This is an original excerpt written by our team to show structure, depth and referencing. It is modelled on the course named above but is not a university document. Use samples as a study guide and follow your school's academic integrity policy.
Aim statement
Increase observed hand hygiene compliance at room entry and exit on the unit from a baseline of 68% to 90% within 16 weeks.
Measures
- Outcome: percentage of observed opportunities with correct hand hygiene, using the WHO "My 5 Moments" framework (World Health Organization, 2009).
- Process: alcohol-based hand rub dispenser availability at every room entrance.
- Balancing: staff-reported skin irritation.
Change ideas and PDSA cycles
Using the Model for Improvement, each change is tested on a small scale before spreading (Langley et al., 2009; Institute for Healthcare Improvement, n.d.).
- PDSA 1: move dispensers to the door-handle side of each room on one hallway; observe for two weeks.
- PDSA 2: add real-time peer feedback cards during the same period.
- PDSA 3: spread successful changes to the whole unit and add a weekly run chart to the huddle board.
Sustaining the gains
Compliance data will be reviewed monthly, and ownership will transfer to the unit practice council once the aim is met for eight consecutive weeks.
References
Institute for Healthcare Improvement. (n.d.). Model for improvement. https://www.ihi.org/library/model-for-improvement
Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.
World Health Organization. (2009). WHO guidelines on hand hygiene in health care. https://www.who.int/publications/i/item/9789241597906
