7. HANDHYGIENECOMPLIANCE
“HANDY”TIPS FOR SUCCESS!
Here are some ideas to help you get maximum support for hand hygiene compliance in
your departments:
Take a “hands” on approach: Play an active role in leading the hand hygiene
compliance effort by setting an example and demonstrating good hand hygiene
yourself!
Lend a “hand”: When schedules get hectic, it’s easy to forget even the most
important of tasks, such as practicing good hand hygiene. Encourage employees
to help each other out with gentle reminders to wash their hands. The only
response when reminded should be “thank you” (Clean – Remind – Thank!).
After all, it’s better to have a colleague remind you than to have a patient ask
you.
All “hands” on deck: Use hand hygiene as an opportunity to foster teamwork
and strengthen relationships. Regular department meetings are a great occasion
to remind everyone about expectations.
Be a safe pair of “hands”: Remind your teams that patients already have
enough to worry about. Wondering if their healthcare providers are practicing
safe hand hygiene shouldn’t be a concern! Patient safety is everyone’s
responsibility.
Give a “hand: Don’t forget to celebrate small wins in addition to the big
successes. Be sure to thank employees for their hard work and let them know
that their adherence to standards makes a difference in our community and the
care we provide our patients.
Remember, achieving goals is most successful when everyone participates. Be sure
to ask employees for feedback on how to improve your department’s hand hygiene
compliance rates. With your support, Team UMHS can tell germs to talk to the “hand!”
MARCH 2016
Hand Hygiene
Manager Action Plan

8. Goal
• Goal is to have 90% of all UMHS employees hand hygiene compliant by June 1.
Immediate Action Required
You are responsible for:
• Achieving 90% total compliance in your departments.
• Communicating the importance of hand hygiene to all employees using the provided
talking points. Plan to complete your initial meetings with employees by XXX.
• Setting clear expectations regarding the value of, support for, and adherence to
hand-hygiene practices.
• Developing a reporting structure to demonstrate that you have communicated with all of
your employees. The reporting deadline to your XXX is XXX.
Ongoing Action Required
• Monitor your department’s hand hygiene observation reports and take additional action
when necessary to increase results.
• Set an example! Be enthusiastic and supportive about the importance of hand hygiene,
and most importantly, demonstrate adherence to hand hygiene practices.
Contacts:
• Lisa Sturm, infection prevention director, UMH, 6-6355
• Nicole Templeton, quality improvement manager, office of clinical affairs, 6-5438
• Laraine Washer, MD, associate professor of internal medicine, 6-5205
ACTIONPLAN
• Thank you for attending today’s meeting.
• As many of you know, hand hygiene compliance is an ongoing priority for UMHS.
• Currently, our health system’s overall compliance rate is 63%. I’m sure you all agree that this is unacceptable.
• While the good work surrounding hand hygiene has helped to move the needle in a positive direction over the
last several months, there’s still more work to be done.
• And we need your help.
• In an effort to continually reduce patient infection rates, a goal of 90% hand hygiene compliance has been set for
the organization.
• The deadline to reach this goal is June 1.
• As healthcare professionals, we have a responsibility to promote and practice good hand hygiene measures with
our patients and each other.
• I expect you to wash your hands before and after caring for each patient. This is the standard not just within the
unit, but across the organization.
• The reason is simple: Clean hands are the first line of defense and one of the most important ways to prevent the
spread of infection and illness.
• To be clear, employees who violate this policy will be subject to disciplinary action including (Insert
department-specific discipline policy here).
• I know I can count on all of you to deliver on our mission to achieve higher levels of excellence in patient care.
• If you have further questions about hand hygiene or suggestions on how we can meet or exceed our compliance
goal of 90%, please let me know.
TALKINGPOINTS

9. ORDERENTRY
Compounding
takes extra time
FILLING QUALITYASSURANCE
What we check:
• Five medication “Rights”
• Drug interactions
• Allergies
For discharge Rx’s,
Pharmacy notifies
care team for pick up
PICKUP
To serve patients, we need:
• Patient confirmation to fill Rx here
• RxInsurancecard
• AccurateRx≥4hrsaheadofdischarge
• Compoundsmustbeprintedandsent
to tube station
NEED TO CHANGE OR CANCEL RX?
IT’S OK! CALL 61041
GUIDETO DISCHARGE PRESCRIPTIONS
TYPES OF RX’S THAT SHOULD BE FILLEDAT TAUBMAN: Highcostanddifficulttoobtainmedications,
like compounds, injections, controlled substances, and medications requiring prior authorizations.
HOURS: M-F 9:00 am - 6:00 pm • Sat 9:00 am - 4:30 pm • DISCHARGING PTS ONLY : Sun 11:00 am - 3:00 pm
CONTACT INFORMATION: Main 734 936 8260 • Direct 734 936 1041 • Discharge Triage RPh Pager: 34831 • Tube Station: 351
LIST OF DIFFICULT TO OBTAIN MEDICATIONAVAILABLEAT: https://pharmwebsp.med.umich.edu/AmC/SitePages/Home.aspx

10. DEFINING VALUE
Making improvements in:
MECHANISMS TO INCREASE VALUE
HOW CAN WE
IMPROVE OUR VALUE?
In my new role here, I’m charged to be a resource to all
units across the system to help make improvements that
add value to our missions in the most cost effective way.
- Keith Gran
Chief Value Improvement Officer
Patient
Experience
Faculty
Staff
Experience
Students
Residents
Experience
Operational
Effieciency
Workflows
Focus
Develop internal expertise to maintain changes made with
help of external resources.
Manage Change
Lead and manage change in both clinical and non-clinical
settings.
Measurement
To track our progress on both financial and non-financial
goals.