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6 The following list includes the composite-level average percent responses by medical office staff reported to AHRQ. 1. Teamwork — 86 percent of respondents re- ported their office has a strong culture of team- work, mutual respect and close working relation- ships among staff and providers. 2. Patient care tracking and follow-up — 86 percent of respondents reported their office con- sistently reminds patients about appointments, documents how well patients follow up treatment plans, follows up with patients who need moni- toring and follows up when reports from an out- side provider are not received. 3. Overall perceptions of patient safety and quality — 80 percent of respondents reported overall positive perceptions of patient safety and quality. The majority of office workers said their office processes are good at preventing mistakes, though they also indicated that getting more work done is valued more highly than quality of care. 4. Organizational learning — 80 percent of re- spondents said their office values organizational learning by indicating their offices evaluate the need to make process changes when problems arise and they assess improvements in patient care when changes are made. 5. Staff training — 75 percent of respondents said their office provides adequate staff training when new processes are adopted. 6. Communication about error — 70 percent of respondents reported open communication about errors. Survey responses show the major- ity of respondents say their offices are willing to report mistakes they observe and they actively discuss ways to prevent future mistakes. 7. Owner, managing partner and leadership support for patient safety — 70 percent of re- spondents believe their office leadership priori- tizes the need to improve patient care, but there is room for improvement. 8. Office processes and standardization — 69 percent of respondents indicated their offices ef- fectively follow standardized processes to get tasks done, but there are occasionally problems with workflow. 9. Communication openness — 68 percent of respondents said the providers in their office are open to staff ideas about improving processes and encourage staff to express alternative viewpoints, but they feel afraid to ask questions when some- thing is wrong. 10. Work pressure and pace — 50 percent of respondents believe their office has too many patients to provide effective care, and staff feel rushed when delivering patient care. n prevent the transmission of harmful pathogens and microorganisms to pa- tients. Examples of such efforts include improving disinfecting procedures, designating hand-washing monitors and increasing education on HAIs. The following 20 hospitals have stood out as some of the most notable hand hygiene success stories in recent years. Baptist Health, located in Jacksonville, Fla., began using uniforms made of Vestex fabric, which is designed to help fight pathogen transmission. Baptist Health is one of the first and largest in health system to use uniforms made of Vestex. The fabric is fluid-repellent on the outside, which inhibits any splatter or spill of blood, bodily fluid or other substance from soaking through scrubs and touching the healthcare workers' skin. The fabric is also antimicrobial, preventing the growth of bacteria on the uniforms, and is breathable as it wicks away sweat on the inside. The dual approach of being both antimicro- bial and fluid-repellant is unique to this specific fabric. Cedars-Sinai in Los Angeles improved its hand hygiene performance from around 70 percent to 95 percent within the year of 2010. In 2013, the organiza- tion-wide compliance rate was at 98 percent. The hospital used several tactics to achieve these improvements. To start, hospital leaders shifted the organiza- tion's prior goal of reducing HAIs to eliminating HAIs. Leaders pointed out the hospital should be striving for zero infections, not merely to reduce the rate of infection by 5 or 10 percent. Medical staff and other leaders also agreed hand hygiene compliance should be incorporated into the measure of an employee's overall performance. Subjecting healthcare workers to disciplinary action for poor hand hygiene or praise for protocol-compliant hand hygiene effectively helps shape behavior. In order to measure the rate of compliance, Cedars-Sinai opted to use trained nurse observers who used direct observation to measure compliance on a departmental and individual basis. Processes were amended throughout the initiative to ensure continued improvement. The Six Sigma methodology factored into Wheat Ridge, Colo.-based Exem- pla Lutheran Medical Center's efforts to improve hand hygiene while col- laborating with the Joint Commission Center for Transforming Healthcare Project between 2008 and 2010. Prior to taking part in the project, Exempla Lutheran used posters and glow powder to educate staff on hand hygiene. Using Six Sigma, the medical center evaluated hand hygiene thoroughly — reviewing room cleaning processes, food delivery, changing a light bulb and more — to see how a regimen could standardize hand hygiene and eliminate waste. Weekly data on compliance was collected and a report was distributed to the entire staff every month regarding compliance, HAIs and other measures. Additionally, Exempla Lutheran used hand hygiene observ- ers and implemented a strict hand hygiene policy with consequences for non-compliance. Staff members who don't wash their hands receive one ver- bal warning, followed by written warnings and finally, termination. During the program, Exempla Lutheran achieved a hand hygiene compliance rate of over 90 percent for more than five straight months and continues to work toward improving compliance. As part of the Joint Commission Center for Transforming Healthcare Proj- ect, Froedtert Hospital in Milwaukee applied the Six Sigma methodology to hand hygiene. Between 2008 and 2010, Froedtert defined and measured hand hygiene, analyzed data, and improved processes and workflow. One change the hospital made to improve hand hygiene compliance was adding hand sanitizer dispensers to high-traffic and high-touch areas such as by pa- tients' doors, telephones in the hallway, elevators and other areas in the unit. Froedtert also specially trained specific staff members to inspect and record observations regarding compliance. During the pilot program, the hospital observed roughly 85 percent of clinician behavior and recorded a compliance rate of approximately 80 percent. Froedtert continues to work toward achiev- ing its goal of 100-percent hand hygiene compliance. Johns Hopkins Hospital, located in Baltimore, achieved doubled rates of compliance with hand hygiene protocols between 2007 and 2008, and in- creased compliance again by 27 percent from 2008 to 2009 through the im- plementation of a hospital-wide communication and education campaign. The first step of the campaign in 2007, WIPES, contained five steps to help "wipe out hospital infections" that were displayed throughout the hospital on posters. The second step was to make the hospital environment optimal for practicing hand hygiene. This included putting hand hygiene sanitizer dispensers outside of each patient room and following up with educational outreach sessions to emphasize the importance of using the sanitizer. Further efforts included improved leadership engagement, and an online reporting tool that made hand hygiene compliance data readily available. Kirklin Clinic of University of Alabama Hospital in Birmingham successfully improved hand and environmental hygiene through an improvement project that resulted in a 50 percent improvement in hand hygiene compliance. In 2007, the Kirklin Clinic of UAB Hospital implemented a comprehensive hand and environmental hygiene program. The program focused on reducing all five instances of the nosocomial transmission of pathogens, including the trans- mission of pathogens from a healthcare worker's hands to a surface and onto the patient. To address this last type of transmission, the clinic implemented the use of Super Sani-Cloth germicidal disposable wipes, which were designat- ed for disinfecting high-touch surfaces such as the exam table, the patient chair, countertops and door knobs between patient visits. For potential outbreaks, 10 Statistics on Patient Safety Culture (continued from cover) 20 Hospitals With Great Hand Hygiene Programs (continued from cover)