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BACKGROUND: In 2010 Memorial Hermann Health System (MHHS) implemented the Joint Commission Center for Transforming Healthcare’s (the Center’s) Web-based Targeted Solutions Tool ®(TST ®) for improving hand hygiene through-out its 12 hospitals after participating in the Center’s first project on hand hygiene, pilot testing the TST, and achieving significant improvement for each pilot unit. Because hand hygiene is a key contributing factor in health care-associated infections (HAIs), this project was an important part of MHHS’s strategy to eliminate HAIs.

METHODS: MHHS implemented the TST for hand hygiene in 150 inpatient units in 12 hospitals and conducted a systemwide process improvement project from October 2010 through December 2014. The TST enabled MHHS to measure compliance rates, identify reasons for noncompliance, implement tested interventions provided by the TST, and sustain the improvements. Data on rates of ICU central line- associated bloodstream infections (CLABSIs) and ventilator- associated pneumonia (VAP) were also collected and analyzed.

RESULTS: Based on 31,600 observations (October 2010- May 2011), MHHS’s systemwide hand hygiene compli- ance baseline rate averaged 58.1%. Compliance averaged 84.4% during the “improve” phase (June 2011-November 2012), 94.7% in the first 13 months of the “control phase” (Decem ber 2012-December 2014) and 95.6% in the final 12 months (p < 0.0001 for all comparisons to baseline). Con comitantly, adult ICU CLABSI and VAP rates decreased by 49% (p = 0.024) and 45% (p = 0.045), respectively.

CONCLUSION: MHHS substantially improved hand hygiene compliance in its hospitals and sustained high levels of compliance for 25 months following implementation. Adult ICU CLABSI and VAP rates decreased in association with the hand hygiene compliance improvements.


Shabot, M.M., Chassin, M.R., France, A.C., Inurria, J., Kendrick, J. and Schmaltz, S.P. (2016) Using the Targeted Solutions Tool® to Improve Hand Hygiene Compliance Is Associated with Decreased Health Care-Associated Infections. Joint Commission Journal on Quality and Patient Safety. 42(1), p.6-21.

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