A different kind of bundle

St. Joseph Health Services of Rhode Island program has achieved high compliance with isolation attire and hand hygiene.

Where: St. Joseph Health Services of Rhode Island.

The issue: Improving clinician compliance with established infection prevention measures.


In 2006, bundles were a hot trend. Hospitals around the country were starting to use them to reduce infections associated with catheters and ventilators. Marlene Fishman, MPH, CIC, the director of infection prevention and control for St. Joseph Health Services of Rhode Island, wondered if they could have broader applications.

“I thought it would be a great idea to implement a general bundle that was very simple—a bundle that could connect the dots for everyone and impact health care-associated infection outcomes,” said Ms. Fishman.

She and her colleagues decided to target three key components of infection prevention for clinicians in the hospital to work on improving compliance. “We decided we needed to combine hand hygiene, isolation attire, and clean and disinfected equipment,” she said.

How it works

They created a compliance publicity campaign that revolved around the number three: “It's as easy as 1, 2, 3” and “Don't be puzzled over preventing infections. Remembering is easy when you take it in 3s.”

Each of the three components also had three steps. “For hand hygiene, it was first that people should wash their hands, before and after patient contact. Two, either wash with soap and water or rub your hands with alcohol hand rub for 15 seconds. The third was to use a paper towel or your elbow to turn off the faucet,” said Ms. Fishman.

The three-part messages were promoted in posters, buttons, events, even a video playing in the cafeteria. “We created storyboards to be used in different programs on patient safety and infection prevention,” Ms. Fishman said. “There were raffles [and] games to catch people washing their hands, cleaning the equipment and wearing the attire.”

Changes were also made to the hospital to facilitate compliance with the recommendations, including the installation of touch-free alcohol dispensers and a new system of identifying clean equipment. “We purchased a custom tag that our rehabilitation team had designed and they successfully piloted that on their unit. It looks like a coiled key ring with a bright neon-pink tag with the slogan ‘Ready for Use’ on it,” said Ms. Fishman. “People put that on equipment that they have cleaned and disinfected, so that the next colleague who needs to use that piece of equipment will be able to recognize that it's clean.”

Program champions were appointed and taught how to approach fellow clinicians they witnessed not complying with all the recommendations. “They had some options in how to approach the person. A pre-scripted response makes it a little easier to talk to people in a nonthreatening, nonpunitive manner,” Ms. Fishman said.


The program started as a targeted effort on three floors, and the program leaders assessed its effects by simply observing practices on the pilot units.

“We calculated a simple compliance rate, and we provided feedback every quarter to the targeted floors. Our goal was to achieve at least 90% compliance with isolation attire, and we did that initially for four consecutive months on two of the targeted floors,” said Ms. Fishman. Other floors voluntarily joined the project and have had similar successes, she added.

Hand hygiene rates have been similarly high, but the team just launched a new secret shopper program to better assess compliance with this measure. “Hand hygiene compliance is really dependent on how the observations are done. We know that we can't be out there every second of the day,” said Ms. Fishman. Now any hospital staff member could be a secret shopper watching and recording opportunities taken or missed to wash hands.

Next steps

Building on this success, Ms. Fishman is moving her focus to “Clean Spaces, Healthy Patients,” a new collaborative initiative by the Association for Professionals in Infection Control and Epidemiology and the Association for the Healthcare Environment.

“As our first step, we asked [hospital staff] to be committed to the environment. If they see something, like a small spill [or] somebody dropped a wrapper, be committed to fixing that—cleaning it up or getting help from people who are properly trained,” said Ms. Fishman.

Words of wisdom

Bundling holds potential as a solution to some of the challenges faced by many hospitals, Ms. Fishman said. “It's a question of focus and engaging people to motivate colleagues. As long as an organization keeps the bundle simple, then people can focus on where they need to improve and how they can keep patients safe.”