Hands can be the most useful tools in health care. They can also be the most harmful.

Stopping HAI

Besides carrying out almost every task a nurse or physician can perform, hands can carry bacteria and germs that are often root causes for health care-associated infections (HAIs). Approxi­mately 1.7 million HAIs occur in U.S. hospitals each year, resulting in 99,000 deaths and an estimated $20 billion in health care costs.

Fortunately, the simple act of washing your hands can help eliminate the danger of HAIs. Unfortunately, hand hygiene is simply not where is could be in today’s health care environment. According to research, hand hygiene compliance lies at less than 50 percent at most hospitals.

To get from low to high reliability, MHHS leadership and staff adopted a commitment to achieving zero patient harm across every level of organizational leadership...

Assessing hospital reliability

Focusing on hand hygiene can be a key step on the path to a health care facility becoming a high-reliability organization (HRO). HROs, such as aircraft carriers and nuclear power plants, are those organizations that are complex, risky and dynamic, yet avoid catastrophes over long periods of time. With hundreds of thousands of preventable infections and deaths, health care is not a highly reliable industry.

Around 2002, the 12 Memorial Hermann Health System hospitals began looking at ways to deliver better care to patients. Four years later, two blood transfusion errors within days of each other killed one patient and left the other in critical condition. Those incidents led to a sense of urgency across the organization to dramatically improve the reliability of the care they delivered.

Realizing zero patient harm

MHHS began to learn about the concept of high reliability and how important it can be in health care. In order to get from low to high reliability, MHHS leadership and staff adopted a commitment to achieving zero patient harm across every level of organizational leadership, a culture of safety throughout the organization and widespread deployment of a highly effective approach to performance improvement.

As part of its high reliability efforts to specifically tackle HAIs, MHHS collaborated with the Joint Commission Center for Transforming Healthcare on its first improvement initiative, which targeted hand hygiene. The results were dramatic, as the average across all its hospitals went from a baseline of 58 percent to 95 percent hand hygiene compliance using Robust Process Improvement®, a management system with a set of strategies, tools and methods to define and measure the impact of the problem, discover specific causes and create targeted solutions. During this time, the average rate of central line-associated bloodstream and ventilator-associated pneumonias across the system decreased to essentially zero.