Running Head: PORTFOLIO 1
Portfolio
Name
Chamberlain College of Nursing
NR 631: Nurse Executive Concluding Graduate Experience
Date
,Running Head: PORTFOLIO 2
Project PICOT Question
(P) When considering hospitalized patients, (I) how does increasing the hand hygiene
compliance rate through the use of alcohol based hand rub or soap and water (C) compare to
decreased hand hygiene compliance rates (O) correlate with the decreased incidence of hospital-
acquired infections within an organization (T) in a 12-week period?
Abstract Summary of Project
For the reason that my background is Infection Control, I decided to base my project on
hand hygiene, the single most important way to reduce the spread of infection (Toney-Butler &
Gasner, 2020). Hand hygiene is a step in patient care that is often taken for granted and not
performed correctly. When this act is performed correctly it drastically reduces the chance of
spreading infections from patient to patient, and therefore decreasing the rate of hospital-
acquired infections (HAI's). Hand hygiene is held very dear to my heart. I have recently started at
a new facility in which the compliance for hand hygiene is very low and the HAI's are very high,
which goes to show the direct correlation between the two topic areas. HAI's are very important
to understand because these are caused by none other than our healthcare providers themselves
(multi-disciplinary) as well as cause harm to our patients. The hospital also does not get
reimbursed for these identified HAI's and receive negative remarks within other accrediting
agencies.
Health care associated infections are drawing increasing attention from patients, insurers,
governments and regulatory bodies. This is not only because of the problem in terms of the
associated morbidity, mortality and cost of treatment, but also due to the growing recognition
that most of these are preventable (Toney-Butler & Gasner, 2020). I find this topic very
interesting, concerning, and one that needs to have more attention drawn to it for the safety of ort
,Running Head: PORTFOLIO 3
hospital population. With the implementation of my project I plan to assign secret shoppers the
responsibility of collecting hand hygiene observations to get a compliance percentage of
coworkers who wash their hands upon entry and exit of the patient rooms. The secret shoppers
will be going from unit to unit and total compliance score will be noted at the end of the 12
weeks. Throughout the 12-week period there will be a period of teaching and “just-in-time
coaching” in which staff will be notified on the spot then they are not compliant. This will, in
hopes, increase hand hygiene compliance rates and therefore decrease the incidence of HAI’s
throughout the facility. I plan to use The Joint Commission (TJC) as my resource and hand
hygiene audting tool. TJC also has a lot of learning materials that can provided to staff for
educational purposed, in which I plan to utilize as well when providing teaching to the staff.
References:
Toney-Butler TJ, Gasner A, Carver N. Hand Washing (Hand Hygiene) [Updated 2020 May 29].
In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK470254/
, Running Head: PORTFOLIO 4
Literature Review: Hand Hygiene and its Relevance to Hospital Acquired Infections
In the 1840’s a gentleman by the name of Ignaz Semmelweis discovered a significant
decrease in mortality by simple improvements in hand hygiene practices (The Joint Commission
(TJC), 2020). The simple most effective way to reduce the spread of infection is by instill the
techniques of appropriate hand hygiene, in which the spread of resistant organisms can be
prevented (Centers for Disease Control and Prevention, 2019). Keeping hands clean is a low-cost
simple way of increasing patient safety, which can be dramatically enhanced just by compliance
alone (World Health Organization (WHO), 2020). High incidence of hospital acquired infection
has been closely related to a decreased hand hygiene compliance rate and therefore have created
hand hygiene adherence programs (McCalla, Reilly, Thomas, McSpedon-Rai, McMahon, &
Palumbo, 2018).
Hospital acquired infections, or HAI’s, are infections acquired during the stay in a
healthcare facility which are not present or incubating at the time of admission (Monegro,
Muppidi, & Regunath, 2020). The risk for getting a hospital acquired infection depends on an
individual’s immune system and the category of risk they fall under, such as immunosuppression,
older age, underlying medical conditions, the presence of central lines or indwelling catheters,
just to name a few (Monegro, Muppidi, & Regunath, 2020). Hospital acquired infections are
attributed to high mortality and morbidity within the healthcare organizations throughout the
United States and are associated with a substantial cost each year that is tied the healthcare
facility itself (Healthy People, 2020). It has been spoken that there needs to be an
implementation of educational resources when it comes to hand hygiene and its importance as it
has been observed that healthcare workers seem to care most about appropriate measures of hand
hygiene only when it seems to be a direct cause to their wellbeing (Shobowale, Adgunle,
Portfolio
Name
Chamberlain College of Nursing
NR 631: Nurse Executive Concluding Graduate Experience
Date
,Running Head: PORTFOLIO 2
Project PICOT Question
(P) When considering hospitalized patients, (I) how does increasing the hand hygiene
compliance rate through the use of alcohol based hand rub or soap and water (C) compare to
decreased hand hygiene compliance rates (O) correlate with the decreased incidence of hospital-
acquired infections within an organization (T) in a 12-week period?
Abstract Summary of Project
For the reason that my background is Infection Control, I decided to base my project on
hand hygiene, the single most important way to reduce the spread of infection (Toney-Butler &
Gasner, 2020). Hand hygiene is a step in patient care that is often taken for granted and not
performed correctly. When this act is performed correctly it drastically reduces the chance of
spreading infections from patient to patient, and therefore decreasing the rate of hospital-
acquired infections (HAI's). Hand hygiene is held very dear to my heart. I have recently started at
a new facility in which the compliance for hand hygiene is very low and the HAI's are very high,
which goes to show the direct correlation between the two topic areas. HAI's are very important
to understand because these are caused by none other than our healthcare providers themselves
(multi-disciplinary) as well as cause harm to our patients. The hospital also does not get
reimbursed for these identified HAI's and receive negative remarks within other accrediting
agencies.
Health care associated infections are drawing increasing attention from patients, insurers,
governments and regulatory bodies. This is not only because of the problem in terms of the
associated morbidity, mortality and cost of treatment, but also due to the growing recognition
that most of these are preventable (Toney-Butler & Gasner, 2020). I find this topic very
interesting, concerning, and one that needs to have more attention drawn to it for the safety of ort
,Running Head: PORTFOLIO 3
hospital population. With the implementation of my project I plan to assign secret shoppers the
responsibility of collecting hand hygiene observations to get a compliance percentage of
coworkers who wash their hands upon entry and exit of the patient rooms. The secret shoppers
will be going from unit to unit and total compliance score will be noted at the end of the 12
weeks. Throughout the 12-week period there will be a period of teaching and “just-in-time
coaching” in which staff will be notified on the spot then they are not compliant. This will, in
hopes, increase hand hygiene compliance rates and therefore decrease the incidence of HAI’s
throughout the facility. I plan to use The Joint Commission (TJC) as my resource and hand
hygiene audting tool. TJC also has a lot of learning materials that can provided to staff for
educational purposed, in which I plan to utilize as well when providing teaching to the staff.
References:
Toney-Butler TJ, Gasner A, Carver N. Hand Washing (Hand Hygiene) [Updated 2020 May 29].
In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK470254/
, Running Head: PORTFOLIO 4
Literature Review: Hand Hygiene and its Relevance to Hospital Acquired Infections
In the 1840’s a gentleman by the name of Ignaz Semmelweis discovered a significant
decrease in mortality by simple improvements in hand hygiene practices (The Joint Commission
(TJC), 2020). The simple most effective way to reduce the spread of infection is by instill the
techniques of appropriate hand hygiene, in which the spread of resistant organisms can be
prevented (Centers for Disease Control and Prevention, 2019). Keeping hands clean is a low-cost
simple way of increasing patient safety, which can be dramatically enhanced just by compliance
alone (World Health Organization (WHO), 2020). High incidence of hospital acquired infection
has been closely related to a decreased hand hygiene compliance rate and therefore have created
hand hygiene adherence programs (McCalla, Reilly, Thomas, McSpedon-Rai, McMahon, &
Palumbo, 2018).
Hospital acquired infections, or HAI’s, are infections acquired during the stay in a
healthcare facility which are not present or incubating at the time of admission (Monegro,
Muppidi, & Regunath, 2020). The risk for getting a hospital acquired infection depends on an
individual’s immune system and the category of risk they fall under, such as immunosuppression,
older age, underlying medical conditions, the presence of central lines or indwelling catheters,
just to name a few (Monegro, Muppidi, & Regunath, 2020). Hospital acquired infections are
attributed to high mortality and morbidity within the healthcare organizations throughout the
United States and are associated with a substantial cost each year that is tied the healthcare
facility itself (Healthy People, 2020). It has been spoken that there needs to be an
implementation of educational resources when it comes to hand hygiene and its importance as it
has been observed that healthcare workers seem to care most about appropriate measures of hand
hygiene only when it seems to be a direct cause to their wellbeing (Shobowale, Adgunle,
