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Classification of the PSP |
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Type of Patient Safety Practice
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Safe
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Clinical Practice (CP)
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Related practices from PaSQ database
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| "Best fit" category of the reported practice |
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Hand hygiene
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| Topic of the reported practice |
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Quality improvement project
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Aim and the benefit of the Patient Safety Practice
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The Hand Hygiene Compliance Program performance evaluation process is suitable for gathering exact, up to date and relevant data about the hand hygiene practices of those departments participating in the program and for comparing these results on the basis of a premeditated tool system.
Following the comparison, the next step is the evaluation of the results. There after corrective suggestions are made. The resulting changes are to be followed subsequently.
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Description of the Patient Safety Practice
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In Zala County Hospital, there are three kinds of methods used for the evaluation of hand hygiene efficiency.
I. Ecolab Hand Hygiene Evaluation programme (At the Dept. Of Infectology and Dept. Of Traumatology) between February 2012 and February 2013
Objectives:
- Formation of unified guidelines and practices concerning the use of hand disinfectants at the Dept. of Traumatology and at the Dept. of Infectology
- Continuous survey of the hand hygiene practices performed on the basis of predetermined and identical requirements.
- To stimulate the improvement of hand hygiene practices with data feedback
- To establish a volume of hand disinfectant consumption justified by patient turnover data
- Continuous monitoring of overall hospital hand disinfectant costs while the departments adhere to the requested hand hygiene policy
- Prevention of HCAI in order to achieve the best possible patient safety.
Potential benefits:
- The prevention of the development of infections with the use of effective hand hygiene policies and disinfectants.
- Increasing the standard of healthcare by developing a patient safety indicator.
Information used:
- The Policy For The Use Of Hand Disinfectants at the Dept. of Traumatology and Infectology in Zala County Hospital
- The consumption and cost of hand disinfections (quantity/month and HUF/month) calculated for the dept. of Traumatology and Infectology.)
- The justified disinfectant consumption calculated on the basis of the overall functional and patient turnover data of the departments
Results:
- The acquisition and application of the appropriate hand disinfection method
- Cost effective disinfectant consumption resulting in cost reduction
Quality indicator:
- Costs before and after the introduction of the project, HUF value of cost reduction.
- Percentage of the justified and that of the actual disinfectant consumption
- Percentage of positive cultures taken on hygienic surveys.
II. Monitoring of hand hygiene policy with immunofluorescency
The investigation of the even dispersion of the disinfectant with the use of fluorescent test (So called „trial” hand disinfection with disinfectant containing fluorescent component followed by detecting the disinfectant dispersion on hands and arms under UV light)
Objectives:
- The staff should employ the appropriate techniques.
- Practising the hand hygiene methods should become natural among staff members
- Teaching the proper hand hygiene techniques should be a vital part of new staff members’ education.
Target group:
- All staff members of the Hospital, working in inpatient departments.
Duration of the investigation
- By scheduled plan or randomly
III. Direct observation of the hand hygiene practice
Observation of compulsory hand disinfection during nursing activity
The five momentums of hand hygiene are as follows:
1. Before touching the patient
2. Before aseptic procedures
3. After contamination with secretions
4. After touching the patient
5. Following contact with the patient’s environment
Objective:
- Staff members should use the appropriate hand hygiene techniques properly, at the right time and in all the required cases
Target group:
- All staff members of the Hospital, working in inpatient departments.
Duration of the investigation
- By scheduled plan or randomly
A base survey was carried out before the introduction of the hand hygiene performance evaluation programme at the departments involved in the project. During the one-year long programme, repeated surveys and educations were carried out monthly, and in every three months respectively. The program was closed with a final evaluating survey.
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| Attachment of relevant written information and/or photos, as appropriate |
387_WP4_kézhigiénés ellenőrző lap 2013.02.25..doc
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Effectiveness of the Patient Safety Practice
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| Degree of implementation of reported practice |
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Yes, fully
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| Level of implementation of reported practice |
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Unit or ward level
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| Specific and measurable outcome for the reported practice were defined |
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Yes
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| A baseline measurement before implementation of the reported practice was obtained |
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Yes
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| A measurement after full implementation of the reported practice was obtained |
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Yes
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| Evaluation of a "positive" effect of the reported practice on Patient Safety |
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The evaluation showed improvements in Patient Safety outcomes
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| Type of before-and after evaluation |
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Quantitative
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| Enclosure of a reference or attachment in case of published evaluation's results |
No
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Health care context where the Patient Safety Practices was implemented
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Hospital
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Transferability
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| Successful implementation of this Patient Safety Practice in other health care settings than above stated |
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Yes
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| Specification of implementation in another health care setting(s) |
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Nursing facility
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| Successful implementation's level of this Patient Safety Practice across settings |
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Yes, across multiple specialities across different health care settings
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Involved health care staff
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Physicians
Nurses
Dieticians/ Nutritionists
Clinical support
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Patient Involvement
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| Direct service user's involvement as integral part of this Patient Safety Practice |
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No
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| Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice |
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| Point of time in which service user or their reprasentatives' involvement takes place |
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There is no specified text here
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| Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice |
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| Short description of the service users' level of involvement |
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| Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users |
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No
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| List of sources where public information is accessible |
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Implementation of the Patient Safety Practice
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| Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice |
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No
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| Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc. |
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Yes
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| List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice |
No motivation among staff
Staff or management did not recognise the need for change
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| List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice |
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| Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice |
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No
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| Description of used incentives, if any. |
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| Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice |
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Yes
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Costs of the Patient Safety Practices
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| Completion of cost calculation related to this Patient Safety Practice |
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Yes
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| Total number of person days required to implement this Patient Safety Practice |
Clinical staff: 0
External consultants: 0
Support staff: 80
Managerial staff: 0
Others: 0
Not relevant: 0
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| Total number of person days required for training as preparation for implementation of this Patient Safety Practice |
Clinical staff: 86
External consultants: 0
Support staff: 0
Managerial staff: 0
Others: 0
Not relevant: 0
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| Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice |
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0
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| Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice |
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0
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Contact information
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Name: Gabor Kecskés
Country: HUNGARY
Organisation: Zala County Hospital
E-mail: minoseg.min@zmkorhaz.hu
Phone: +36 92 331 420
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