Hand Hygiene Compliance

Western Governor University

Task 1 C493 Leadership Identify a problem or issue that aligns with the organizational priorities you seek to solve. Explain the problem or issue, including why it is applicable to the area of practice you chose and the healthcare environment When identifying an organizational problem to solve, a major concern that I found was that infection control is still an issue. Preventing the start of infections in the hospital is a multi-disciplinary approach. Infections effect more than 1.7 million Americans are diagnosed with a hospital-acquired healthcare-associated infection (HAI), with almost 100,000 dying from their infection( Four Facts about Infection and Its Prevention 2018) In my current role as a registered staff nurse on a 16 bed medical surgical unit hand hygiene is major contributor to hospital acquired infections. This is applicable to the area that I practice in because decreasing hospital acquire infections is an important preventable task that is a responsibility to my career.

Discuss your investigation of the problem or issue. Provide evidence to substantiate the problem or issue (e.g., organizational assessment, national source documents, evidence from a stakeholder). In my facility we use hand monitors to monitor hand hygiene compliance on each unit and outpatient setting. These monitors observe the providers, nurses, respiratory therapist, physical therapist, patient care techs, sitters, dietary, transporters and janitors are all secretly watched by someone on their unit. The monitor observes anyone who interacts with patients. The monitor watches to see if they have used hand sanitizer or wash their hand before, after or in between patient contact, they also make sure all staff are using personal protective equipment (PPE). The secret monitors a minimum of 50 observations in each month and turns them into infection prevention. The previous three months of hand hygiene compliance are prior to my project are as follows below. Critical Care Hand Hygiene Month Compliance percent January 2019 100% February 2019 75% March 2019 55% April 2019 59%

The expectation is 100% compliance for hand hygiene within the hospital. The Joint Commission completed their site visit in January which is why I feel these numbers were somewhat increased in February but continued to decrease. These decrease in numbers had let to what we considered to be hospital acquired infections on my unit....

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