Lori Moore joined GOJO Industries in 2013 as a Clinical Application Specialist. In this position, she provided leadership and support to healthcare organizations as they implemented electronic compliance monitoring (ECM) to more accurately measure hand hygiene performance. She has been a trusted partner to hospital key stakeholders in the development, design and implementation of hand hygiene improvement efforts. Areas of expertise include root cause analysis with targeted solutions, just-in-time coaching and ECM software data analytics. In January 2017, she transitioned to the position of Clinical Educator for Healthcare. She began her professional career in healthcare in 2010 as a registered nurse in the medical intensive care unit at the Cleveland Clinic Foundation (where she continues to work on the weekends). Her passion for patient safety and quality of care sparked her interest in infection prevention, and she worked as an infection preventionist prior to joining GOJO. Lori has a well-rounded academic background which includes a Bachelor’s of Arts in Management from Malone College, a Bachelor’s of Science in Nursing from the University of Akron, and a Master’s degree in Public Health from the University of Akron. She is a member of the Association for Professionals in Infection Control and Epidemiology, American Society of Professionals in Patient Safety, and the American Medical Writers Association. She has also earned the credential of Certified Health Education Specialist (CHES) and Certified Professional in Patient Safety (CPPS).

1. The Complexity of Hand Hygiene
Sharing the Load
Lori Moore, BSN, RN, MPH, CPPS
©2018. GOJO Industries, Inc. All rights reserved

2. Objectives
• Discuss the disproportion responsibility between infection prevention and
control professionals and hand hygiene behavior change of those at the
bedside
• Describe why the nurse manager is better positioned to impact hand
hygiene behavior
• Summarize how a paradigm shift can lead to improvements in hand
hygiene
• Discuss the value of unit-led Just-In-Time coaching in providing a strong
infrastructure upon which to improve unit-level safety culture
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3. Why is Hand Hygiene Challenging?
Complexity Theory
• Healthcare systems are systems that are
complex and adaptive
• Actions in delivering health care are not always predictable
• Variation results from unpredictability of behavior
• Some actions need to be predictable with a high level of reliability
• A few simple rules can guide complex behavior toward a goal
SIMPLE
COMPLEX
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4. Why is Hand Hygiene Challenging?
Complexity Theory
Simple
The
mechanics
of cleaning
hands
Complicated
The development
of innovative products
for cleaning hands
Complex
Hand hygiene within a healthcare system
• Involves many individuals—all independent thinkers
and decision makers
• The task that is performed the most in any healthcare
setting:
• Unit level
• 24-bed ICU = 34,000 room entry/exit per week
• 30 bed Med = 35,000 room entry/exit per week
• Hospital level (22 units, 500 beds)
• 520,000 room entry/exit per week
• 74,000 room entry/exit per day
©2018. GOJO Industries, Inc. All rights reserved

5. Why is Hand Hygiene Challenging?
• Hand hygiene responsibility and accountability typically falls on the
shoulders of infection prevention and control professionals / quality
personnel
• The responsibility is disproportionate to the opportunities for hand hygiene
• ICPs are not in a position of responsibility or authority over the individuals
entering and exiting patient rooms who are the targets of behavior change /
modification
• Disadvantage in follow-up ability
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6. Safety Culture
Organizational Level Local Level
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7. Relationship Building
Nurse Managers
Strong impact on direct patient care providers
• Create culture—leadership sets the culture
• Responsible and accountable for the care of the patient
and outcomes (by anyone who provides care to the patient
or the environment); ensure quality metrics
• Strong influence over performance
• Manage underperformance, set goals, plan for improvement
• Reside on the unit
• Inspire and empower unit staff to solve problems
• Ability to easily and often observe caregiver performance
Infection Prevention and Control Professional
Impact on direct patient care providers----
• Program management
• Global perspective
• Consultative role
• Interpretation of the 4 Moments in the context of workflow
• Hand hygiene education development and roll out©2018. GOJO Industries, Inc. All rights reserved

8. What Makes Sense?
10
NURSE
MANAGERS
50
STAFF
MEMBERS
Responsible
for hand
hygiene
behavior of:
1
INFECTION
PREVENTION
AND CONTROL
PROFESSIONAL
500
STAFF
MEMBERS
Responsible
for hand
hygiene
behavior of:
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9. Shifting the Paradigm
NURSE
MANAGERS
DIRECT PATIENT
CARE
PROVIDERS
INFECTION
PREVENTION
AND CONTROL
PROFESSIONAL
Working through others to influence behavior and safe patient care at the bedside
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10. Front Line Leadership Engagement
Unit Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9
1
Rate 27% 29% 35% 30% 29% 36% 38% 44% 51%
Events 27,988 30,259 36,643 32,303 29,234 40,329 37,043 44,910 51,715
2
Rate 52% 50% 50% 50% 51% 58% 57% 59% 65%
Events 65,905 60,749 64,067 68,304 65,214 72,428 73,322 69,147 77,198
3
Rate 36% 39% 44% 46% 48% 49% 45% 50% 60%
Events 63,706 68,671 76,487 81,309 72,878 86,328 84,649 81,486 95,268
4
Rate 24% 28% 24% 24% 24% 33% 31% 34% 36%
Events 23,852 24,075 20,636 22,132 20,915 31,282 26,258 28,484 31,224
Nurse Managers became engaged with hand hygiene
©2018. GOJO Industries, Inc. All rights reserved

11. Just-In-Time Coaching
• Interact with frontline staff
• Directly observe barriers to hand hygiene
• Observe instances of noncompliance and ask caregivers why they did not
clean hands
• Provide reminders, feedback and education
• Categorize directly observed and solicited barriers to hand hygiene
• Tailor solutions to each barrier
OBSERVE
Behavior & Workflow
SEEK
Barriers
EDUCATE
REMIND
RAISE
Awareness
ENCOURAGE
FEEDBACK
DEVELOP
Solutions
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12. METHODS
A trained HH observer entered a nursing unit at
9 a.m. and gathered healthcare workers (HCWs)
to determine perceived barriers and other
factors felt to be contributing to the low unit
HHP. The observer informed HCWs that
workflow would also be observed to identify
barriers. At 11 a.m. observation ended, and the
HCWs were informed that the observer was
leaving the unit. Unit-level HHP data was
collected via an electronic monitoring system
(EMS) before, during and after the observation
period.
High Hand Hygiene Performance Can Be Achieved Despite Barriers:
The Value of Pairing Direct Observation with
Electronic Hand Hygiene Monitoring
BACKGROUND
Identifying and eliminating hand hygiene (HH)
barriers is imperative to increase HH
performance (HHP). Complete elimination of
barriers is unlikely, but the need to eliminate
barriers to increase HHP may be overstated.
This study examines the effect of direct
observation (DO) on HHP in the presence of
barriers. Results provide insights about the
extent to which barriers limit HHP.
Lori Moore BSN, RN, MPH, Jeff Quinn PhD, Robert Pelz MBA, PMP
GOJO Industries, Inc., Akron, OH
RESULTS
Reported barriers included an insufficient
number and inconvenient placement of
dispensers, empty dispensers, full hands and
physician non-compliance, all of which were
validated through DO. Without removing
barriers, the unit achieved a 56 percentage point
increase in HHP during the observation period.
Staff were notified that observation was ending,
and subsequently HHP decreased by 36
percentage points.
CONCLUSIONS
➢This study demonstrates that HCWs can
achieve high HHP despite barriers.
➢Barriers to HH were present throughout the
shift, even while the observer was present, but
did not prevent staff from reaching high levels
of HHP while being observed.
➢Results show HHP differs greatly when an
observer is present versus absent, an impact
of the Hawthorne effect, that can only be
measured with EMS, not DO.
➢Units relying on DO may inaccurately assume
that HHP is high when an observer is absent,
but it is likely that rates are lower before and
after periods of DO, further demonstrating the
importance of EMS data to provide accurate
estimates of HCW HHP.
➢This study demonstrates that barriers are not a
deterrent to a temporary increase in HH rates.
REFERENCE
Baulcomb, JS. Management of change through force field
analysis. Journal of Nursing Management. 2003; 11:275-280.
For additional information contact: L. Moore,
GOJO Industries, Inc., Email: moorel@gojo.com
©2017 GOJO Industries, Inc. All rights reserved

13. METHODS
A trained HH observer entered a nursing unit at
9 a.m. and gathered healthcare workers (HCWs)
to determine perceived barriers and other
factors felt to be contributing to the low unit
HHP. The observer informed HCWs that
workflow would also be observed to identify
barriers. At 11 a.m. observation ended, and the
HCWs were informed that the observer was
leaving the unit. Unit-level HHP data was
collected via an electronic monitoring system
(EMS) before, during and after the observation
period.
High Hand Hygiene Performance Can Be Achieved Despite Barriers:
The Value of Pairing Direct Observation with
Electronic Hand Hygiene Monitoring
BACKGROUND
Identifying and eliminating hand hygiene (HH)
barriers is imperative to increase HH
performance (HHP). Complete elimination of
barriers is unlikely, but the need to eliminate
barriers to increase HHP may be overstated.
This study examines the effect of direct
observation (DO) on HHP in the presence of
barriers. Results provide insights about the
extent to which barriers limit HHP.
Lori Moore BSN, RN, MPH, Jeff Quinn PhD, Robert Pelz MBA, PMP
GOJO Industries, Inc., Akron, OH
RESULTS
Reported barriers included an insufficient
number and inconvenient placement of
dispensers, empty dispensers, full hands and
physician non-compliance, all of which were
validated through DO. Without removing
barriers, the unit achieved a 56 percentage point
increase in HHP during the observation period.
Staff were notified that observation was ending,
and subsequently HHP decreased by 36
percentage points.
CONCLUSIONS
➢This study demonstrates that HCWs can
achieve high HHP despite barriers.
➢Barriers to HH were present throughout the
shift, even while the observer was present, but
did not prevent staff from reaching high levels
of HHP while being observed.
➢Results show HHP differs greatly when an
observer is present versus absent, an impact
of the Hawthorne effect, that can only be
measured with EMS, not DO.
➢Units relying on DO may inaccurately assume
that HHP is high when an observer is absent,
but it is likely that rates are lower before and
after periods of DO, further demonstrating the
importance of EMS data to provide accurate
estimates of HCW HHP.
➢This study demonstrates that barriers are not a
deterrent to a temporary increase in HH rates.
REFERENCE
Baulcomb, JS. Management of change through force field
analysis. Journal of Nursing Management. 2003; 11:275-280.
For additional information contact: L. Moore,
GOJO Industries, Inc., Email: moorel@gojo.com
©2017 GOJO Industries, Inc. All rights reserved
©2018. GOJO Industries, Inc. All rights reserved

14. Unit-Led Just-In-Time Coaching
©2018. GOJO Industries, Inc. All rights reserved

15. 6%
15%
10%
3%
15%
10%
18%
33%
39%
45%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8 9 10
%ImprovementOverBaseline
Months Post Installation
Staff
Education
JIT
Coaching
Unit
Leadership
Engagement
Physician
Engagement
% improvement over baseline Linear % improvement over baseline Sr. Leadership Engagement
Sr. Leadership
Engagement
One Hospital Unit's Journey
©2018. GOJO Industries, Inc. All rights reserved

16. 6%
15%
10%
3%
15%
10%
18%
33%
39%
45%
48%
36%
52%
82%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8 9 10 11 12 13 14
%ImprovementOverBaseline
Months Post Installation
Post Study
Staff
Education
Unit
Leadership
Engagement
Physician
Engagement
Night
staff
engaged
Unit-Led
JIT
JIT
Coaching
Sr. Leadership
Engagement
The Journey Continues
% improvement over baseline Linear % improvement over baseline
©2018. GOJO Industries, Inc. All rights reserved

17. Summary
• ICPs historically have held a disproportionate role in the task of changing
hand hygiene behavior of care providers
• Nurse managers are best positioned to influence and impact behavior at
the bedside
• This paradigm shift can lead to improvements in hand hygiene
• Unit-led Just-In-Time Coaching
• When we have a unit full of independent problem solvers, we have created a
culture of safety
©2018. GOJO Industries, Inc. All rights reserved

18. Summary
• ICPs historically have held a disproportionate role in the task of changing
hand hygiene behavior of care providers
• Nurse managers are best positioned to influence and impact behavior at
the bedside
• This paradigm shift can lead to improvements in hand hygiene
• Unit-led Just-In-Time Coaching
• When we have a unit full of independent problem solvers, we have created a
culture of safety
“You’ll know you’ve achieved a safe culture when you see
someone low in the hierarchy—say, a new nurse—reminding a
senior physician to wash his or her hands, and the physician
responds by simply saying, “thank you,” then turns to the sink
or gel dispenser.”
Robert M. Wachter, MD, Understanding Patient Safety
©2018. GOJO Industries, Inc. All rights reserved
©2018. GOJO Industries, Inc. All rights reserved

19. THANK YOU!
©2018. GOJO Industries, Inc. All rights reserved

20. References
• Boamah, SA, Spence Laschinger, HK, Wong, C, & Clark, S. 2017. Effect of transformational leadership
on job satisfaction and patient safety outcomes. Nursing Outlook.
https://doi.org/10.1016/j.outlook.2017.10.004.
• Gawande A. The Checklist Manifesto: How To Get Things Right. New York: Metropolitan Books;2009.
• Plesk, P. Redesigning health care with insights from the science of complex adaptive systems.
Appendix B in: Committee on Quality Health Care in America, Institute of Medicine. Crossing the
Quality Chasm: A New Health System for the 21st Century. National Academy Press; 2001:309-322.
• Pronovost PJ, Sexton B. Assessing safety culture: guidelines and recommendations. Qual Saf Health
Care 2005;14:231-233.
• The Joint Commission. Hand Hygiene Project: Best practices from hospitals participating in the Joint
Commission Center for Transforming Healthcare Project. November 2010.
http://www.hpoe.org/Reports-HPOE/handhygiene11.2010.pdf
• The Joint Commission. Sustaining and spreading improvement in hand hygiene compliance. Journal on
Quality and Patient Safety. 2015;41(1):1-25.
• Wachter, RM. Understanding Patient Safety. China: The McGraw-Hill Companies, Inc., 2012.
©2018. GOJO Industries, Inc. All rights reserved