QUALITY IMPROVEMENT

HANDWASHING
KATHERINE SHEPPARD

QUALITY IMPROVEMENT PURPOSE

THIS QUALITY IMPROVEMENT PROJECT WAS TO INCREASE COMPLIANCE ON
HANDWASHING AT MARY IMMACULATE HOSPITAL.
BASELINE HANDWASHING COMPLIANCE 47.1% (JOINT COMMISSION, 2016).

The monitoring was conducted

by using a tool provided by Joint
Commission.

Materials

Environment

Dispensor Location
Sink Location

Methods

Education tools

Gloves
Sink supplies (paper towels, soap, and
water)
Hand Sanitizer

Role modeling
behavior

Educational Tools
Training

Frequent Entry/Exit
Hands full of supplies

How often is compliance being

measured?

Compliance with rules

How methods to
compliance are
measured.

Training/skills
Person

Measure

Hand
Washing
NonCompliance

The chart to the left shows the majority of

reasons handwashing was non-compliant.
The improvement project was to help
educate staff on these barriers.
Dispenser location was ranked number
one reason of non compliance. This issue
was addressed immediately with the
addition of placement of alcohol
dispensers. In addition staff were given
clip-on hand sanitizers that were easily
accessible.
Education of staff was the second
implementation of this quality
improvement.

IMPORTANCE
ACCORDING TO THE INSTITUTE FOR HEALTHCARE IMPROVEMENT, "HEALTH-CARE-ASSOCIATED
INFECTIONS ARE IMPORTANT CAUSE OF MORBIDITY AND MORTALITY OF PATIENTS
WORLDWIDE"(INSTITUTE FOR HEALTHCARE IMPROVEMENT).
HAND WASHING AND INFECTION CONTROLS IS THE BEST WAY TO HELP PREVENT
TRANSMISSION OF HEALTH-CARE ASSOCIATED PATHOGENS.
COMPLIANCE HAS SHOWN TO BE LOW, THE INSTITUTE OF HEALTHCARE IMPROVEMENT STATES
LOWER THAN 50%. IT IS IMPORTANT TO WASH HANDS WITH ALL PATIENT CONTACT.
SOME REASONS THAT POOR HANDWASHING HAS BEEN DISCOVERED IS THE LACK OF
KNOWLEDGE, SO WITH THIS PROJECT TECHNIQUES WAS TO EDUCATE STAFF ON THE
IMPORTANCE AND THE HOW TO CORRECTLY WASH HANDS.

IMPLEMENTATION (EDUCATE)
DO THE 10 AT 10
TO PREVENT INFECTIONS
INFECTION PREVENTION IS ASKING FOR ALL STAFF & PROVIDERS TO PAUSE & TAKE A FEW
MOMENTS TO CLEAN THEIR HANDS (MAY USE SOAP/WATER OR AN ALCOHOL HAND RUB)
DO THE 10 = CLEANING YOUR TEN FINGERS & HANDS
WHEN THURSDAY THE 10TH AT 10 AM & 10 PM
TAKE THIS OPPORTUNITY TO TELL PATIENTS, FAMILIES, VISITORS ABOUT THE IMPORTANCE
OF HAND HYGIENE
INTERVENTIONS PRODUCED WITH MARY IMMACULATE INFECTION CONTROL TEAM.

CONCLUSIONS AND IMPLICATIONS

ACCORDING TO OUR MONITORING THROUGH THE JOINT COMMISSION SITE
IMPROVEMENT ON HAND HYGIENE INCREASED FROM 47.1% TO 55.2%
COMPLIANCE.

REFERENCES
American Nurse Association. (2010). How to Create An Effective Poster Presentation.
Retrieved from http://americannursetoday.com/how-to-create-an-effective-posterpresentation/