Balancing Systems and Individual Accountability in a Safety Culture

December 22, 2010To: Medical Director, MDAdministrative ManagerFrom: Thomas R. Talbot, MD, MPHChair, Hand Hygiene Pillar Goal CommitteeGerald B. Hickson, MDDirector, VUMC Clinical Risk and Loss PreventionNancye Feistritzer, RN, MSNCo-Chair, Hand Hygiene Pillar Goal CommitteeAssociate Hospital Director, Perioperative ServicesCC: Department Chair, MDQuality and Patient Safety Director, MDAssociate Hospital Director (units), RN, MSNAdministrative Area Manager, RN, MSNWe are allcommitted tominimizing therisk ofhealthcareassociatedinfections.Performinghand hygiene isthe mostimportantaction we cantake …Awareness Letter…your areacompliancerate was 35%,and for FY11-to-date, 47%.A member of ourPillar GoalCommittee team willcontact you toschedule a time tomeet so we maypartner in achievingincreased handhygiene in your area.Re: Hand Hygiene Compliance - Level 1 “Awareness”We are all committed to minimizing the risk of healthcare-associated infections. Performing hand hygiene is the most important action we can taketo reduce the spread of these infections to our patients and ourselves. For FY11, VUMC’s reach goal for hand hygiene is 95% compliance.A recent audit of hand hygiene observations places your area among those services with a low rate of compliance with hand hygiene. We arewriting to share the data with you.The average compliance rate for all VUMC units was 80% in November 2010 and 79% for FY11-to-date. Many units have achieved compliancerates above the threshold goal of 85%. For November 2010, your area compliance rate was 35%, and for FY11-to-date, 47%.A member of our Pillar Goal Committee team will contact you to schedule a time to meet so we may partner in achieving increased hand hygiene inyour area. In the interim, a copy of the hand hygiene expectations for all Vanderbilt employees is attached so that you may review with your staff.Information on how to improve hand hygiene compliance may also be found at www.mc.vanderbilt.edu/handhygiene.Thank you in advance for your team’s active participation and efforts to improve your area’s hand hygiene compliance rate to help us reduce therisk of infection for VUMC patients. As this is an ongoing quality improvement program, we will continue to provide you with regular reportsregarding the compliance rate within your area. If you have questions or need more information, please do not hesitate to contact either of us.This material is confidential and privileged information under the provisions set forth in T.C.A. 63-6-219 and shall not be disclosedto unauthorized persons.67NPSF Professional Learning Series