1. Patient Hand Hygiene Protocol Project
By: Shannon Dembowske

2. Project Overview
The Patient Hand Hygiene Protocol was implemented in the ICU to increase hand hygiene awareness to decrease the rates of hospital acquired infections (HAIs)
Patient hand hygiene was not being offered due to the lack in awareness, resources, and convenience.
Some studies show that patients hand washing compliance of patient’s decreases while they are in the hospital, than compared to at home. “The knowledge and attitudes of patients, and the accessibility of hand hygiene facilities, can influence their personal hand hygiene.” (Drumright & Coffey, 2015)
A 2015 Patient hand hygiene protocol, using scheduled CHG cleansing showed a slight reduction in HAIs, and also showed a increase in staff compliance of hand hygiene as well. (Fox, et al, 2015, p )
The patient hand hygiene protocol was presented on the ICU/IMCU unit in the attempt to decrease hospital acquired infections (HAIs). However, during the project process, I had to adjust my protocol into patient hand hygiene awareness because the unit was resistant to another protocol. In the end, I educated the unit about the importance of patient hand hygiene and was able to get resources, like hand sanitizing wipe packets, into the unit. The purpose of this project was to promote clean hands in patients. Hand hygiene not only reduces the spread of infection at the bedside, but also reminds staff and visitors to perform proper hand hygiene as well. Reducing HAIs will lead to better patient outcomes, improve patient satisfaction scores, and reduce hospital costs. Additionally, clean hands also help to not only protect the patient, but the staff as well from acquiring illness or infection. The staff was open to assisting patients with hand washing (soap & water, wipes, foam, or gel) after specific queues (toileting, blowing nose, before eating, ect) and in the critical (vented) patient at scheduled times during the day. Having sanitizing wipes at the bedside made it convenient for staff to offer and encourage patient hand hygiene. In the vented patient, it became a new standard for the use of CHG wipes on the patients hands at least once a shift. This was easily accepted by RNs because we already use CHG wipes on every central line and Foley catheter once a shift, and with two wipes in each packet, and many times only one wipe is needed, so it was convenient to use the extra wipe for the hands. By implementing this project, the action of patient hand hygiene has increased with the expectation that HAIs will decrease. It is too soon to measure whether or not there is a reduction in HAIs.

3. Project Goals/ Objectives
The main goal of this project was to implement a patient hand hygiene process which includes action, education, and documentation.
Objectives/Tasks- Completed/Met
Objectives/Tasks- Not Completed/ Not Met:
Literature Review
Literature research
Organize information to include in a PowerPoint
Method of education
Develop PPT presentation
Pitch Project Presentation
Project approval from unit manager/educator
Present to UPC for project approval
Gain UPC resources and support
Protocol Development
4.2 Identify strategies for implementation
4.3 Establish timing/ technique
Identify and obtain resources
Educate/Implementation
Educate staff about new protocol
Implement protocol
Educate patients/visitors and reinforce
Evaluate
Establish Barriers
Report results to UPC and unit educator
4. Protocol Development
4.1 Pre-protocol hand-hygiene audit
4.5 Finalize unit protocol
6. Evaluate
6.1 Perform post-protocol audit
Some of the goals in my project were not met due to system reasons. For instance, I could not change how we chart in the electronic medical record (time restraint and lack of importance) the act of patient hand hygiene. Without the ability to track whether or not hand hygiene was being completed, I was unable to perform pre and post hand hygiene audits. So the overall goal of documentation was not met. However, I was able to obtain resources and educate the unit on patient hand hygiene and I was able to implement a patient hand hygiene awareness project. The Unit Action Council thought that because there have been many new protocols, that the staff would not be receptive to another, so we changed the focus from a protocol to awareness. This change did not necessarily mean that I did not meet the goal of my project, but I did change the objectives, making it less formal. In the end, I was able to complete the objectives of focusing on patient hand hygiene awareness along with having convenient resources and also having positive feedback from the unit staff.

4. Quality and Safety Quality Improvement Process
Aimed to reduce hospital acquired infections
(The Joint Commission’s National Patient Safety Goal)
Improve patient satisfaction scores
Education about the spread of infection and proper hand hygiene techniques.
Employee development, involvement, and direct patient care
My project, patient hand hygiene protocol, is aimed at reducing the spread of infection and hospital acquired infections, while also improving patient satisfaction through the act of caring about small details such as clean hands. My project addresses the “reduce the risk of healthcare-associated infections” goal for The Joint Commission’s National patient Safety Goals for hospitals (Yoder-Wise, 2015, p. 376). This project meets criteria for quality management because it involves direct patient care procedures, aimed at patient satisfaction, and improvement on patient safety through the reduction of HAIs. “Quality management refers to a philosophy that defines a healthcare culture emphasizing customer satisfaction, innovation, and employee involvement” (Yoder-Wise, 2015, 362). Moreover, my project meets the criteria for quality improvement more so than quality assurance because “quality improvement refers to an ongoing process of innovation, prevention of error, and staff development” (Yoder-Wise, 2015, p. 362). My project is not only developed and driven by nurses, but acts are also dependent on daily nurse-to-patient care activities. “Nurses maintain a unique role in quality management and quality improvement because of the amount of direct patient care provided at the bedside and because they have an understanding of the day-to-day issues and ‘real world’ nursing involved in delivery of care” (Yoder-Wise, 2015, p. 362).

5. Process, Progress, and Completion of Project
Idea for this project came from a lecture from NTI, along with the realization that my unit documented the hand hygiene was being taught, but it was not actually getting done.
Before presenting my project to the unit, I researched and developed a case for why patient hand hygiene was important.
After many meetings and s, I was able to get support for the project through the UPC and unit manager with a few changes.
Patient Hand Hygiene Protocol > Patient Hand Hygiene Awareness
In the end, the ICU now stocks hand sanitizing wipe packets in every patient room along with staff education and reinforcement that the wipes are available.
The idea of implementing patient hand hygiene awareness came from a lecture I attended during NTI this past spring, along with a detail that I noticed in the current RN charting flowsheet in the electronic medical record. There is a section where RNs are supposed to select “yes” or “no” to educating the patient about respiratory and hand hygiene infection prevention. In this area of charting, there are recommended talking points, which detail to the action of having an individualized hand wipe on each meal tray. However, through further investigation, nutrition services do not place a wipe on each meal tray, nor have they ever. Additionally, the ICU unit did not have any products that we could use for hand hygiene (the hand foam is outside the room and patients not able to reach the sink). Throughout the process I had many s and meetings with the unit manager, nutritional manager, Unit Action Council (UPC), and other RNs on the hand hygiene committee. Support for the project came from the UPC and unit manager. However, they wanted to change it from a protocol to awareness for fear from staff push-back regarding another protocol.
In the end, I was not able to complete all of my goals, but I was able to increase awareness and educate the staff about the importance of patient hand hygiene. The unit now stocks hand sanitizing wipe packets in every patient room. Since the implementation, there has also been reinforcement reminding staff about the wipes.

6. Obstacles and challenges of project
Biggest Challenge-
Nutritional services did not want to place individual hand wipes on each tray, claiming that it would just be a waste because patients never use them.
Smaller Challenges-
Changing from a protocol to an awareness campaign
Documentation
The biggest challenge-
My goal was to implement the action of what we are supposed to be teaching, and have nutrition services start doing this, however, as of now, the nutrition manager just wants to change the charting. I have presented this issue via to the organization’s hand hygiene committee, but they do not meet until December, so I have not heard anything back yet. I hope that I can present a strong case to get committee support to change the actions, not the charting.
Smaller challenges-
Changing the protocol to an awareness campaign. Due the “protocol fatigue” the UPC suggested this change so that the staff would be more receptive to this project.
Documentation. As stated in the objectives slide, I was unable to perform audits because of the lack of how to document this task. Changing the documentation process is extremely involved and time consuming, so it would not be complete by the end of this project anyway. There is however the hand hygiene documentation area, but RNs answer yes to this 99% of the time regardless of completion or not, thus not being an accurate measurement.

7. Ethical/ Professional Issues
No ethical or professional issues to report.
Hand Hygiene Protocol Project can be related to the ethical principle of beneficence.
“The basic obligation to assist others” (Yoder-Wise, 2015, p. 92). These actions are taken to promote good.
This project requires actions by staff to assist patients with hand hygiene and promote good through the reduction in the spread of infection.
Throughout my project, there were no ethical or professional issues to report about.
However, I can relate my project to the ethical principle of beneficence. Beneficence is the actions one takes to promote good. “The basic obligation to assist others” (Yoder-Wise, 2015, p. 92). Patients in the ICU are hooked up to many monitoring wires, and/or are too ill to get out of bed. It is the responsibility of the staff to assist these patients with everyday hygiene, and encourage good practices such as hand hygiene. This project brings awareness to assisting patients with hand hygiene and also promotes good through reducing the risk for the spread of infection.

8. Lessons Learned as a Project Manager
Elements that shaped my role as a project manager and team leader
Leading by example
Building self-confidence
Having a positive attitude
Theory of Innovation-Decision Process
Five Stages for Creating Change
1. Knowledge
2. Persuasion
3. Decision
4. Implementation
5. Confirmation (Yoder-Wise, 2015, p. 310).
Collaborative Leadership Role
“Collaborating involves a group of people working together to achieve a common goal”(Yoder-Wise, 2015, p. 580).
As a leader of this group keeping a positive attitude about the goal, set the tone for the other members of the group.
This is the first project I have been a leader or manager on. Throughout this process, I have learned a lot about what it takes and means to be a leader. I have found that building trust, having respect for others, and setting an example have been very helpful for managing this project. In the grand vision of this project, it was a simple one, so there were not many moving parts which was good. I had a small group of people I was working with which made it easier to collaborate with. I was able to lead change with the support of my peers and manager. I found that if you are enthusiastic about a goal, and can prove the evidence-based practice, then many people are willing to support the project and do their part. Having the support of my peers helped me to gain the confidence I needed to be a good leader.
I found that by overcoming the barrier to creating change, it was helpful to follow the Innovation-Decision Process for change theory. The five stages are listed above, and I found that if you give people the knowledge as to why the change is occurring, then they are more receptive to participating. This theory also promotes collaboration through persuading people to join the cause and to create decisions. Following these stages helped me as a leader by providing me with an easy to follow pathway for creating and implementing my project.
As a collaborative leader during this project, I found that keeping the enthusiasm and high-energy kept the project moving forward and helped us to reach our goals. The feedback that I have heard from my peers are all positive ones about how its great to have resources at the bedside for patient hand hygiene.

9. Conclusion
I think that this project was a success because I was able to make change in the ICU unit.
Hand hygiene resources now available
More awareness to patient hand hygiene throughout the entire hospital
Patient hand hygiene is now being talked about at the hand hygiene committee meetings
While I realize I was unable to complete all of my goals and objectives, I think that this project was a success because I was able to make change in the ICU unit. I was able to get wipes on the unit and provide education to my co-workers. Throughout this process I have also created
more awareness to patient hand hygiene throughout the entire hospital, including the nutritional services.
Patient hand hygiene is now being talked about at the hand hygiene committee meetings. Where before they only discussed staff and visitor hand hygiene compliance.

10. References:
Drumright, K. & Coffey, J. (2015). Patient hand hygiene: overlooked factor in the spread of healthcare-associated infections [PowerPoint slides]. Retrieved from
Fox, C., Wavra, T., Ash Drake, D., Mulligan, D., Pacheco Bennett, Y., Nelson, C., Kirkwood, P., Jones, L., & Bader, M. (2015). Use of a Patient Hand Hygiene Protocol to Reduce Hospita-Aquired Infections and Improve Nurses' Hand Washing. American Journal of Critical Care, 24(3),
Yoder-Wise, P.S. (2015). Leading and managing in nursing, (6th Ed.). St. Louis, MO: Elsevier Mosby.