Hand hygiene compliance is a critical component of health and is necessary for preventing infections. This is practiced and assessed regularly in hospitals, however, there little is done to track its implementation and the compliance level in other health settings like nursing homes. It is important because it helps in reducing the spread of diseases between the health providers and the patients in nursing homes, thus, improving the quality of medical services offered to patients. Batalden and Davidoff, define quality improvement as the efforts of medics, patients, their families, and other stakeholders, to initiate changes that can produce better patient outcomes, better care, and better professional development. The focus on enhancing healthcare standards in the field of nursing and the entire health provision aims to attain efficiency, minimize operation costs, and realize satisfactory patient treatment outcomes. It involves collecting and reviewing both patient and their medical data, and analyzing how the care was administered to evaluate the extent of its delivery successes and areas to improve on.
The auditing done on hand hygiene compliance for quality improvement is to reduce medical errors, limit patients getting other infections during the care process, and prevent hospital readmissions. The goal of improvement is to enhance patients’ safety, provide care that is timely, respectful, and adhere to patient preferences. Further, it aims to provide scientifically backed interventions that are not wasteful in terms of ideas, treatments, equipment, and drugs. Hand hygiene compliance quality must also not vary depending on patients’ gender, race, location, and socioeconomic status. This framework ensures the effectiveness of the care, and the safety of the patients, and makes clients understand and see the meaning of the care provided.
This essay is focused on a Dublin nursing home with a bed capacity of 41 patients. The facility does a hand hygiene compliance audit every month and the last one was carried out on March 01, 2022. The process is usually conducted by the Assistant person in charge, however, the exact date is unannounced although it normally falls between the 1st and 2nd week of the month. In the past, audits were done after all staff went through hand hygiene online training. Contrary to what was expected, there were still no improvements in compliance by the healthcare practitioners. Thereby, prompting the assistant person in charge to form a team and to organize a meeting with nurses, carers, and other staff to deliberate on reasons for non-compliance. Issues such as lack of enough posters, skin irritation, forgetfulness, negative attitude of nurses, lack of time, workload, and poor role models by nurse leaders have identified reasons for poor compliance. Therefore, the team initiated a one-month project to correct this weakness at the facility. The purpose of the project was to plan, design, implement, audit, evaluate interventions, and provide feedback for the nursing home.
Dublin nursing home intends to comply with NPSG.07.01.01 and standard precautions. It will achieve this by implementing a hand hygiene program that follows groups IA, IB, and IC of CDC 5. Additionally, the nursing home must follow the current WHO hand hygiene guidelines as reported by the Joint Commission 6. Nursing homes followed the hierarchical viewpoint to infection control standards including the local, state, and federal regulations 6. Based on the organization’s risk assessment, its priorities, commitments to see the project of hand hygiene compliance succeed, and the resources available, Dublin home decided to set its compliance goal numerically at 90%. Meaning that by mid-April, the nursing home will have increased hand hygiene compliance among all nurses, carers, and other providers to 90%. Dublin nursing home leaders will ensure that all tasks and interventions are implemented by all the staff 6. Data will be collected, analyzed, and reports generated will be shared and communicated to all stakeholders for action.
Stakeholders of the Dublin nursing home convened a meeting at the facility following the poor findings of the last audit report done on March 1, 2022. The stakeholders resolved to improve on the areas identified as the weaknesses impeding the success of hand hygiene compliance. It was agreed that the whole intervention is rolled out as a specific project with deliverables for a period of one year to assist the team in learning and practicing the standards.
Stakeholders approve that larger posters with information about hand hygiene compliance be displayed at all entry points to the facility, all doors for accessing the patients’ rooms, general wards, consultation rooms, and treatment rooms. Nurse leaders will be expected to demonstrate commitment to hand hygiene and they will actualize this by appointing one of the leaders to monitor the conduct of their colleagues. The stakeholders agreed to purchase hand sanitizers that are not irritating the skin. Further, it was agreed that every month a seminar will be held to sensitize staff on the importance of hand hygiene and to motivate them to have positive attitudes towards the process. Additionally, hand hygiene compliance will be implemented at 8 designated points within the nursing home.
Direct observation of hand hygiene by the nurses and carers was used to gather data each and every time the nurses attended to patients in different wards and rooms. This method is capable of generating data that is beyond numbers and statistics and gives real-time information. The observation involves documenting activities, behavior, and physical aspects of a situation without having to depend on peoples’ willingness or ability to respond accurately to questions. In this project, both simple and behavioral techniques of observation were used. Numerical data were gathered using a toolkit that was marketed each time the nurses and carers washed their hands at any of the 8 washing points. The behaviors of the staff towards the hand hygiene program were also monitored and recorded every time they passed the designated areas before seeing the patients. This method enabled the Dublin nursing home to gather the number of staff who comply with hand hygiene daily and to monitor how effectively the nurses and carers are adhering to the program.
Evaluation and Reporting
The data collected was evaluated using the quality improvement toolkit with specific, measurable, actionable, and achievable, relevant to Dublin home care, and timely. The assessment was based on the changes the facility expected to realize as the possible outcomes when the project is completed. And these changes are presented in the forms of graphs and numeric information and the state of hand hygiene compliance after the intervention. The findings of this project were then reported to key stakeholders of the Dublin nursing community including nurses, care assistants, housekeeping, Catering staff, and other auxiliaries. Reporting is meant to let stakeholders know where they stand currently in terms of compliance goals of the nursing home. Further, it will increase the staff focus on the importance of scaling up the hand hygiene activities in the whole Dublin nursing home by improving the weak areas. Additionally, the stakeholders will be able to inculcate strong hand hygiene practices within the facility.
All the staff of Dublin nursing home was audited for a period of 1 day during the second week of April 2022. The data were recorded before some procedures on the patients and after. It included before touching a patient, before clean/aseptic procure, after body fluid exposure risk, after touching a patient, and after touching patient surroundings. Additionally, observation was made of Health workers wearing no more than 1 ring, no wrist jewellery is worn, staff sleeves are short, nails are short, no nail vanish is worn, and no false nails are worn. Auditing was conducted on all nursing home employees who included staff nurses, care assistant, catering staff, housekeeping, and other auxiliary.
The sub-compliance rate for health workers before touching a patient was 94.5% and before clean/aseptic procedure 94%. After the procedures, the compliance rates were 100% after body fluid exposure risk; 90% after touching the patient; and 65% after touching the patient surroundings. On other behaviors, Health workers wearing no more than 1 ring had and, no wrist jewellery is worn had 85% and 80% compliance respectively. In addition, staff sleeves are short, nails are short, no nail vanish is worn, and no false nails are worn 100%, 75%, 95%, and 100% compliance rates. The staff of Dublin nursing home achieved the goal and even surpassed the target of 90% compliance on the following measurable indicators health workers before touching a patient, before clean/aseptic procedure, after body fluid exposure risk, and after touching a patient.
There was also compliance on having their sleeves short, no vanish is worn, and no false nails are worn. In contrast, the health providers fell short of the 90% compliance target after touching patient surroundings which were way below 25%. Likewise, medics wearing no more than 1 ring and them putting on no wrist jewellery fell short of the target by 5% and 10% respectively. Further, the providers ensuring their nails are short fell below the goal by 15%. The overall hand hygiene compliance for the project in April after the intervention was 89%. On the other hand, the compliance for March 2022 was 72%. Showing an improved compliance rate of 17% after the quality improvement aspect was introduced in the hand hygiene program of Dublin nursing home. The average hand hygiene compliance missed the target by 1%, this could be corrected by sustained vigilance.
There was an improvement in hand hygiene of 17% between March and April 2022. However, the following four indicators after touching the patient’s surroundings, no more than 1 plain are worn, no wrist jewellery is worn, and no short nails recorded ratings below the 90% goal. The indictors were more tied to the behavior and attitudes of the healthcare providers. It seems some staff felt that just touching patients surrounding was not harmful and could not infect either the patients or themselves. Further, a number of them were not happy or ready to remove their rings and jewellery or cut their nails for handwashing.
The management of Dublin nursing home must put in place mechanisms to lure some of their health providers into accepting to change their behaviors. Firstly, the team leaders must have one on one with all the providers in the home care individually. They should let them understand that they are protecting patients by not transmitting the viruses or bacteria to them. Such persuasive talk will make the nursing staff and others feel motivated by the need to protect the clients even when they do not have the desire to do it for themselves. In addition, this will make the healthcare staff be conscious of the people who will benefit if they do not get sick. Past studies have shown this strategy to be effective and most recent research on handwashing during COVID-19 revealed success in the context of behaviors.
Dublin nursing home management must commit to hand hygiene through ongoing monitoring, evaluation, and feedback on the compliance levels, particularly on the indicators which did not meet the target. The team must continuously conduct education and training for staff, patients, families, and visitors. Additionally, they must increase the use of posters, pocket cards, and brochures for training and visibility in all installations and buildings within the facility. Establishing hand hygiene behavior and accountability through contests and rewarding staff who excellently comply. Lastly, the management must provide constant reminders to the facility to keep the workers, patients, and visitors to raise the level of awareness by everyone.
In terms of the successful implementation of strategies to improve certain indicators, it is necessary to visualize important data. A map of the important elements to improve hygiene performance in a Nursing Home was made. The main objective is to increase hand hygiene performance, which will include four primary drivers. These include training and promotion, reminders and workflows, monitoring, and finally, changing the organizational culture.
Trainings and promotions articulate the idea of the informational stimulus that can be achieved through online meetings and webinars. In addition, one can provide staff with the opportunity to watch thematic films and videos, which will also improve the information indicator. The environmental stimulus includes visual hand hygiene stimuli, namely posters or hand hygiene stations. Besides, it is necessary to improve control through online surveys, video surveillance cameras, and special sensors. Finally, motivation is an important factor, which may include monetary rewards for those who perform better in hand hygiene.
Hand hygiene compliance help in preventing infections and reducing the spread of diseases between the health providers and the patients in nursing homes by improving the quality of medical services offered to patients. This can only be achieved through auditing the program to eliminate errors and provide scientifically backed interventions. The auditing is best done through proper data gathering and in this case important information was collected using direct observation technique whereby health providers’ behaviors and compliance to handwashing at a nursing home were recorded and analysed. Results showed that in the month of April 2022 after specific interventions were done by Dublin nursing home leaders, there was improvement on hand washing hygiene within the facility. Further, it was note that some staff still needed sensitization to change their behaviors for them to embrace hand hygiene compliance fully.
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