The project that is the subject of this presentation took place in a federally run 27 acute care bed facility that is combined with 160 long-term care beds in a small town in Ohio. The problem identified was that hand hygiene compliance was consistently below the goal established by the facility and required action to increase compliance. A review was made of 30 peer-reviewed credible sources on the subject of hand hygiene that were published within the last five years. Each source was reviewed for applicability to the project, had an evidence grade assigned, had a general appraisal of the findings, and had a determination made of whether the source would be included or excluded from the final list of sources for the project. Based on the review, an evidence-based plan was written that proposed to use the Joint Commission Center for Transforming Healthcare’s Targeted Solutions Tool for Hand Hygiene. A PowerPoint presentation was made to the Infection Control Committee and nursing leadership at the facility. The presentation included three identified best practices, which were direct observation of staff, identifying barriers, and employing supportive strategies. It included an explanation of how the Joint Commission Center for Transforming Healthcare’s Targeted Solutions Tool for Hand Hygiene can be utilized to improve hand hygiene compliance.
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