Practice Improvement Plan Proposal

A1. Describe a healthcare-related situation prompting a systems-level patient safety concern that has the potential to impact multiple patients.

A healthcare-related situation prompting a systems-level patient safety concern that has the potential to impact multiple patients is the lack of or improper hand hygiene by healthcare providers and other hospital staff. This patient safety concern contributes to increased healthcare-associated infections (HAI), including CAUTI, among hospitalized patients.

A2a. Analyze background information about the concern by describing the data that support or would support the need for change.

Each year, hundreds of millions of patients worldwide are affected by healthcare-associated infections (HAIs). HAIs are the most frequent adverse event in health care.

Most HAIs are preventable through good hand hygiene practices – cleaning hands at the right times and in the right way. The World Health Organization’s multimodal hand hygiene improvement strategy is the most effective approach to improving practice [WHO, n.d.]. Studies demonstrated that a substantial reduction in healthcare-associated infections would be seen if healthcare organizations could sustain hand hygiene compliance rates of 70-80%. The WHO reported that despite the importance of hand hygiene in preventing infections, rates are still meager, with an average of 38.7%. [Joint Commission International, 2020]

A2b.  Explain how one or more national patient safety standards apply to this situation.

A national patient safety standard for this situation is Prevent Infection NPSG.07.01.01, set by the Joint Commission. This goal is to improve hand hygiene and the proper ways to do this.

A3a. Assess the impact of the safety concern on the patient(s), staff and the organization as situated in the identified healthcare setting. Explain how the safety concern affects value for the patient(s) and healthcare setting.

Lack of proper hand hygiene affects patients, staff, and the organization in many ways. For patients, it increases the risk of developing an HAI, which in turn increases the length of hospital stay, increases the anxiety in the patient, and can lead to mortality. It makes the patient not feel safe in the hospital because they came to the hospital for one reason, and now, they developed an infection from being in the hospital. This patient safety issue also affects the staff because they can get sick from these infections, causing them to miss work and pay. It affects the organization by not getting reimbursed for these preventable events most of the time. The organization loses money that could have been spent on other stuff. When staff gets sick, it affects the organization, putting a strain on staffing when there are not enough nurses and techs already.

A4. Recommend an evidenced-based practice change that addresses the safety concern.

An evidence-based practice change that addresses the safety concern would be to have everyone do hand washing for at least 30 seconds. When soap and water are not available, they use alcohol-based gel to sanitize their hands. Teach all employees about the right times to perform hand hygiene: before touching the patient, before any aseptic procedures, after exposure to bodily fluids, after touching a patient, and after touching the patient’s belongings. According to Martos-Cabrera et al (2019), hand washing promotes hygiene in hospital settings which helps improve several healthcare outcomes.

A4a. Discuss how this recommendation aligns with the principles of a high-reliability organization.

The recommendations of evidence-based practice change for everyone doing hand washing for at least 30 seconds align with the principles of a high-reliability organization by being aware that there is a worldwide problem causing patient harm