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7 the Kirklin Clinic uses a 1:10 dilution of bleach solution. The clinic focused heavily on product availability not only for the healthcare provider team, but also the patients themselves. By making the alcohol-based hand wipes available in each exam room and in high traffic areas such as elevators, lobbies and pa- tient entrances, hand hygiene compliance went from 41 percent to 90 percent. MetroHealth Medical Center in Cleveland has reduced rates of hospital- acquired infections by 38 percent since 2010 due to the implementation of a vigilant hand hygiene program. A bacterial infection that spread from room to room in 2010 prompted the implementation of the hand hygiene pro- gram. The program included hiring four hand washing monitors who moni- tored everyone's comings and goings and noted who washed their hands after walking in and out of patient rooms. This provided hospital administration with data on hand hygiene compliance on every floor and allowed them to look for improvement opportunities. Since 2010, central line-associated bloodstream infections at MetroHealth Medical Center have decreased by 35 percent, ventilator-associated pneumonia cases reduced by 71 percent and surgical site infections dropped 64 percent. Mount Sinai Health, based in New York City, opted to follow the World Health Organization's recommendations for removing personal protective equipment without coming in contact with potentially infectious materials. The WHO's protocol includes many opportunities for hand hygiene. According to Mount Sinai officials, the hospital elected to adopt the WHO's protocol because there is a hand hygiene step built in for every time a healthcare worker removes a piece of PPE. Following the WHO hand hygiene protocol, healthcare workers at Mount Sinai wash their hands after removing each layer of PPE, as opposed to alternate guidelines that suggest washing hands after removing all PPE. North Shore University Hospital in Manhasset, N.Y., has tried numerous techniques to improve hand hygiene compliance. In addition to communi- cating directly with physicians who hadn't met the hygiene standard and us- ing secret shoppers to observe hand washing habits, NSUH participated in a study that involved a remote video auditing system. As part of the study, video cameras were placed in intensive care unit rooms to record behavior 24/7 and send information to third-party auditors who determine compli- ance to the program standards. NSUH credits the monitoring system for its increased ICU hand hygiene compliance rate, which grew from less than 10 percent to more than 85 percent in less than four weeks a rate that the hospi- tal has maintained for three years. In 2010, Princeton Baptist Medical Center, located in Birmingham, Ala., collaborated with Proventix, a technology company, to improve hand hygiene compliance. The hospital implemented Proventix's system, nGage to provide radio frequency identification badges for all hospital staff and physicians. At every soap or hand sanitizer dispenser, a device registered the presence of the RFID badge whenever its wearer cleaned his or her hands. The system then tracked overall compliance with hand hygiene, as well as individual compli- ance. The device also had a screen that presented general or personalized messages to reinforce hand hygiene. Between February 2010 when the system was implemented and August of that year, the rate of healthcare-associated infections was 22 percent lower than the same time frame in 2009. St. Joseph Health Services, located in Providence, R.I., implemented a bun- dle program to reduce the rate of hospital-acquired infections. According to a study published in 2013, the hospital's bundle program, which combined hand hygiene, isolation attire and clean and disinfected equipment, helped the hospital achieve significantly higher levels of compliance with cleanli- ness protocol. St. Joseph's hand hygiene system within the bundle program required hospital employees to wash their hands before and after patient con- tact. Additionally, employees were instructed to wash their hands with either soap and water or with alcohol hand rub for 15 seconds. Lastly, a paper towel or an elbow was used to turn off the faucet. Physicians, nurses and other staff who came into contact with patients were reminded to comply with the hand hygiene component of the bundle program by promotions in posters, buttons, events and even a video that played in the cafeteria. All aspects of the bundle program led to improved compliance rates at St. Joseph's. The hospital met its goal of 90 percent compliance with isolation attire for four consecutive months after implementing the program, and maintained simi- lar levels for the next few years. Norfolk, Va.-based Sentara Healthcare vastly improved its hand hygiene compliance rates across seven hospitals from about 75 percent to 92.5 per- cent in 2012. Initially, hospital officials believed the rate of compliance hov- ered around 95 percent, but a revised audit process showed an actual rate of about 75 percent. Upon this realization, 83 health professionals brainstormed fast and affordable ideas that could help drive up hand hygiene rates. The system hired QualPro, a Knoxville, Tenn.-based consulting form, to help test and analyze 21 interventions in 48 nursing units. Sentara implemented in- terventions including computer screen savers encouraging hand hygiene and Hero of the Month awards to hospital employees who achieved high compli- ance rates. Additional interventions were done in 32 nursing units, including white-board notes, installing red stop signs to remind healthcare workers to clean their hands and written hand hygiene quizzes for physicians and other workers who were randomly stopped by a department leader or executive. These interventions ended up proving most effective. Novant Health's Thomasville (N.C.) Medical Center, increased compliance with hand hygiene protocol from 49 percent to 99 percent between 2005 and 2008. The improvement of hand hygiene behavior led to a 53 percent reduction in MRSA infection rates across the healthcare system. Thomasville Medical Center implemented an internal communication campaign that included screensavers, cling stickers, billboards, yard signs and other tactics to educate hospital work- ers and help change hand hygiene behavior. In 2008, Novant Health and Thom- asville Medical Center were named national winners of the Ernest A. Codman Award from The Joint Commission, an award presented to organizations that demonstrate exemplary performance to achieve healthcare quality improvement. In July 2010, UCSF Medical Center worked with UCSF Benioff Children's Hospital, an infection control team, physicians, nurses, therapists, technicians, spiritual care staff, engineers and others to create a proper hand hygiene pro- gram. Discreet, open and video-recorded monitoring collect hand hygiene compliance data, and a report is created and distributed to hospital staff every