Task 1 C493 Leadership
Name:
May 18, 2020
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
pra
...
Task 1 C493 Leadership
Name:
May 18, 2020
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 seeking information for an organizational problem to work to fix I found
that a major concern of the hospital is infection control. 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 hospital it is estimated to cause an increase cost of over $30,000 an admission and
add over 7 days to a patients length of stay. Infections are costly, life altering and deadly so
because of this infection prevention is key. I work in a very busy 16 bed critical care unit. We
take care of the sickest of the sick and often patients come in with one problem and leave with a
hospital acquired infection. When assessing what areas my unit can improve our infection
prevention numbers I found that hand hygiene was a serious area that we were lacking on.
According to the CDC, about 1 in 25 patients acquires a health care-associated infection (HAI)
due to poor hand hygiene during their hospital care, resulting in up to 722,000 infections a year.
Of these, 75,000 patients die of their infections (Hand Hygiene in Healthcare Settings, 2018)
Healthcare workers are the front line to caring and touching patients. Without adequate hand
hygiene it allows antibiotic resistant bacteria to spread. In one study WHO found that” on
average, 61% of healthcare workers—in some facilities up to 90%—do not adhere to best
handwashing practices, even when supplies are available.” (The Global Handwashing
Partnership 2017) Also one fact I found is it “estimates of the cost of hospital-acquired infections
range from $28 billion to as high as $45 billion per year” (Healthcare-Associated Infections
2019)
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 what we call “secret shoppers” to monitor hand hygiene
compliance. These are chosen representatives of a specific unit that observes the actions
taken by those in the unit. In this assessment this includes all personnel such as nurses,
MD, Respirator, lab techs radiology and so on that enter the room or have patient
contact. The secret shopper watches someone go into the room and t hey are assessed
based on needed actions “Did they foam or wash before going in”? Did they foam or
wash between surface touches?” Did they foam or wash coming out?”. The secret
shopper writes down job title on the form and mark Yes or No based on if they followed
proper hand hygiene. The secret shoppers make minim 50 observations in 1 month and
turns them into infection prevention. The previous 3 months of hand hygiene
compliance percent prior to my project are as follows below.
Critical Care Hand Hygiene
Month Compliance percent
January 2019 70%
December 2018 58%
November 2018 62%
The expectation is 100% compliance for hand hygiene hospital wide and with the
numbers above for my unit we are far off. There was definitely significant room for
improvement. With these numbers I investigated what our actual unit infection numbers
was. In these 3 months we have had 1 cases of C-diff, 1 central line infection and 1
Foley catheter related infection. Though I originally did not think 3 infections were that
bad I compared those number to similar units and found 3 confirmed infections in 3
months was bad. This required action.
Analyze the state of the situation using current data. Analyze areas that might
be contributing to the problem or issue.
There are several areas that I feel are contributing to this extensive lack of
compliance on hand hygiene. The first is education, not just initial education but
continued education. Hand hygiene is conveyed to be important in new hire orientation
but continued updates or annul education is not common. Keeping the information fresh
in the mind helps ensure understanding the why behind something.
Another concern is the set up for the foam-based appliances are broken, empty or
ill placed around the unit. They are not placed at eye level or right next to the door
before walking in. The set up does not support conveyance or draw your eye to it. Some
of them are broken or consistently empty.
Third is the staff rushing in and out. Doctors, nurses and other teams often feel
busy or overwhelmed and rush passed into the room to care for the patient’s needs.
Propose a solution or innovation for the problem or issue. Justify your proposed
solution or innovation based on the results of your investigation and analysis.
For my project I proposed a hand hygiene improvement project to be initiate d in
my unit rolled out by me and evaluated by the infection prevention RN to ensure
fairness of the results. This consisted of education to all staff that enter my unit through
education flyers, e-mails, huddles and one on one conversations. Justification of
education is to provide a refresher of knowledge and help staff to understand the
importance of hand hygiene.
My second action item was to work with the hospital facilities to not only add
additional foam appliances but to reposition the ones we already had to an adequate
height. I ensured foam containers on each side of the door of the left and the right as
well as the inside of the door in the room. Justification for this action is to make it
readily available so that there are no barriers to them foaming in or out. If the staff have
a hard time of getting to the hand sanitizer they are more likely not to use it.
My next action item was I created small “STOP” signs that stat e ”Did you foam
In”? or “Did you foam out”? and ‘Clean Hands Saves Lives”. These were placed on the
outside and inside of every patient room, by all foam containers, restrooms and nurse’s
stations. My justification of this was to draw the eye to the foam container. In hopes to
get the staffer to notice the sign, slow down and foam in or out.
Recommend resources to implement your proposed solution or innovation. Include
a cost-benefit analysis of your proposed solution or innovation.
There are many resources that I have available to me to assist me in this project. As
for non-hospital I the CDC website to gather information needed for my education. I
used the internet to search for pictures and information. In hospital resources that I
used, were my leadership team VP of Nursing, Director and manager for project
approval. I collaborated with the infection prevention team that assisted me in gathering
data and assess compliance once all my action items were rolled out. Facilities assiste d
in repositioning any foam/soap containers I needed. Another resource is the ICU
educator who found hospital approved flyers and facts that I could use to educate the
staff of the unit. One of the most important resources to my project was the critical ca re
medical director. I was able to use his interest in infection prevention to allow me to get
the physicians on boards. Without his influence it would have been difficult to stop a
MD about his lack of hand washing. With his backing I was able educated no t just
nurses but all staff. The hospital print shop made my fliers and laminated my “Stop”
signs.
STOP!
Did you foam in?
Clean hands save lives!
The cost benefit analysis is as follows each foam container cost 13.50 and I have facilities
place and replace items for a total of 7. I then had many flyers and color laminated signs made
through the print shop totaling $23 totaling $117.50. The cost versus benefit assessment is
compare to the cost of just 1 hospital acquired infection can cost almost $30,000. The cost of the
supplies to improve compliance is worth the prevention of these infections. Also, the benefit of
reported nursing satisfaction with the additional foam containers and moving to move convenient
spots.
Provide a timeline for implementation based on your proposal.
My timeline is 1 month to educate staff, fix the availability and location of foam
containers to staff and do in the moment auditing and bedside education. Then another 2
months of infection prevention team doing secret compliance audits to compare to my
original numbers. This will be for a total of a 3-month project.
Discuss why each key stakeholder or partner is important for the implementation of the
solution or innovation. Summarize your engagement with the key stakeholders or
partners, including the input and feedback you received Discuss how you intend to work
with those key stakeholders or partners in order to achieve success.
For my project I had many key stakeholders that affected my project outcomes.
First is my leadership team the VP or nursing, director of nursing and manager. I set up
a meeting with my leadership team to go over my proposal. In this meeting I presented
the need for my project, I answered questions and explained what hospital resources I
needed. They asked questions and provided suggestions. Without their approval and
encouragement, I would not have been able to get other departments to take my project
seriously and help me roll it out. This directly contributed to the success of the project.
I will continue to provide them updates and will meet with them for a final review of
data.
My next key stakeholder is the infection control team. I met with them to
understand how they gather their compliance data. This is important for me to
understand so I know how my nurses are measured and how I need to set my project up
to be measured after my action items. The IP team assessed compliance rates after I
completed all of my action items and I used those numbers to measure success of my
project.
Another key stakeholder was the critical care medical director. Hand hygiene and
infection prevention is not cause by just nurses. It is related to any healthcare worker
who touches the patient. When assessing the previous months audits, it was noted that a
lot of our failures were MD’s going in to see the patient. So, for me to improve hand
hygiene compliance I needed to focus my project on all disciplinaries. It can often be
very difficult as a nurse to attempt to educate or ask a MD to improve an area. With the
Critical care medical director help and support he made it a priority across the board.
This made it possible for me to provide real time feedback when they do n ot meet
compliance.
My main stakeholders are those that provide direct care. The nurses, techs and
hospital staff that are measured for compliance. I spent a lot of time talking, educating
and answering questions of these nurses. Continued success was not ed as I saw other
staff members identifying if someone wasn’t complaint. The staff strived to get their
own numbers up and feedback was that they were surprised how low our numbers were
an eager to improve them.
Discuss how your proposed solution or innovation could be implemented, including
how the implementation could be evaluated for success.
Right now my proposed solution is just a unit specific measure to improve hand
hygiene and ultimately infection scores. It can be implemented system wide to improve
a global hand hygiene compliance. To evaluate this project success rate, I will use an
anonymous survey to poll the staff to see if they feel more informed on hand hygiene
and like the new positioning of the foam in and out containers. Most importantly I will
use the data from the “Secret Shopper” audits converted to percent to compare to
previous months to see if compliance is better. For long term I can use unit infection
numbers in hopes they will decrease or completely go away.
Explain how you fulfilled the following roles during your process of investigation
and proposal development:
Scientist- When working on this project I was a scientist in that I researched a topic of
need for my unit that needed improvement. I hypothesized that if I made specific
changes in my unit that I could improve hand hygiene and decrease infections rates. I
then created a testable project with different variables that allows me to see if those
changes make an impact on my original concerns. To create this project and idea I had
to do research and experiment with ideas to have an impactful outcome.
Detective- For this project I was also a detective. When I identified an area for
improvement I used the skills of the detective to reach out to staff, question them on
gaps in their knowledge, assess the environment and tools that were there or missing.
With this information I was able to format a plan that could be impactful on my goal. I
then used observation to assess success.
Manager of the healing environment- I am a manager of the healing environment for
clean hands and surfaces are all a part of the patient’s environment. When a patient
comes in to be healed we need to not put them at further risk of harm. We need to keep
their environment and space clean and germ free. As I spread this information and
project out to all the staff I am improving the healing environment for all patients
touched by a care giver thus preventing longer stays, promoting patient safety and
reducing infections.
Results- When I originally set out to do this project I did not realize it was more
hypothetical. I did spend the last few months managing this project so wanted to share
the results. After education sessions, e-mail, flyers and moving the foam containers for
1 month. I also did real time observations. If I saw someone being non-compliant I
stopped them and friendly handed them a small hand hygiene brochure to keep it light
and to prevent any animosity with my co-workers. This included information and how
to do proper hand washing. After this month the secret shoppers did 2 months of
anonymous auditing. I wanted to share my results below
So after the initiation of this project hand compliance improved, I will continue to
monitor this and my units infection rates to assess the impact my project had.
Month Compliance percent’s
April 2019 92%
March 2019 86%
References
Four Facts about Infection and Its Prevention. (2018, March 31). Retrieved from
https://www.agingresearch.org/four-facts-about-infection-and-its-prevention/
Hand Hygiene in Healthcare Settings | CDC. (n.d.). Retrieved from
https://www.cdc.gov/handhygiene/index.html
The Global Handwashing Partnership. (n.d.). Retrieved from
https://globalhandwashing.org/about-handwashing/faqs/
Healthcare-Associated Infections. (2019). Retrieved March 16, 2019, from
https://www.healthypeople.gov/2020/topics-objectives/topic/healthcare-associatedinfections
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