IHP 355 Module 7 Project Two Example

Project Two: A Hand Hygiene Compliance Plan Built on Honest Measurement

[Student Name]

Southern New Hampshire University

IHP 355: Healthcare Regulatory Compliance and Accreditation

Project Two

[Instructor Name]

[Date]

Project Two: A Hand Hygiene Compliance Plan Built on Honest Measurement

Riverbend's infection prevention dashboard showed two numbers that could not both be right. Monthly hand hygiene audits reported 94% compliance, among the best in the hospital's regional network. Meanwhile, hospital-onset C. difficile infections had risen for three straight quarters, and two units had MRSA clusters. When the infection preventionist shadowed staff informally for a week, she saw hand hygiene before patient contact in roughly half of opportunities. This project proposes a compliance improvement plan for hand hygiene, beginning with the requirements behind it, then correcting how compliance is measured and finally introducing interventions supported by evidence.

Sources of Authority

Hand hygiene sits under two requirements with different authorities. The Medicare conditions of participation, federal regulations the hospital must meet to receive Medicare payment, require an active infection prevention and control program, and surveyors review how the hospital prevents transmission of infections, including hand hygiene. Separately, The Joint Commission, the hospital's accreditor, sets a national patient safety goal requiring accredited organizations to follow either the CDC's or the World Health Organization's hand hygiene guidance, to set improvement goals and to improve compliance based on those goals. A failure could therefore lead to a Medicare deficiency citation and an accreditation finding, each with its own follow-up process.

What Compliance Usually Looks Like

Erasmus et al. (2010) reviewed studies of hand hygiene compliance in hospitals and found a median compliance rate of about 40%. Compliance was lower in intensive care units than elsewhere, lower among physicians than nurses and lower before patient contact than after, a pattern suggesting that staff protect themselves more consistently than they protect patients. Against that background, Riverbend's reported 94% is not a sign of excellence but a warning that the measurement system may be flawed.

Why Audits Inflate Compliance

Srigley et al. (2014) used an electronic system that recorded every use of hand hygiene dispensers on hospital units and compared dispenser use when human auditors were visibly present with use when they were not. Hand hygiene events were about three times as frequent when auditors were in view. The study provides direct evidence of the Hawthorne effect, in which people change behavior when they know they are being watched, and shows that directly observed audits can substantially overstate compliance.

Riverbend's audits are performed by unit staff wearing badges that identify them as auditors, at predictable times, with results compiled by the same units. The 94% figure likely measures how staff behave when observed rather than how they behave the rest of the day.

What Improves Compliance

Gould et al. (2017) pulled together the trial evidence on raising hand hygiene rates for the Cochrane Library. They found low-certainty evidence that multimodal strategies, which combine several elements such as alcohol-based hand rub at the point of care, education, reminders, performance feedback and administrative support, may slightly improve compliance, and that single interventions had less consistent effects. The quality of studies was generally limited, and many relied on direct observation with the biases Srigley and colleagues describe. The review supports a combined approach while cautioning against expecting dramatic change.

Step One: Measure Honestly

The first step is to replace the current audits. Trained secret shoppers, drawn from departments outside nursing and unknown to the units they observe, will perform audits at varied times, including nights and weekends, recording opportunities before and after patient contact. Where the budget allows, the hospital will pilot electronic dispenser monitoring on two high-risk units to track the volume of hand hygiene events over time. The hospital should expect reported compliance to fall sharply when measurement changes and should communicate that clearly to staff and the board so the drop is understood as a more accurate baseline, not a decline in performance.

Step Two: Make the Right Action Easy

An environmental review will check that alcohol-based hand rub is within reach at every bedside and room entrance and that dispensers are refilled reliably. Facilities will add dispensers where gaps are found, and environmental services will own daily checks. Glove boxes and sinks will be reviewed on units caring for patients with C. difficile, since alcohol rub is less effective against its spores and soap and water are required.

Step Three: Education, Reminders and Feedback

Education will focus on the moments of hand hygiene, especially before patient contact and before clean procedures, where compliance is lowest. Reminders will include signage at room entrances and brief discussion at safety huddles. Monthly unit-level feedback, using the new honest data, will show each unit its rate by role and moment and will be posted where staff can see it. Physician leaders will present physician-specific data at medical staff meetings.

Step Four: Leadership and Accountability

Nursing's and medicine's top executives will co-sponsor the program and set unit goals. Staff will be encouraged to remind one another, including physicians, with a simple phrase agreed on in advance, and leaders will publicly support staff who speak up. Accountability will focus on units and systems first; individual coaching will follow repeated observed lapses.

Owners, Timeline and Measures

Table 1 summarizes the plan. Process measures are compliance rates from secret shopper audits by unit, role and moment and, on pilot units, dispenser event counts. Outcome measures are hospital-onset C. difficile and MRSA rates. A balancing measure is skin irritation reported to employee health, since heavier use of hand rub can cause dermatitis that discourages compliance.

Table 1. Plan Elements, Owners and Timeline

Note. Owners report progress to the infection prevention committee.

Conclusion

Riverbend's 94% hand hygiene rate was a measurement artifact. By measuring honestly, making hand hygiene easy, providing feedback and engaging leaders, the hospital can meet both its regulatory and accreditation obligations in substance rather than on paper and give infection rates a real chance to fall.

References

Erasmus, V., Daha, T. J., Brug, H., Richardus, J. H., Behrendt, M. D., Vos, M. C., & van Beeck, E. F. (2010). Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infection Control & Hospital Epidemiology, 31(3), 283-294. https://doi.org/10.1086/650451

Gould, D. J., Moralejo, D., Drey, N., Chudleigh, J. H., & Taljaard, M. (2017). Interventions to improve hand hygiene compliance in patient care. Cochrane Database of Systematic Reviews, 2017(9), Article CD005186. https://doi.org/10.1002/14651858.CD005186.pub4

Srigley, J. A., Furness, C. D., Baker, G. R., & Gardam, M. (2014). Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: A retrospective cohort study. BMJ Quality & Safety, 23(12), 974-980. https://doi.org/10.1136/bmjqs-2014-003080