Group #3, Quality Investigators:
Altidor, Paula, Bergmann, Lenka, Gspandl, Melissa
Johnston, Caitlin, Lacara, Alison,Wallach, Jacqueline
July 17, 2012
We, the Quality Investigators, pledge not to plagiarize.
Executive Summary:
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Section I - Description of the Problem and the Significance of the Problem
1. Identify a need for continuous quality improvement within a real health care
organization.
Hospital associated infections are a profound problem nationwide. Approximately
2.4 million patients admitted to hospitals in the United States acquire one or more
hospital related infection. Nosocomial infections cost over $2,300 per incident and an
estimated $4.5 billion a year in extended care and treatment (LeTexier, 2000).
Nonetheless, many of these infections are preventable through interventions such as
appropriate hand hygiene by healthcare employees. It is vital that healthcare
organizations have thorough hand hygiene policies and procedures in place and
continually make it a priority through continuous quality improvement.
There is an immense need for continuous quality improvement within an
organization related to hand hygiene. The Centers for Disease Control and Prevention
(CDC) has identified hand washing as the most important means of preventing infection
(LeTexier, 2000). Following an effective hand hygiene system is the most efficient way
to reduce the transmission of pathogens in the healthcare environment. Hospital
associated infections are an extreme risk to patient safety and increase costs and
demand on healthcare resources. Numerous studies have indicated that adherence to
hand hygiene procedures remain inadequate and improvement efforts lack needed
sustainability. National statistics show that only 50% of direct healthcare providers
comply with the current hand hygiene standards (The Joint Commission, 2009, p. 2). In
order to maintain positive outcomes in relation to hand washing, continual monitoring is
critical.
In order for this vital continuous quality improvement project to succeed, it is vital
that hospital leadership and clinical leaders demonstrate commitment to the program.
They must identify opportunities and implement improvements to the organizational
hand hygiene program as a part of their infection control and risk management
strategies (LeTexier, 2000). Proper hand hygiene observation can lead to reduced rates
of healthcare associated infections. Healthcare organizations which employ
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comprehensive hand hygiene protocols provide the most adequate environment to
deliver safe and efficient patient care.
2. Identify why there is a need for improvement related to organizational goals
and internal and external benchmarks.
Most healthcare organizations have their mission, vision, values, and goals
related to delivering high quality healthcare and improving the health of those they
serve. Without proper infection control guidelines, the healthcare organization puts
those exact people at risk. The transmission of microorganisms from patient to patient
or nurse to patient through hand contact can result in numerous adverse clinical
outcomes. Expanding on that point, hand-mediated transmission is a major contributing
factor in most infection threats to hospital patients (LeTexier, 2000). In addition to
organizational goals, national patient safety goals set annually by the Joint Commission
require improved compliance on patient safety issues such as hand hygiene (The Joint
Commission, 2009, p. 1). Numerous other patient safety groups have exacted
benchmarks in regards to patient safety and hand hygiene. The World Health
Organization (WHO) has named hand hygiene a quality indicator of patient safety. They
believe that event in a setting of constrained resourced, basic hand hygiene should be
consistently performed with a defect rate of less than 10% (The Joint Commission,
2009, p. 73).
It is important to relate a proper hand hygiene program to the organizational
goals and benchmarks due to its potential impact on patient outcomes. The Joint
Commission, which accredits healthcare organizations, requires a minimum of 90%
compliance regarding hand hygiene (The Joint Commission, 2009, p. 92). Defining
specific and measureable goals for improvement is a vital part of the process. An
effective had hygiene program sets annual goals for the safety initiative, charts the
progress monthly, and works directly with the caregivers. It is imperative that healthcare
organizations compare its internal quality measures against benchmarks in order to
monitor performance. In order for organizations to provide safe patient-centered
healthcare and increase satisfaction scores, the patient must be a priority. Effective
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hand hygiene programs are just an example of an organization pursuing their mission of
improved healthcare delivery.
Improving hand hygiene involves changing habits and employee mindset.
Sustaining the improvement requires knowledge, commitment, and accountability. High
quality, safe healthcare is the result of well-designed systems and processes created to
protect and heal the patient. It is the healthcare organization’s responsibility to have a
comprehensive hand hygiene process in place and keep patient safety and quality
improvement as a top priority.
Section II - Literature Support for Your Position and Analysis
3. An organizational design for participation in the CQI process.
Parallel design is a type of organizational design that supports the
implementation of Continuous Quality Improvement (CQI) and Total Quality
Improvement (TQM). Its purpose is to “promote the quality of working life in an
organization” (Kaluzny & Shortell, 2006, p. 333). For example, hand washing in the
workplace is a major concern. If this task is not done routinely, it can cause a ripple
effect of health hazards. Parallel design requires the participation of everyone working
in clinical and non-clinical aspect of healthcare. However, it is not an organizational
design that focuses only on the position of managers and upper levels.
This approach addresses external and internal issues because of the
involvement of everyone. Parallel design makes CQI a priority within an organization
which in turn enhances patient satisfaction. The difference between parallel design and
other organizational designs is the initiative taken by a group of individuals from various
levels of the hierarchy to provide better quality service in healthcare. The established
group focuses on pin-pointing the core quality issues in the organization and creates
solutions that can resolve the issues. These quality issues being addressed is going to
enhance the organization’s reputation and relationship with patients, and among staff
because parallel design focuses more on the quality issues affecting the health and
safety of those involved.
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There are multiple advantages for staff and an organization when utilizing parallel
design such as: “expansion of power among staff, opportunities to affect the
organization’s decisions, the feeling of being involved in organizational issues, potential
for individual growth from variety of activities, increase performance and quality”
(Kaluzny & Shortell, 2006, p. 333). The most vital of the advantages is increase
performance and quality which is essential for any CQI process. Furthermore, the
increase of involvement from staff will set a positive tone for the healthcare
organization. It is factors like motivation and self-empowerment of parallel design that
triggers the continuous effort in an organization which is a long-term benefit that will
pay-off tremendously.
4. Quality theorists and/or theoretical framework(s) that will be used to guide the
development of a successful CQI process.
The three theorists that have the most impact on quality improvement such as
CQI is W. Edwards Deming, Joseph M. Juran, and Philip B. Crosby. Their philosophies
solidified the importance of CQI and other quality improvement concepts. W. Edwards
Deming emphasized on the role of management, the authority to eliminate barriers that
can block high quality of work, and recommends all employees to be involved in
decision making. There are many other advantages Deming’s philosophy provides
which include: “increase in quality, customer loyalty, and decrease costs by reducing
waste, rework, and staff attrition” (Joshi et al. 2008, p.64). As a result of situations
occurring from lack of quality improvement, Deming developed a concept called 14
points for Western Management. The purpose of the 14 points for Western
Management is to produce quicker quality improvement results in unstable conditions.
The theoretical framework of Deming’s Plan-Do-Study-Act (PDSA) is a great guidance
tool for a successful CQI process. It is a step-by-step set of guidelines that promotes
continual improvement. Each part of PDSA cycle consists of tasks that should be
completed before going to the next step such as the objective, educate and train the
staff, assess the effect of the change, compare results to predictions, and act what you
have learned (Joshi et al. 2008, p.68). Once the PDSA cycle is complete, three
questions must be answered if followed correctly:
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•What are we trying to accomplish?
•How will we know that a change is an improvement?
•What change can we make that will result in improvement? (Joshi et al. 2008, p.69).
It is the responsibility of everyone participating in CQI to make sure each step of
PDSA is followed accordingly because it will affect the success of the CQI process. CQI
is an organization-wide type of process due to the nature of quality improvement topics
within healthcare. It is a practice and a mindset that must be utilized on a regular basis
in order to maintain positive results and outcomes. Joseph M. Juran founded the “Juran
Trilogy” which is strategies for managing and improving quality improvement. The
“Juran Trilogy” consists of three processes: quality planning, quality control, and quality
improvement. Juran encourages training from management on the subject of quality
and promotes communication among employees in order to create a better and safer
working environment. This concept opens doors to address patient-related and
organizational-related issues because communication has improved. Philip B. Crosby
believed that prevention is the key if the right and strict guidelines for quality
improvement is put in place. Crosby established the Four Absolutes of Quality
Management that includes “quality is defined as conformance to requirements, not
goodness or elegance, the system for causing quality is prevention, not appraisal, the
performance standard must be zero defects, and the measurement of quality is the
price of nonconformance” (Joshi et al. 2008, p.67). The layout for Crosby’s Four
Absolutes of Quality Management is to eliminate any possibility of errors from occurring
which helps reduce healthcare costs, improve quality and safety within a workplace.
According to Kaluzny & Shortell, these theorists contributed to multiple other
philosophical concepts that are essential for a successful CQI process which consists
of: “productive work involves processes, the customer is central to every process,
eliminate defects and add features that meets customer’s needs, the main source of
quality defects is problems in the process, quality defects are costly in terms of internal
losses by lowered productivity and efficiency, focus on the most important processes to
improve, involve every worker in QI and set standards for performance” (2006, pp. 439440).
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5. Assessments that need to be made to identify the nature and scope of the
quality problem. Include tools you would use. Complete the tools with the help of
the literature and professional contacts.
When evaluating the nature and scope of hand hygiene there are about nine
parts that must be evaluated. The first being components, that is the type of hand
sanitization methods being utilized, the type of professional organization, is hand
sanitization utilized after removing gloves, and how thorough the hand cleaning process
is. Indications references when the sanitization occurs, such as before/after contact,
when body fluids are present, as well as following contact with a patients surroundings.
Structural considerations tie into how accessible and how available the hand
sanitization methods are. Product use discusses how much of the sanitization product is
used by staff and how frequently and by which particular staff members. Adherence to
policy is important when evaluating standards such as nail length. Staff knowledge with
regards to hand sanitization. Staff competence is the ability to appropriately follow hand
standards. Perceptions of attitudes, how the staff views hand hygiene as well as how
patients and their family members view hygiene. Finally, satisfaction both from the
workers and the patients on the availability, ease of access, and utilization of hand
hygiene methods.
Measuring hand hygiene is most effectively done by observation, product
measurement, and surveys. Observations involve studying the placement of hand
hygiene products. Product measurement entails measuring the amount of product used
in various areas by different staff over the course of the day. Surveys gather direct
information from the staff and patients on their perceptions of hand hygiene in the
healthcare facility.
6. Evidence-based recommendations for changes that may be used in achieving
the improvement--in progress.
There are several valuable recommendations that should be used for causing
change with hand hygiene. The first factors being what leads to the lack of compliance.
One such article studied factors of what caused reduced compliance and links were
shown to which shift was worked (weekday versus weekend) being a physician or
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nursing assistant as opposed to a nurse, what protective clothing was worn, and which
unit the physician or nurse (nursing assistant) was working in. In addition other factors,
such as ease of access to hand washing facilities, and thinking gloves eliminated hand
washing needs. Furthermore, the type of hand washing options also impacted
compliance. If the available hand sanitization methods will dry out or irritate skin there is
less of a desire to follow compliance suggestions. When there is an understaffed or high
work load environment the ability to comply also decreases.
Transitioning to a primarily alcohol based hand sanitization method is effective
because it is cost efficient and easy to place in multiple locations for ease of access.
Additionally, by increasing the awareness and communication of information to the
health care workers has shown effective.
On May 5, 2009 the World Health Organization (WHO) issued guidelines on
hand hygiene, built on the idea of five key moments in patient care when hand hygiene
should be utilized. They are as follows “before touching a patient, before a clean/aseptic
procedure, after body fluid exposure risk, after touching a patient, after touching patient
surroundings” (Pittet, Allegranzi, & Boyce, 2009).
The value to the WHO five steps of hygiene is that it addresses traditional
barriers to hand hygiene uniform factors. It included religious and cultural aspects,
ability to promote on a national scale, social marketing, and the needed infrastructure so
that hygiene can eventually be promoted everywhere regardless of monetary resources
available (Pittet, Allegranzi, & Boyce, 2009).
One study conducted by at a Veterans Affairs hospital in Pittsburgh showed that
physicians and other health care workers were less likely to respond to hand hygiene
protocols than nurses. Briefest patient contact and shortest episodes of care also
revealed that these were times more likely not to be compliant with hand hygiene. In
order to achieve improvement it is significant that hand hygiene be emphasized to all
health care workers and be utilized every time, not at the discretion of the employee
(Dedrick et al,2007).
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7. Quality and cost indicators that will be used to monitor the improvement over
time.
Quality is something that is necessary in relation to hand hygiene. Orlando
Health expresses how serious this matter is. Signs are posted everywhere on how to
prevent transferring diseases to other patients. Foaming stations are located in and out
of every patient’s room; this is mandatory and can hold high consequences if not done.
Extra precautions are implemented with patients that have Clostridium Difficile, better
known as C. diff. Hand washing is mandatory upon leaving their room. There are posts
all over the hospital for alcohol pumps, foam canisters, and hand washing stations.
Even at the time of hire, employees are taught proper hand washing techniques and
potential consequences if not done properly.
Costs are calculated by the amount of soap and foam that is ordered in a month
by each department. This amount is compared to other departments and number of
team members in that department. Nursing stations should be ordering the same
amount each month. If one floor is ordering less than others, than an investigation will
take place in regards to quality. Knowing that a department is using less than the
standard amount will prove that hand sanitation is not up to par for that department.
Someone from the Compliant Department will go to that department and perform a
visual test for hand hygiene. This test will be conducted by observing clinical staff
entering and exiting a non-specified room and documenting if they use the appropriate
measures.
As mentioned earlier, visual hand hygiene tests are performed to test a unit’s
compliance. Random tests are done by each person in the Compliance Department.
Approximately ten tests are done by each member of that department monthly. The
tests are done in various ways. The staff is able to collect information manually, and
then enter the data in at a later time or computerized systems for immediate usage.
Results are compiled and data is generated for that month. A comparison process will
take place for that month and others. A consistency must be maintained over a course
for time. If there is any deviation, action must be taken immediately. Hand hygiene
education will take place for any units that need additional attention.
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Section III - Your Proposed Solution
8. Plans for implementation of the improvement.
Healthcare Facilities need to have numerous hand washing stations throughout
the entire hospital or they can be held in no-compliance by the hospital or The Joint
Commission.. To prevent the transmission of bacteria that can cause pass infections to
patients. It is important to have hand washing stations available to staff around every
corner or patient room. This can be either soap and water or alcohol-based antiseptic.
Antiseptic needs to be easily accessible to both doctors and nurses that come into
contact with patients. It is extremely important that all staff member wash their hands or
use antiseptic before and after seeing patients, to ensure their hands are disinfected.
Hospitals need to have hand washing stations that are convenient and easy to
use. Having an abundance of washing stations will help staff members remember to
wash their hands, while also making it easy to use, and opportune. Making hand
washing stations more accessible would increase their use by staff. Policies by hospital
administrator give specific instructions on how to properly wash hands and use
disinfectant. With “hand-hygiene rates range from 30 to 70 percent” (Terry, 2012) there
is cause for concern.
Educating medical staff of the safety concerns and showing them acceptable
ways to decontaminate themselves is an important step. Staff members are expected to
wash their hands before and after seeing a patient. Educating hospital staff on the
proper way to wash their hands and how to use instant sanitizers will reduce
transmission of infections. Once hospital staff members know what is expected of them;
ensuring the rules are being followed is the next step.
There are a few ways to monitor if medical staffs are appropriately using the
hand sanitation stations. One way, is opening communication lines between hospital
personnel and hospital administrators. Nurses, doctors and other staff members have
someone higher up to report hospital personnel that do not comply with the hand
washing policies. Executives and administrators are encouraged to walk around the
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hospital floors to show staff members they are committed to making a change and
increase patient safety in the hospitals (Terry, 2012).
Hand hygiene is a significant component in preventing the spread of potentially
life threatening bacteria and infections. Executives and administrators need to show a
hand on leadership approach to sustain consistent hand hygiene. Also, coworkers need
to help speak up and report when they see unacceptable hand hygiene. Signs and
instructions near hand washing stations help staff learn the proper way to wash their
hands. Placing hand washing stations in convenient to use areas; which promotes an
increased usage. Combined, this should decrease the transmission of infectious
bacteria; this will respectively increase patient safety (Terry, 2012).
9. Plans for communicating the results of the project.
There are many ways to convey the results of the usage of hand washing
stations by hospital staff. Data taken from surveys, observations, the amount of hand
washing products used, and hand testing; are converted into charts and graphs for
interpretation. If hand hygiene protocols are being followed, there should be a decrease
of patients contracting hospital infections. Some hospitals have even gone to the
extreme to make sure their staff is complying with hand washing policies (Rosenberg,
2011).
Surveys and observations are best represented in pie charts and bar graphs.
These charts and grafts are easy to compare results to previous years, or data
collection points. The supply of hand soap and hand sanitation can also provide
information about which sections of the hospital are using an adequate amount of soap;
while other areas may be lacking. There should be a direct correlation between soap
usage and the amount of supply ordered; the more that is used, the more that is
ordered. A direct correlation should also be found between an increase in hand hygiene
and a decrease in infections transferred to patients in the hospital.
Technology allows for innovative ideas to be tested out in specific hospitals. One
of these inventions is a bracelet that monitors the amount of times a staff member
washes their hands. This requires sensors put in at each hand washing station; the
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sensor then transmits to the bracelet that the staff member was there and then blinks a
green light. The green light indicates the hospital personnel have washed their hands.
This is an expensive endeavor, but effective way to encourage individuals to be held
accountable (Rosenberg, 2011).
Researchers can currently monitor sections of the hospital to see which area
uses the most soap and sanitizers. These finding are best represented by charts and
graphs that can then be presented to all medical personnel. This allows staff members
to see where improvements need to be made and therefore allows for more progress to
be made in the prevention of spreading infections.
10. Plans for maintaining the improvement.
Usually, shortly after communicating the need for improvement and making
everyone aware of a new initiative, there is an instant progress. However, sustaining the
improvement is what most organizations have difficult times with and it requires
constant effort.
Similarly to many other important aspects, expectations should be clearly
communicated by management. To maintain the hand hygiene improvement, every
healthcare administrator, patient-care manager, and department manager should
emphasize the importance of complying with hand washing guidelines as well as
monitor everyone’s adherence to it (Cantrell, 2004). To standardize hand hygiene, The
World Health Organization (WHO) has introduced “My 5 Moments for Hand Hygiene”, a
simplified guide to help healthcare professionals to remember when to wash their
hands. Those five moments are before touching a patient, before clean/aseptic
procedure, after body fluid exposure risk, and after touching patient’s surroundings.
WHO issued several tools to aid hand hygiene habits, such as posters and leaflets that
can be strategically placed throughout the workplace and near hand washing stations to
remind everyone of the moments and of correct ways to wash hands. With these aids,
healthcare facilities should be adequately equipped for success.
To maintain improvement, employees need to be regularly reminded of the
importance of hand hygiene. Education and training can contribute to increased
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compliance; therefore, employees should be scheduled regularly to attend training
sessions and workshops. Hand washing protocols and policies should be reviewed on
regular basis to ensure they are up to date and current copies should be available to all
workers within the facility. Aside from being aware and educated, it is important to have
hand washing stations easily accessible to ensure healthcare professionals do not have
to go out of their way to comply with hand hygiene. The stations should be regularly
checked to ensure they are clean and stocked with all necessary hand washing
supplies, such as soaps, antiseptics, sanitizers, towels, etc.
To monitor hand hygiene compliance and to change the culture, the state of
Maryland has launched a statewide initiative to train employees at most of the state’s
hospitals to report their co-worker’s hand-washing compliance (Meyer, 2010). Meyer
explains that the main idea behind the initiative was for anyone who sees another
worker who forgot to wash their hands to remind them. The result of this initiative was
extremely successful, increasing compliance tremendously (Meyer, 2010). This
approach is a good example of getting everyone engaged to work together towards a
common goal, a compliance to hand washing. It does not necessarily have to be a
nationwide or statewide initiative, but a single healthcare organization or even a
department within the organization can come up with something similar to ensure
maintained improvement. One idea would be to implement recognition and reward
system for those who are identified as always compliant and diligent to hand washing.
The reward approach gives employees an additional incentive to try hard in order to
achieve the best results possible. On the other hand, if it is observed that one or more
of the employees do not comply, the manager should address the issue and its
consequences privately with the employee.
In today’s society, nearly every industry and every profession relies on use of
technology and modern equipment and healthcare is no exception. Several companies
have been working on creating automated systems for monitoring compliance to hand
washing. In 2012, company called DebMed introduced the world’s first electronic hand
hygiene monitoring and system that can be used to monitor compliance with hand
washing (DebMed, 2012). Heather McLarney, Vice President of Marketing for DebMed
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states that “By moving hygiene monitoring to an electronic platform and away from
direct observation, we will change the landscape of infection control and help to reduce
the unnecessary HAIs that hospitals are currently experiencing each year” (DebMed,
2012). While electronic hand hygiene monitoring system may be little too advanced for
majority of healthcare organizations today, it may possibly be the answer for
maintaining improvement in the future. This would provide instant results and allow
leaders to recognize non-compliance nearly instantly.
Section IV - Conclusion and Recommendations
11. Conclusions, future recommendations and lessons learned during the
development of your project.
Hand washing is a simple, yet vitally important procedure. It should be something
done automatically by every healthcare worker; however, it is not always as respected
and practiced as it should be and there is a need for improvement. Our research made
us realize the huge impact poor hand washing practices or non-compliance have on
patients. The fact that 2.4 million patients who are admitted to hospitals in the United
States acquire a hospital related infection each year (LeTexier, 2000) is extremely
alarming. Even worse, these infections are a direct cause of estimated 30,000 deaths
and contribution to another 70,000 deaths (LeTexier, 2000). It made us realize the
complexity that is involved in implementation of practices in a workplace. Even though
hand Hygiene has been given a lot of attention and is seemingly simple practice, the
alarming number of infections proves that something is not working right. There is a
tremendous need for improvement. We live in a modern society and have all the
resources to reduce the negative impact, yet we struggle with accomplishing it.
Once proper hand washing is taught, implemented, and situation improved, the
next critical step is to maintain the improvement. Our recommendation for monitoring
and maintaining improvement would be a combination of all of the above mentioned
practices: having clear direction set by leadership, being reminded of the importance
and re-educated on regular basis, implementing various initiatives to enhance
compliance, and monitoring any newly released technologies. Following these
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recommendations should help maintain improvement and prevent transmission of
infection greatly.
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References:
Cantrell, S. (2004). Hand-hygiene: Thumbs up for importance, thumbs down for
implementation. Healthcare Purchasing News, 28(11), 34-34,36,38. Retrieved
from:
http://ezproxy.lib.ucf.edu/login?url=http:////search.proquest.com/docview/2079518
22?accountid=10003//
DebMed(R) to debut benefits of world's first electronic hand hygiene compliance
monitoring system using the WHO five moments at annual infection control
conference. (2012). PR Newswire, pp. n/a. Retrieved from
search.proquest.com/docview/1017650169?accountid=10003|http://ezproxy.lib.u
cf.edu/login?url=http:http:search.proquest.com/docview/1017650169?accountid=
10003
Dedrick, R., Sinkowitz-Cochran, R., Cunningham, C., Muder, R., Perreiah, P., Cardo,
D., & Jernigan, J. (2007). Hand hygiene practices after brief encounters with
patients: an important opportunity for prevention. Infection Control And Hospital
Epidemiology: The Official Journal Of The Society Of Hospital Epidemiologists Of
America, 28(3), 341-345.
Joshi, M, Nash D., Ransom, E. & Ransom, S. (2008). The Healthcare Quality Book:
Vision, Strategy, and Tools. 2nd Ed. Chicago: Health Administration Press
Kaluzny, A.D. & Shortell S.M. (2006). Health Care Management: Organization Design
and Behavior. 5th Ed. New York: Delmar Cengage Learning
LeTexier, R. (2000). Preventing Infection Through Handwashing. Infection Control
Today. Retreived July 2, 2012 from
http://www.infectioncontroltoday.com/articles/2000/07/preventing-infectionthrough-handwashing.aspx
Meyer, H. (2010). Measurement ensures better handwashing compliance. Managed
Healthcare Executive, 20(7), 25-26. Retrieved from
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http://ezproxy.lib.ucf.edu/login?url=http://search.proquest.com/docview/73478018
4?accountid=10003
Pittet, D., Allegranzi, B., & Boyce, J. (2009). The World Health Organization Guidelines
on Hand Hygiene in Health Care and their consensus recommendations.
Infection Control And Hospital Epidemiology: The Official Journal Of The Society
Of Hospital Epidemiologists Of America, 30(7), 611-622.
Rosenberg, Tina. (2011). Better Hand-washing Through Technology. Retrieved July 15,
2012, from The New York Times Web Site:
http://opinionator.blogs.nytimes.com/2011/04/25/better-hand-washing-throughtechnology/
Terry, Ken. (2012). Do You Hold Staff Accountable for Safety. Retrieved June 20, 2012,
from Hospital & Health Networks website:
http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/A
rticle/data/02FEB2010/1002HHN_FEA_patientsafety&domain=HHNMAG
The Joint Commission. (2009). Measuring Hand Hygiene Adherence: Overcoming the
Challenges. Illinois: The Joint Commission
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