Assigment .Apa seven . All instructions attached.

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Enhancing Hand Hygiene Compliance

Leticia Romeo

Walden University

Leading Org Qual Improvement-Fall 2024

Dr. Susan Lisa Huehn

September 23, 2024

Enhancing Hand Hygiene Compliance

Healthcare can benefit from project management techniques to reduce the QI practice gap and improve patient safety and care. The precise area I have earmarked in my organization, based on the said gap analysis, is the lack of compliance to hand hygiene measures and, therefore, Healthcare-associated Infections (HAIs), Catheter-associated urinary tract infections (CAUTIs), and Central Line-Associated Bloodstream infections (CLABSIs) (Mouajou, Adams, DeLisle, & Quach, 2022). This gap can be effectively closed through the effectiveness of structured project management techniques that would address the needs of the patients.

Quality Improvement Practice Gap

Despite being proven effective, hand hygiene compliance is not rigorous or Standard in my organization, and HAIs remain a concern. The consequences of this behavior are severe as it has led to patient morbidity, increased hospitalization period as well as the general expenditure of fusion as a result of preventable diseases such as CAUTIs and CLABSIs. Focusing on this problem speaks to the Institute for Healthcare Improvement's (IHI) Triple Aim initiatives of optimizing the patient’s experience, improving population health, and decreasing healthcare expenses (Kokko, 2022). Thus, paying attention to this problem is essential to reduce infection rates and patients’ safety and enhance the quality of the provided health care, paying attention to this problem is necessary.

SMART Objectives for the Project

To close this practice gap successfully, it is possible to identify SMART goals that will help facilitate project delivery. These objectives are specific, measurable, assignable, realistic, and timely.

1. Objective 1: Increase hand hygiene compliance among staff from 70% to 95% within six months through enhanced training and daily monitoring.

· Specific: Target compliance rates among nursing staff.

· Measurable: Monthly audits will track compliance.

· Assignable: The infection prevention team will lead the initiative.

· Realistic: The goal is achievable based on prior interventions.

· Timely: Compliance will be assessed monthly, aiming for 95% in six months.

2. Objective 2: Reduce the incidence of CAUTIs and CLABSIs by 50% within one year by improving hand hygiene compliance and increasing access to hygiene resources.

· Specific: Target specific infection types linked to non-compliance.

· Measurable: Infection rates will be monitored monthly.

· Assignable: The infection control team will oversee the initiative.

· Realistic: Proven strategies show this reduction is achievable.

· Timely: With quarterly evaluations, the goal is to reach this reduction within one year.

Recommended Project Management Activities

Two key project management activities—the Plan-Do-Study-Act (PDSA®) cycle and Root Cause Analysis (RCA)—are recommended to support the successful execution of these objectives. Both tools offer a framework for systematically planning, evaluating, and sustaining interventions.

Plan-Do-Study-Act (PDSA) Cycle:

The PDSA cycle is an approach through which the effects of some types of interventions can first be piloted at a small scale before scaling up. The first strategy map would involve specific strategies such as installing more dispensers of hand sanitizers in more frequently used places or creating an information campaign. Such alterations would be done (Do), and the effectiveness would be examined (Study) from the patient compliance rates and the results registered. From the findings, further enhancements can be made under the Act to enhance the interventions’ efficacy in increasing hand hygiene standards.

Justification:

The PDSA cycle entails small iterative, practical changes to enable solutions to be implemented to overcome newer barriers (Manandi, et al., 2023). For example, if the level of compliance does not increase as planned, more investments or classes of intervention may be provided before enlarging the program's scope.

Root Cause Analysis (RCA):

RCA is needed when analyzing why patients were not isolated to reduce the spread of the virus, as it helps to find the root of a problem. It might also feature that the staff workload, poor awareness, or inadequate access to appropriate hygiene products are to blame for the practice gap. Once these root causes are established, specific interventions can address these barriers by altering staff workflows, providing more hygiene products, or offering a broader training regimen.

Justification:

RCA helps to target the root causes of noncompliance and, thus, makes interventions much more efficient (Kumar, et al., 2024). For instance, if workload is defined as a problem, actions such as changes or additions to staffing may be taken to ensure that the solutions selected fit the situation.

Conclusion

In conclusion, filling the gap in hand hygiene compliance is essential in eradicating HAIs and enhancing patient safety. If the organization has well-defined SMART objectives and uses tools like the PDA cycle and RCA in its interventions, it is possible to work towards making such interventions sustainable. Again, these tools allow for upstreaming an approach in PDCA and closing the gap by applying good evidence. Therefore, there will be safer patient care and improved healthcare outcomes.

References Kokko, P. (2022). Improving the value of healthcare systems using the Triple Aim framework: A systematic literature review. Health policy, 302-309. https://doi.org/10.1016/j.healthpol.2022.02.005 Kumar, P., Veluri, A., Palagummi, S. V., Al Dhaheri, S. M., Bazuhair, A., & Surendran, S. (2024). Transforming Reactive into Proactive Monitoring Through Effective Lessons Learned and Enhanced Safety Culture to Prevent Incidents. SPE International Conference and Exhibition on Health, Safety, Environment, and Sustainability? https://doi.org/10.2118/220516-MS Manandi, D., Tu, Q., Hafiz, N., Raeside, R., Redfern, J., & Hyun, K. (2023). The evaluation of the Plan–Do–Study–Act cycles for a healthcare quality improvement intervention in primary care. Australian Journal of Primary Health. https://doi.org/10.1071/PY23123 Mouajou, V., Adams, K., DeLisle, G., & Quach, C. (2022). Hand hygiene compliance in the prevention of hospital-acquired infections: a systematic review. Journal of Hospital Infection, 33-48. https://doi.org/10.1016/j.jhin.2021.09.016