Implementation of Hand Hygiene Compliance in the Operating Room

Implementation of Hand Hygiene Compliance in the Operating Room
Description of Steps
The implementation of hand hygiene protocol in the operating room involved a series of steps geared towards achieving effective hand hygiene among staff. The initial step involved seeking approval from the hospital administration regarding the implementation of new change in the organization. An initial draft explaining the importance of the new change was presented to the administrators. The draft explained the various steps of implementing the change including resources for pre and post-implementation. The second step involved the review of the WHO hand hygiene guidelines and the identification of gaps among OR healthcare providers. The hospital hand hygiene guidelines were reviewed with the help of the clinical nurse educator to ensure all aspects were included. The result was a complete guideline of hand hygiene that took into consideration the hospital policies and WHO guidelines.

Implementation of change in the healthcare organization required the support from nurse leaders and staff. The third step involved sharing the new guidelines with the OR charge nurse and the clinical nurse educator. This step was necessary because of the power and influence of the nurse leaders towards the realization of set goals. Upon approval of the whole plan by the administration and other leaders, the next step involved the identification of key stakeholders and their roles during the implementation of the new change. The OR nurses were the primary stakeholders involved alongside other healthcare providers like the surgeons, surgical technicians, and subordinate staff.

The initial intervention plan for hand hygiene compliance involved the development of a multimodal plan that included in-class education, hands-on simulation training, and professional modeling. The next step involved designing an education program for nurses on hand hygiene using the WHO guidelines. Upon education, simulation training was offered to ensure that the staff acquired the skills to effectively wash their hands. For instance, demonstration of the six steps for handwashing was demonstrated by the nurse educator, and emphasis was put on washing hands for 20 to 30 seconds. Professional modeling was emphasized during the implementation of the new change to ensure that nurse leaders were engaged in the exercise. The final step involved the printing of the new hand hygiene guidelines and ensuring their availability at every hand washing station in the OR. The staff were prepared for the handwashing exercise and informed on the four weeks monitoring period.

Discussion of Changes

The operating room is a busy unit in any healthcare facility and implementation of new change requires time. The initial plan involved the use of in-class education and simulation training for staff. However, the two exercises were combined because of time due to the busy nature of the staff. Secondly, it was difficult to provide education and training for staff for night and day shift staff. The result was a split of in-class education for staff to incorporate night shift education of staff. This change ensured that all staff got an opportunity for training and observing how effective hand washing was done. The clinical nurse educator also involved external stakeholders to help educate the OR staff on the importance of hand hygiene to the organization with an emphasis on its effectiveness on HCAHPS scores. There was also the incorporation of online sharing of educational materials like videos for reference and sharing of sessions for both day shift and night duty staff. Because of these changes, an extra week was added to the initial time of implementation to ensure all activities were completed.

 Discussion of Barriers

Infection prevention and control in healthcare organizations have remained to be a challenge despite the implementation of various changes. The first challenge experienced was the acceptance of the new change by the OR staff. Most individuals argued that the new WHO guidelines were not that different from the CDC handwashing guidelines. Secondly, there was a problem with creating time for education and training from staff because of understaffing in the OR. The busy nature of the OR meant that split education was needed for staff. Additionally, training for night shift staff was a problem and this led to the incorporation of an extra education program at night.

Overcoming Barriers

The first challenge experienced was the acceptance of the new change by the OR staff. There was an argument that the CDC guidelines present were not different from the WHO guidelines. This challenge was dealt with by using a comprehensive education program on the WHO guidelines. For example, the staff was informed that hand washing exercise should last for 20 to 30 seconds as per the WHO guidelines. The staff was also informed on multiple occasions in the OR that hand washing was applied using the moments for hand hygiene guidelines by the WHO. Through the education and training program, most professionals understood the importance of the new change and the differences between CDC and WHO hand hygiene guidelines.

The second challenge experienced was a lack of enough time for training and education due to understaffing. To overcome this challenge, split training of day shift staff was practiced to ensure the OR had enough staff to take care of other operations. Secondly, training during the morning hours was recommended before the commencement of the day’s activities. During the night shifts, the nurse educator offered a training session to ensure the nurses were equipped for the exercise. Another strategy used was the use of online groups which were used to post-training and simulation videos. This strategy ensured that all staff acquired the same experience on handwashing using the new WHO approach.

Identification of Interprofessional Relationships

The implementation of the new change involved various professional teams like the nurses, surgeons, surgical technicians, and clinical educators. These personnel worked together to ensure the success of the new change and the sustainability of the project. The hospital administration and the nurse educator organized for the presence of external stakeholders to guide during education and training. Interprofessional collaboration is important in the implementation of evidence-based practice because it increases sharing of ideas and sustainability of change.

Discussion of Relationships

Nurses. Nurses form the largest team of healthcare professionals in any healthcare organization making them key players in change processes. The OR staff nurses were actively involved during the implementation of a new change in the facility. Firstly, the team was involved in education and training on how to perform handwashing using the WHO guidelines. The nurses worked closely with the surgeons and surgical technicians during the implementation phase to monitor hand hygiene and report any challenges experienced to the nurse leaders. A good relationship between the nurses and other OR staff ensured a successful implementation of the new change.

Surgeons. Surgeons were actively involved in the implementation of the new change through participation in training and education. There was a need to educate the surgeons and surgical technicians on the WHO guidelines because they are part of the OR staff handling patients every day. The team was also involved in giving feedback to the administration regarding the effectiveness of the new change and any barriers experienced during the implementation phase. A good relationship with nurses and other personnel ensured effective communication and identification of gaps leading to the success of the project.

Nurse Educator. The clinical nurse educator played a key role during the implementation of the new change. The provision of education and training was coordinated by the nurse educator to ensure every member of the OR acquired the necessary skills for implementation of the change. The nurse educator acted as a link between the nurses and the surgical team to ensure understanding and collaboration during the exercise. The clinical nurse educator and the administration collaborated to bring on board external stakeholders who stressed the importance of hand hygiene to both the patients and the healthcare organization. Lastly, the nurse educator ensured successful education and training for day shift and night duty staff including the availability of online education and sharing of materials. An extra education program for night duty staff was organized leading to the success of the project.

Information Technology Team. The integration of health information technology into healthcare has led to the improvement of quality and patient safety today. The IT team was involved in the implementation of the new change by organizing the availability of computers during the education process. Secondly, the team was involved in coordinating events leading to the formation of the OR online group and sharing of videos for education.

Chapter 4: Post-Capstone Project Considerations

Discussion of Successes

Quality improvement in healthcare is a process that requires education, training, and monitoring for the achievement of better outcomes. The implementation of the new change in the organization improved quality in various aspects. For example, the nurses and other healthcare teams understood the importance of hand hygiene and its influence on patient outcomes. Understanding these effects has demonstrated improved compliance of handwashing by OR staff. There is also a demonstration of teamwork and collaboration towards the reduction of infections through hand hygiene compliance. Today, the nurses, surgeons, and surgical technicians follow hand-washing guidelines using the five moments of hand hygiene as directed by the WHO.

The second aspect of success in the organization is the demonstration of effective implementation of evidence-based practice. The use of WHO guidelines for hand hygiene is supported by research to be effective in reducing hospital-acquired infections. The project demonstrates that healthcare organizations can improve quality and patient outcomes through the use of evidence-based practices. For example, the rate of HAIs has decreased gradually in the facility due to the use of WHO hand hygiene guidelines. Education and training were part of the approaches used to implement hand hygiene in the unit. The use of these approaches demonstrates the success of the project because nurses and other healthcare providers are now able to understand the importance of handwashing to patients and the organization.

How Successes Will Inform Future Projects

The success of this project indicates that change can be achieved in healthcare organizations using evidence-based practices. The use of WHO guidelines for hand hygiene is supported by evidence to reduce hospital-acquired infections. Future projects should also use evidence-based practices to improve quality and patient outcomes. The multidisciplinary collaboration was another approach used to achieve good outcomes in the project. Nurses, surgeons, surgical technicians, and the clinical nurse educator worked together to ensure the success of the project. In the future, interprofessional collaboration should be among the approaches to achieve quality outcomes in the institution. Lastly, education and training played a key role in informing staff on the importance of hand hygiene. Future projects should use this approach before implementing change in any organization. Lastly, the new change demonstrates that a good plan should be laid to overcome barriers.

Aspects That Did Not Go Well

The availability of challenges during the implementation of the change made it difficult to achieve the desired outcomes on time. For example, it forced the nurse educator to organize split education programs due to understaffing. It was also necessary to organize a separate education program for night shift staff to ensure every OR staff was educated. Time was another limiting factor during the implementation of change. The adjustments made to the original plan meant an extra week was required to fully complete the project. The initial acceptance of the new change by OR staff was poor because of the already existing CDC guidelines. It was until education and training were offered that nurses started to acknowledge the importance of the new change.

Understanding What Did Not Go Well

The implementation of WHO hand hygiene guidelines use in the OR has helped me understand how the change process and how to overcome barriers to change implementation. I have realized that education is an important factor for the promotion of change and acceptance of new projects in healthcare organizations. Future projects should consider the incorporation of education and training for healthcare workers. The new change has expanded my understanding of the change process, barriers to change implementation, and how to overcome these barriers. For example, I have understood that time is important during change implementation and adequate resources should be allocated before new change begins. I believe this change process has expanded my understanding of quality improvement in healthcare and the change management process.

Explanation of How the Gap Was Bridged

The WHO hand hygiene guidelines provide a review of evidence on handwashing to give direction on effective handwashing by healthcare workers (WHO, 2009). The problem identified in the healthcare organization was noncompliance to the CDC hand hygiene guidelines. There was a gap in performing hand hygiene using the appropriate technique, at the right time, and in the right manner. Random audits in the OR confirmed that proper handwashing was a challenge for nurses, surgeons, and surgical technicians. Additionally, there was a lack of role modeling from nurse leaders and senior staff leading to poor hand hygiene in the OR. To ensure hand hygiene was properly followed, the new change involved the use of the WHO guidelines through education and training for staff.

The use of education to implement the new change ensured that nurses and other healthcare workers acquired the necessary education on hand washing. Simulation training helped OR staff understand how handwashing is done using the recommended six steps by the WHO. The second part was the use of a collaborative approach to reduce the rate of HAIs in the operating room. Nurses, surgeons, and surgical technicians were part of the team working to ensure hand hygiene was practiced. The end results demonstrated increased compliance to the WHO handwashing guidelines and also increased understanding of staff on the importance of handwashing to the patient’s health.

Supporting the Plan

The plan for post-implementation support includes routine monitoring of hand hygiene in the OR, provision of regular reports about hand hygiene, and formulation of policies to govern hand washing in the OR. The charge nurse and senior staff will ensure nurses, surgeons and surgical technicians adhere to hand washing protocol as per the WHO guidelines. Individuals found to poorly practice hand hygiene will face disciplinary action or face the consequences appropriately. Weekly reports to the administration about hand hygiene practices in the OR will serve to hold nurse managers responsible for the new change. These reports will also dictate the course of action when hand hygiene is not properly practiced or when any changes are needed to be made.

Another plan for sustainability is the making of policies to govern hand hygiene in the OR and other hospital departments. For instance, printed WHO guidelines should be availed at every hand washing station to remind staff of the right handwashing procedure. Lastly, continuing education and training for staff and new workers should focus on hand hygiene to ensure successful implementation of the new change. Nurse leaders should be at the frontline to organize education sessions and practice role modeling for the sustainability of the new practice change.

Resources for Post-Implementation

The effective use of WHO guidelines for hand hygiene in the OR will require education, training, and finance to sustain the practice. Educational resources for the change will include education rooms and audio-visual technology for teaching. Secondly, writing materials will be required during the education sessions and routine reports given to the administration. Financial assistance for the printing of the WHO guidelines and buying soap and sanitizers will be required in the unit. Healthcare personnel like the clinical nurse educator will be required to provide education and training for new staff and during continuing education.

Chapter 5: Reflection

Integrated Outcomes

The first program outcome that I believe I demonstrated in the project is the integration of clinical reasoning with organizational, patient-centered, culturally appropriate strategies to plan, deliver and evaluate evidence-based practice. The practice change involved the implementation of WHO hand hygiene guidelines which is supported by evidence. In the previous section, I provided a comprehensive literature review on how the WHO hand hygiene guidelines have helped healthcare organizations reduce hospital-acquired infections.

The second program outcome that I managed to integrate was the construction of interprofessional teams to communicate, coordinate, collaborate and consult with other health professionals to advance a culture of excellence. The new change involved members from various professional groups like nurses, surgeons, and surgical technologists. These teams worked closely to ensure effective implementation of the change in the OR.


Healthcare-associated infections (HAIs), such as post-operative wound infections, have been on the rise and have led to increased morbidity and mortality among surgical patients. Hand hygiene is recognized as the most basic precaution to prevent these infections by the CDC, WHO, and other professional organizations. The problem of hand hygiene compliance in the OR was identified to be a challenge in my healthcare facility prompting a practice change recommendation. Upon review of the literature, the use of WHO hand hygiene guidelines was identified to be the most appropriate solution for achieving positive outcomes. The plan for the practice change was to implement the change through in-class education, hands-on simulation training, and professional modeling. To implement this change, OR staff including nurses, surgeons, and surgical technicians were educated on how to perform hand hygiene using the WHO guidelines. Simulation training and role modeling were also practiced during the implementation phase. Upon completion of the project, it was observed that hand hygiene compliance increased in the OR and staff demonstrated more understanding of the importance of hand hygiene in the OR.


World Health Organization. (2009). WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care [eBook]. Retrieved from

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