We know it's possible to control the transmission of MRSA with proper hand hygiene and screening programs. But small problems can torpedo even the most comprehensive clean-and-screen policies. Whether it's the rushed physician who walks right past the hand sanitizer dispenser or the tech who stops wearing gloves because there aren't enough in the suite, cutting corners on clinical practices while treating a MRSA-infected patient can quickly lead to an outbreak. To prevent this, you need to find and remove the obstacles that make clinical practice guidelines so difficult to follow.

Begin with everyone involved
If people are shortcutting your infection control program, it's not necessarily because they're negligent. It's more likely that they don't know what to do or run into obstacles that make the right thing hard or even impossible to do.

First, find out where the problems are. That means getting input from everyone involved. In a small surgery center, you can accomplish this with a staff meeting, but for larger facilities you may want to create a team of 10 to 12 persons from a wide range of disciplines (don't forget environmental services and supply techs). Ask them what they think is wrong with the current processes related to preventing the transmission of infectious diseases.

This group approach works because often the problems come from isolation, and this gives you a chance to break down barriers between departments. Let everyone say what they see as a problem in front of members from other departments. For example, many facilities have environmental services stock the gowns, but they're already working on another suite before anyone has a chance to let them know that they didn't leave enough.

Once you've identified the problems, the next step is to map out your process to find out the steps involved with these clinical practices, who does what and where the problems are originating in your facility. This will give you and your staff an understanding of the clinical processes, and it can also highlight the importance of teamwork.

Fixing the problems
For infection control practices, particularly procedures designed to prevent the spread of MRSA, you may already have an existing policy requiring staffers to sanitize their hands between patients. But when you sit down with the group, you may uncover excuses: the sanitizers aren't always stocked, they're in an inconvenient location, perhaps the product leaves hands dry and uncomfortable after multiple uses. It's clear you need to make sanitizers easier to access and use. Some ways to do this are to:

• Keep it convenient. Putting a sanitizer in every room will make it easy for staffers to clean their hands. Put sanitizers outside the rooms as well to make it easy for those in the hallway or as a backup in case the first dispenser is empty.
• Standardize. If the dispensers are usually on the right side of the door, a nurse may get confused when she goes into one of the rooms where it's on the left. But if they're always in the same spot, she can get in the habit of reaching to that side before touching anything else. Again, ask the team to try out different locations to find the ones that work for them.
• Make it prominent. If your staffers don't notice white dispensers against white walls, paint the dispensers red or some other bright color to visibly remind them. Make sure that isolation signs reminding staffers how to deal with infectious patients are easily accessible and visible. Be sure to involve the team members when redesigning signs, too.
• Test multiple hand sanitizer products. Bring in multiple vendors and let the staff test and choose the product that they prefer. Then they'll not only be satisfied with the product, but also with the fact that you asked them to participate in the selection process.
• Use 30-seconds-or-fewer as a rule. In general, workplace supplies should be easy to see, to use and (for instruments) to return. For equipment and supplies that are used at least once a month, work with your staffers to organize them so they can be found as quickly as possible. Try to make 30 seconds your goal.

Equation for sustainability
When you're done with this process, you'll find your infection control policies will become a combination of standardized clinical practice guidelines with realistic implementation strategies. And since your staffers have been heavily involved with the process, they'll understand the reasoning for each measure.

In the hospitals that we work in, we've found that the level of standardization is inversely proportional to the level of staffers' engagement. As a result, we have developed an informal rule to limit standardization of practices to those with supporting evidence of impact to patient outcomes (such as hand hygiene and contact isolation for MRSA). For everything else, including the processes that are developed to implement these practices, we encourage the staff members to get involved and find the solutions that work well for them.

Another benefit to using the whole facility or a facilitated team is that the staffers are invested in the solutions and more apt to follow rules that they set for themselves. They now understand what they have to do and why, so they're not as likely to fall back into their old habits.