Thursday, August 9, 2012

Standard Work, Daily Measurement, and Keeping our Patients Safe from Infections

It has been a number of years since healthcare organizations started working on hand hygiene as a way to reduce the spread of infections. We have made some progress, but many outsiders have gotten frustrated with our inability to “just do it” and make “washing in” and “washing out” the rule.

At GBMC, we have improved significantly in this area but we still have defect rates of around 20 percent. It is hard to get closer to perfection on this one. But we have gotten beyond lamenting the reasons why we can’t do it. As I said in the blog a few weeks ago, we are getting better at improvement.

We know that winning organizations don’t rely on hard work and good intentions alone. They design systems to get to the results that they want. Once the system is designed by the people in it, they follow the design… it’s called standard work. Standard work gets us to much higher reliability and much lower defect rates. Teams that create standard work use daily measurement to see how well the design is operating and to reinforce its use. Brief daily conversations about how the design is working also help people see further improvements.

Eileen Skaarer, RN, the Clinical Manager on Unit 45, has been leading her team in the creation of a design to get to better hand cleansing results. They have been doing a quick audit, by a different staff member daily, of their hand hygiene compliance. Twice each day, 5 observations are done of people entering and exiting a room and the results are put on a graph at the nursing station. When a team member is observed to have not washed on the way in or out, the auditor reminds the person of the necessity of washing. The person who did not wash gives the reason why they did not and this is also recorded for learning on a Pareto chart. When the person did wash in and wash out, he or she is congratulated.  At the daily huddle, the previous day’s results are reviewed with the team. 

The chart below shows the Unit’s improvement over time when measured by a secret observer.  You can see that in July, the nursing defect rate was zero!

Eileen and her team will keep working on the design until they get to perfection but what about the rest of GBMC HealthCare? Well, we have to get better at spread. In healthcare we are not as good as we need to be at testing a change, finding out that it works in the test area, and then spreading it to other units. The Hand Hygiene Team is working to spread the Unit 45 design and daily metric to our other inpatient units. I can’t wait to see our improvement over the next few months!

What ideas do you have to help us spread standard work faster?


  1. Great to see the internal data being published. Good to see both the results and the open communication. Well done on both.

  2. I would have to say that I have not been to a hospital that is as pro active in hand washing.
    I have spent untold hours at your hospital since November 2010.
    I brought my friend there with what turned out to be a ruptured appendix and perforated colon. As I sat next to him waiting for results and an open OR, I was struck by the fact that the sink for doctors and nurses and techs was directly across from his bed.
    Never, ever, anywhere have I witnessed the continues use of soap and water, At one point a Doctor rushing in, he stopped and washed his hands, as did the team preparing to move my friend to the operating room. The Doctor took a few steps into the room, came to a complete stop and excused himself to wash his hands. I assured him that I had witnessed the act. He thought for a second and said, " If you don't mind I'll only be a minute. If it was an automatic action that I can't remember I'll just put my mind at ease.

    I have to pass several hospitals, some just minutes away from my home to receive the type of care I cannot find anywhere, except your hospital.
    I might also add that the care my friend received on the 5th floor saved his life many times after the surgery.
    At times, when he had a few set backs, the lights were on, the door was open and everyone on that shift was fully aware of the constant attention he needed.
    It was as if he were in the ICU, and in keeping with the article at hand, not one time , either coming or going was the hand washing overlooked. They watched me with kindness and understanding but scooted me right back out into the hall if I forgot
    I have since spent time with the group of angels in the oncology and radiation department.
    There is overwhelming attention paid to hand washing and sanitation.
    Dr Blumberg and his entire team made me feel as if I were the only and most important patient.
    Since my time there, I have read that many newly diagnosed cancer patients lose the first of battles, not from the cancer, but from the lack of affection from family and friends.
    I would have fallen into that group had it not been for them. They became my family, they became my support.
    After each session I left the building smiling.
    I found there the warm feelings of genuine caring .
    Thank you for the chance to share my appreciation.

    Mary Jones


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