Name
School of Nursing and Health Science, Capella University
NHS-FPX8040
Dr Paula Stechschulte
September, 2024
Project Charter
| Part 1 | |||||
| Project Overview | |||||
| Project Name | Reducing Medication Errors in Hospital Inpatient Units | ||||
| Gap Analysis | Improvement of hand hygiene compliance among the hospital staff has emerged as one of the major opportunities for change (Manias et al., 2020). As established, the compliance rate in our healthcare facility is 72%, below the benchmark established by WHO to prevent HAIs. The desired state is to improve hand hygiene compliance to at least 90% within the next year and align with what others have followed globally. The measurable gap between the current and desired state is an 18% identifiable gap, which could lead to disastrous results if the same is not enhanced. Gap was identified via routine hygiene audits; infection reports and feedback from the Patient Safety Committees. Analysis findings revealed that factors hindering compliance were overloaded staff, the availability of hygiene stations, and the reinforcement of hygiene practices that were not uniform.Indeed, improving hand hygiene compliance would also mean improving patient safety, reduced spread of infection, and decreasing infection incidence rates in hospitals. Infections are the leading causes of prolonged length of stay in hospitals, increased morbidity among patients, and higher healthcare costs. This hospital will both ensure improved patient outcomes and strengthen employee accountability and adherence to infection prevention guidelines. It would thus be significantly narrowed by the implementation of solutions like additional hand sanitizing stations, regular training of staff, and real-time compliance monitoring by electronic surveillance systems. Meaningful and necessary change: The protection of vulnerable patients will be assured, and standards of care will be maintained and respected in a hospital setting (Meza et al., 2022). | ||||
| Current State | Desired State | Identified Gap | Methods used to identify the Gap | Implications/Relevance to Identified Population | |
| Current compliance of healthcare staff rate: 72% during the current audit cycle. This is less than the required benchmark, and thus this has resulted in a rise in healthcare-associated infections among the hospital populations. Contributing factors identified include inadequate convenient access to hand hygiene stations as well as variations in reinforcement among staff regarding hygiene protocols. | A 90% or greater hand hygiene compliance would be the goal: desired state. It would thus be intended to be consistent with and comply with the recommendations of the World Health Organization. Such a level would significantly reduce the incidence of HAIs. Improvement in the overall patient safety outcomes would be noticed. Such a state may be obtained with enhanced access to hygiene stations, employee education, and monitoring. | The gap identified herein is 18% between the declared 72% compliance rate and the desired compliance of 90%. That gap, of course, talks to a general need to improve hygiene protocols, training, and infrastructure for higher compliance. | Hygiene audits, infection control reports, patient safety committee feedback, and electronic surveillance systems monitoring hand hygiene practices identified the gap. This was reinforced through surveys conducted with staff information on patient safety data rates. | Improving hand hygiene compliance is critically relevant to patient safety and the reduction of HAIs, which are particularly pervasive among immunocompromised and vulnerable populations. Closing this gap would squarely contribute to decreased infection rates, shorter hospital stays, and healthier health outcomes in patients, particularly those who are at greater risk of complications from infection. It would also enhance accountability among staff and promote a culture of safety in the healthcare environment. | |
| Evidence to Support the Need | (Issa et al., 2022) have conducted a systematic review and emphasized hand hygiene as a preventive measure against HAIs. The study reports that if high compliance is observed within facilities, the implementation of hand hygiene protocols will eventually reduce HAIs by up to 50%. It thus states that consistent hand hygiene practices among healthcare staff are essential in ensuring that patients lead healthy and safe lives.In addition, the Centers for Disease Control (Marques et al., 2021) and Prevention mention hand hygiene as one of the basic principles in the control and prevention of infection. Their general recommendations point to continuous education and monitoring by healthcare facilities to improve hand hygiene compliance. Moreover, from the information reported by the CDC, hospitals that actively engage themselves in hand hygiene practices have reported lower infection levels.A joint commission benchmarking report (Zhang et al., 2022)has indicated that the national average compliance for hand hygiene is about 82%. This, in itself, directly indicates that there is indeed a huge room for improvement in a majority of healthcare settings. Hence, such reporting becomes a call to hospitals to improve their practice with respect to patient safety on par with national standards.Another evidence that supports the quest for improvement in hand hygiene compliance arises from the fact that there are strong links between proper hand hygiene and patient outcomes (Clancy et al., 2021). For example, an empirical study demonstrates that healthcare providers who adhere to recommended hand hygiene have lower incidence rates of HAIs. Enhanced compliance with focused interventions could lead to increased protection for patients because even minor increases in adherence would significantly reduce infection risk.Regulatory bodies continue to stress hand hygiene practices that stand to point out the need for such adherence is no longer in terms of avoiding patient harm but also a legal and operational requirement to meet the usual standards of healthcare provision(Yeng et al., 2021). Failure to adhere may have financial implications and may result in prolonging the hospital stay of patients, thereby overburdening healthcare resources. Thus, through better hand hygiene practices, patient protection as well as the efficient running of healthcare operations become important. | ||||
| Problem Statement | The current poor compliance with hand hygiene among healthcare providers heightens the risks of developing HAI among patients(Soboksa et al., 2021). This further results in worsening health outcomes and longer stays in the hospital. A series of targeted training initiatives combined with monitoring programs can enhance compliance with hand hygiene practice leading to patient safety improvement, decreased burdens of infections in healthcare settings, and therefore improvements in the health outcomes of patients. | ||||
| SMART Objectives | 1. Concretely specified: The population in this project is the care and support staff nurses in a medium-sized hospital setting, and specific emphasis on an intervention that improves their hand hygiene compliance rate.2. Measurable: The project will increase its hand hygiene compliance rate from the current baseline of 60% to 85% during the duration of the project as measured by observation and audit reports.3. Feasible: The project is realistic, and supported by hospital management. There are enough sources of funds allocated for materials in training and a monitoring system was put in place. The schedule allows opportunities for training sessions and follow-up evaluations.4. Relevant: This is closely related to enhancing patient safety and reducing hospital-acquired infection, fulfillment of the organizational mission of providing good quality care. It has aspects of health equity because every patient receives the same standard of care regardless of ethnic background.5. Timing: The project will commence on January 1, 2025, and will run for six months and end on June 30, 2025, after which the compliance rates of this period will be compiled to evaluate the project. | ||||
| Project AIM | This project aims to enhance hand hygiene compliance of nursing and support staff in a middle-sized hospital from 60% to 85% over six months in the period from January 1, 2025, to June 30, 2025. Direct impacts on patients since healthcare-associated infections will be reduced, and safety will improve for patients. To achieve this end, the project will implement an overall training program on best-practice hand hygiene, supported by audit and feedback mechanisms (Jemilat Siju et al., 2023). This change will be implemented in each of the patient care settings within the hospital; hence, practice the culture of safety and accountability among staff. Evidence-based practice and developed compliance thresholds will help bring sustainable improvement in the overall practice of hand hygiene among individuals in the healthcare setting, thus ensuring health enhancement for all patients treated at the hospitals. | ||||
| References Clancy, C., Delungahawatta, T., & Dunne, C. P. (2021). Hand hygiene-related clinical trials reported between 2014 and 2020: a comprehensive systematic review. Journal of Hospital Infection, 111(1), 6–26. https://doi.org/10.1016/j.jhin.2021.03.007Issa, M., Dunne, S., & Dunne, C. (2022). hand hygiene practices for prevention of healthcare-associated infections associated with admitted infectious patients in the emergency department: a systematic review. Irish Journal of Medical Science (1971 -), 192. https://doi.org/10.1007/s11845-022-03004-yJemilat, S., Uzoma, A., Vernet, E., Moss, M., Javaid, W., & Cassano, K. (2023). The implementation of a quality improvement project using the patient as the observer to improve hand hygiene compliance in ambulatory care practices. Journal of Hospital Infection. https://doi.org/10.1016/j.jhin.2023.08.001Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: A systematic review. Therapeutic Advances in Drug Safety, 11(1), 1–29. https://doi.org/10.1177/2042098620968309Meza, S. U., Perez, G. A., & Rueda, L. J. (2022). Interventions to improve knowledge or compliance to hand hygiene in nursing students: A scoping review. Journal of Infection Prevention, 24(1), 175717742211276. https://doi.org/10.1177/17571774221127696Marques, A. R., Strle, F., & Wormser, G. P. (2021). comparison of lyme disease in the united states and Europe. Emerging Infectious Diseases, 27(8), 2017–2024. https://doi.org/10.3201/eid2708.204763Soboksa, N. E., Negassa, B., Kanno, G., Ashuro, Z., & Gudeta, D. (2021). Hand hygiene compliance and associated factors among healthcare workers in Ethiopia: a systematic review and meta-analysis. Advances in Preventive Medicine, 2021, 7235248. https://doi.org/10.1155/2021/7235248Yeng, P., Fauzi, M. A., Sun, L., & Yang, B. (2021). Legal aspects of information security requirements for healthcare in three countries: a scoping review as a benchmark towards assessing healthcare security practices (preprint). JMIR Human Factors. https://doi.org/10.2196/30050Zhang, Y., Chen, X., Lao, Y., Qiu, X., Liu, K., Zhuang, Y., Gong, X., & Wang, P. (2022). Effects of the implementation of intelligent technology for hand hygiene in hospitals: a systematic review and meta-analysis. Journal of Medical Internet Research. https://doi.org/10.2196/37249 |
