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Hand Washing: A Quality Improvement Process
Patricia Adams, Mary DeWitt, Erin Swartz, and Karla Tennant
Ferris State University




Hand Washing: A Quality Improvement Process
Hand washing has been identified as a simple, effective and primary means of reducing
the spread of infection. Poor hand hygiene increases the risk of infection and places individuals
and organizations at risk. The purpose of this paper is to show how leaders in health care
implement quality and safety initiatives by designing teams to develop, monitor, and use
evidence to implement and evaluate the effectiveness of hand washing programs.
Clinical Need: Why Hand Washing is Crucial
Environmental cleanliness in health care dates back to the Crimean War and Florence
Nightengale; at a time when more soldiers died from infection than the wound itself (Chitty &
Black, 2011). During this period, Nightengale linked cleanliness to disease transmission, and
theorized the main cause of death was related to sanitary conditions. Often referred to as the
founder of nursing, Nightengale’s belief about cleanliness remains a key aspect in infection
control today (Chitty & Black, 2011). In 1860, Nightengale wrote “Every nurse ought to be
careful to wash her hands very frequently during the day” in her Notes on Nursing, What is and
What is Not. Nightengale’s theory proves that this one single standard can improve outcomes and
reduce the risk of morbidity and mortality.
With sepsis being a leading cause of mortality among patients worldwide, one must stop
and reflect upon an age old idea of how a simple act can preserve life and improve care. The
profession of nursing has evolved since the 1800’s and developed standards of care that define
measurable, expected levels of performance. Implementation of evidence into practice has lead
to the development of hand washing guidelines as a primary means of infection prevention.

Interdisciplinary Team Design



Developing a prudent hand washing protocol requires the semblance of an
interdisciplinary team, “the implementation of evidence-based practice (EBP) and development
of research activities have become more interprofessional in nature, with nursing providing
leadership in both areas” (Bohnenkamp, Pelton, Rishell, & Kurtin, 2014, p. 434). The
interdisciplinary team requires a “physician champion”, “physician leadership is crucial to the
success of the quality improvement effort” (Holmboe & Cassel, 2007, p. 18). The team also
requires a member of administration in this case the chief nursing officer. Epidemiology will also
be an important part of this team, giving the team direction. Education will be a key in the
implementation of this quality improvement process. Nursing and physician education will bring
the recommendations back to the patient care areas, with hands on teaching processes.
A team of staff nurses from various departments that represent a cross section of the
inpatient and outpatient services will represent patient needs. This also includes nursing support
such as certified nursing assistants (CENA’s) and leadership representation, “today, progressive
hospitals are realizing that nurses deserve a say in the decision-making processes that determine
clinical policy in hospitals, these hospitals are capitalizing on nurses clinical insights in efforts to
improve patient care” (Koska, 1991, p. 18).
Team members also include housekeeping, and environmental services as these teams
will help install sinks and stock hand washing supplies. “Interprofessional collaboration is a
process by which multiple disciplines share goals and responsibility toward improving patient
outcomes, sharing leadership, and incorporating a holistic view of the patient. Goals for the
patient are collaboratively set and evaluated” (Bohnenkamp et al., 2014, p. 434). This team also
includes consultants from the Medline company makers of soap, and hand foam products, to



utilize product information and teaching resources such as the use of Medline University
(Medline University, n.d., p. 1).
Finally, a committee with one member of each of the patient care disciplines will be
chosen as leaders, this will be deemed the Leader Committee (LC). This committee will evaluate
the current hand washing practices in their respective departments and take the recommendations
back to the collective. The LC will continue to meet for one year after implementation to
continue to bring recommendations back to the collective. “This approach to decision making,
development of a treatment plan, and evaluation of goals often produces greater results than an
accumulation of contributions made without the benefit of the team setting” (Bohnenkamp,
Pelton, Rishell, & Kurtin, 2014, p. 434) .
Data Collection Method
The PICOT format (patient, intervention, comparison intervention, outcome, and time) is
the model that will be utilized for the clinical data collection method, as it is the recommended
clinical question format when evaluating evidence based practice (Yoder-Wise, 2015, p. 395).
The patient population that will be studied are adults on an acute care floor in a hospital setting.
Observation, product measurement, and surveys are the three commonly used methods, or
interventions, for measuring hand hygiene (The Joint Commission, 2009, p. 14). The World
Health Organization (WHO) Guidelines (2009) identifies observation as the “gold standard” for
observing hand hygiene compliance. Observation will consist of the leader committee observing
hand hygiene behavior and recording the number of individuals within a specific time frame that
are either adhering or non-adhering to hospital protocol. According to the World Health



Organization (2009) guidelines for hand hygiene should be completed before and after patient
contact, before an aseptic task, after body fluid exposure, after contact with patient surroundings.
The comparison interventions are product measurement where the amount of soap,
alcohol-based hand rub, gloves, and paper towels are measured over a specific period of time
(The Joint Commission, 2009, p. 18). The weaknesses of this measurement technique are that it
does not assess who is performing hand hygiene or the technique that was used. (Haas J.P. &
Larson E.L., 2007). Another alternative intervention is handing out a survey that will address
knowledge, attitudes, and individual hand hygiene preferences (The Joint Commission, 2009, p.
18). There are several limitations of the survey method which are the validity or reliability for
self-adherence and research shows that health care workers overestimate compliance (WHO,
The outcome of the hand observation monitoring will provide information regarding the
number of opportunities for hand hygiene, the rate of compliance vs. noncompliance, and the
quality of the hand washing technique.
Prevention of infection in patients primarily begins with nurses. Hand washing is the
single most important step in prevention of infections (Center for Disease Control, n.d.). As such,
learning the proper technique and putting that technique into practice will improve patient safety.
Nurses need to not only apply this to their practice, but they need to educate others on the
importance of hand washing to protect one another. The Joint Commission is an organization that
accredits and certifies health facilities nationwide providing accreditation and certification for
approximately 90% of the hospitals. As such, they are continually working to improve patient
safety measures. Each year a new set of guidelines, entitled The National Patient Safety Goals,



are designed to assist healthcare organizations to improve upon patient safety (The Joint
Commission, 2011). Goals for the 2016 year in the prevention of infection, as set forth by the
Joint Commission, include to: “use the hand cleaning guidelines from the Centers for Disease
Control and Prevention (CDC) (CDC, nd) or the World Health Organization (WHO)” (WHO, nd)
and to, “set goals for improving hand cleaning, “ and to “use the goals to improve hand washing”
(The Joint Commission, 2016, para. 5). The role the nurse plays in establishing these goals are
important. The specific process for implementing interventions will directly correlate with the
outcome of reaching these goals. The nurse’s commitment to this process will reduce a number
of infections. In a recent review of more than 20 evidence-based studies in the acute care setting
evidenced showed, “improved hand hygiene was associated with measurable reductions in
carefully defined hospital associated infections” (Godfrey & Schouten, 2014, para. 5).
Implementation Strategies
A well-designed and prudently implemented hand washing program can reduce illness,
prevent death, and save money (Swensen, Dilling, McCarty, Bolton, & Harper, 2013). The first
step in the program is the development of a committee of individuals whom will provide the
education to staff and monitor the results. This committee, previously referred to as the LC will
develop the new procedures. A team leader from each discipline will educate their own team
members on the visualized results of the quiet observation of current practice, importance of
hand washing, and the new program. “ Education plays a key role in setting a good practice base
in hand hygiene, theoretical knowledge, and in skill development, as well as good practice
reinforcement” (Skodona et al., 2015, para. 4). The program includes the following evidencedbased interventions that have been found to be effective in the improvement of compliance in
hand washing as well as the decreased of the spread of infections: hand washing promotion,



education, training, posters, performance feedback, use of soap versus alcohol based hand rubs
(Allegranzi & Pittet, 2009). The new program will be trialed and reviewed by the committee
every week with a focus on determining effectiveness and making agreed upon changes if
necessary. Once it is believed the program is working to its optimal level of functioning the team
will develop a written policy of the new procedure. After which time the committee will meet
monthly for up to a year.
The Joint Commission (2009) recommends five interventions for improving hand
hygiene: education and training, audit and feedback, reminders, use of multidisciplinary teams,
and systematic performance improvement methods (p. 109). Staff meetings will be the main
venue where implementation strategies take place as staff is required to have at least 80%
attendance. The first intervention is that there will be an educational piece that will be discipline
specific presented at each staff meeting. Healthcare workers need more education on hand
hygiene practices as there is a poor understanding of the lack of opportunities to practice hand
hygiene (Pittet, D., 2000 & Ministry of Health and Long-Term Care, 2008). The second
intervention is that the information that is analyzed from the data collection will be shared with
the team so that they can have direct feedback on areas for improvement. The third intervention
will be visual reminders that are spread across the unit. Grol, R., & Grimshaw, J. (2003) found
that reminders made a positive impact in 7 different hand washing studies. The fourth
intervention consists of having a multi-disciplinary team that evaluates and improves hand
hygiene. According to The Joint Commission (2009), “The CDC and WHO hand hygiene
guidelines also recommend use of a multidisciplinary program to improve adherence (p. 110).
The final intervention is the systemic performance evaluation that consists of evaluating the
evidence, implementing the other interventions, and then setting goals that the LC agrees on.



It is vital that health care workers not only learn from the results, but also take the
necessary steps to make individual positive changes that last. According to The Joint
Commission (2009), “Many have had the experience of implementing new programs or systems
to improve hand hygiene, only to find little change in adherence rates or improvements that were
not sustained when the focused attention on hand hygiene was removed” (p. 107). The results
will be categorized by discipline.
The data collection of hand hygiene will be assessed over a 6-month period so that a
strong sample size will be collected. According to the World Health Organization (WHO) (2006),
the LC will observe the recommended minimum of 200 opportunities during each measurement
period to allow for a meaningful comparison for before and after improvement interventions. A
thorough evaluation will consist of the number of opportunities for hand hygiene, the adherence
and non-adherence rates, and if the hand hygiene was being performed in accordance with
hospital protocol. The evaluation will provide valuable information regarding the baseline
statistics and will allow for the LC to determine a plan for improvement. The Joint Commission
(2015) reports that a hospital must improve hand hygiene compliance compared to
the baseline results. The Joint Commission had previously recommended that each organization
have at least 90% hand hygiene compliance, however the new recommendation is that there
must be a goal to improve current statistics. A goal of improving hand hygiene compliance by
25% will be implemented upon reviewing the results of the data collection.



With sepsis being a leading cause of mortality worldwide, the implementation of quality
and safety initiatives by leaders in health care can increase the effectiveness and frequency of
hand washing. Recommendations by the interdisciplinary team rely on the use of the LC to
implement and modify through observation and teaching. The outcomes of reaching goals set
out by the CDC will improve hand hygiene by 25% after evaluating 200 or more cases. This can
decrease the likelihood of sepsis in the inpatient setting. The key to this quality improvement
process is the follow up and consistency of the LC. The implication of this research includes the
expanded role of the nurse leader. This expanded role is crucial in the development and
implementation of quality improvement projects such as this hand washing project, “the focus
has now been placed on improved quality of care and safety in clinical practice” (Bohnenkamp,
Pelton, Rishell, & Kurtin, 2014, p. 434).



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