT TOOL
Note that point values for each response are included as part of
the questions, but these should be removed when using as the tool
1
Our unit is responsible for hand
hygiene improvement and we are held
accountable for meeting monthly/quarterly
compliance growth targets.
a. Strongly agree (10)
b. Agree (7)
c. Neither agree nor disagree (0)
d. Disagree (0)
e. Strongly disagree (0)
2
Our unit leadership’s annual performance
appraisal/bonus is tied in some way to
meeting our hand hygiene improvement goals.
a. Strongly agree (10)
b. Agree (7)
c. Neither agree nor disagree (0)
d. Disagree (0)
e. Strongly disagree (0)
3
Our unit routinely identifies obstacles and
barriers to hand hygiene performance and
then puts in place action plans with the goal
of eliminating them.
a. Strongly agree (10)
b. Agree (7)
c. Neither agree nor disagree (0)
d. Disagree (0)
e. Strongly disagree (0)
4
Our unit identifies the obstacles
and barriers to hand hygiene compliance
using:
a. Direct observation (10)
with the units. Select the response that best describes your unit and
its routine practices. Be honest and frank:
b. Group discussion (7)
c. Other (1)
a. Strongly agree (10)
b. Agree (7)
c. Neither agree nor disagree (0)
d. Disagree (0)
e. Strongly disagree (0)
5
We measure hand hygiene compliance
and give feedback on performance:
a. Daily or weekly (10)
b. Monthly (7)
c. Quarterly (5)
d. Twice a year (1)
e. Once a year (0)
6
We celebrate when goals are achieved
and identify what we will do differently
when they are not.
a. Strongly agree (10)
b. Agree (7)
c. Neither agree nor disagree (0)
d. Disagree (0)
e. Strongly disagree (0)
7
When our goals are met, we then set new,
higher goal.
a. Strongly agree (10)
b. Agree (7)
c. Neither agree nor disagree (0)
d. Disagree (0)
e. Strongly disagree (0)
8
Psychological safety is the way we work;
anyone can speak up when there is risk
of doing harm (such as not doing proper hand
hygiene when it is indicated) without fear of
retribution or other negative consequences.
We are a long way from “getting hand hygiene right,”
and this is just one framework that requires no investment
other than time and that might make sense to consider in
some adapted form. Feel free to modify and adapt in any way
that aligns well with your culture and organization. A three- to
four-unit pilot will help you see if it works for you.
www.healthcarehygienemagazine.com • december 2019
9
Our organization’s senior leaders are re-
sponsible for modeling proper hand hygiene
behavior and they are authentically engaged in
our hand hygiene improvement efforts.
a. Strongly agree (10)
b. Agree (7)
c. Neither agree nor disagree (0)
d. Disagree (0)
e. Strongly disagree (0)
Add 10 points if you stop a healthcare
worker as a matter of standard practice when
doing Direct Observation and they fail to perform
hand hygiene, reminding them that they need to
do so before providing care.
SCORING
• 100: Outstanding. Stay diligent
and focused!
• 80-99: Excellent, but still room for
improvement.
• 60-79: Good, but should make
getting more than 80 a high priority for
the next period.
• Below 60: Poor.
Paul Alper, BA, led the launch of PURELL®, invented the first
electronic hand hygiene monitoring system proven to reduce
infections while improving behavior and eliminating costs
and is now the vice president of patient safety innovation for
Medline Industries, Inc. through an exclusive engagement with
his consulting practice, Next Level Strategies, LLC.
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