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accountability, and adequate placement of ABHR dispensers to improve hand hygiene compliance at Baylor Emergency Medical Center (BEMC) as these components have demonstrated the most success in the literature reviewed. The Extent of How Outcome Measures Achieve Project ObjectivesObjectives for this project were aimed at promoting and sustaining handhygiene practices in an effort to improve compliance. Following implementation of this project, hand hygiene compliance increased by 36.52%from baseline. This boost in compliance increased the mean compliance of theorganization by 5.18%, resulting in a mean overall compliance of 59.03%, which leaves much room for future improvements. Although this remains below the goal of 80%, there were signs of improvement during the months this study was conducted. Therefore, the objective to implement practice changes for hand hygiene compliance was met for the short term. In addition to the knowledge gained from the pre- and post-implementation surveys, informal rounding with staff members provided valuable information regarding barriers to hand hygiene practices at BEMC. For example, one staff member stated that “the foam hand hygiene that the organization currently uses in the wall dispensers causes irritation to her hands” (Mooney, 2019, Personal Interview). This is congruent with other
28Running Head: EVIDENCE-BASED PRACTICE PROPOSALstudies that have identified skin irritation as a common barrier to hand hygiene practices (Chassin et al., 2015). The staff of BEMC also commented onother common barriers including being too busy or having their hands full. Therefore, the information gained from informal rounding in addition to the pre- and post-implementation surveys allowed the objective of identifying common facilitators and barriers of hand hygiene practices at BEMC. Another objective of this project was to provide a more accurate representation of hand hygiene practices at the organization. Following the establishment of having the leadership team responsible for hand hygiene observations, the number of departments reporting hand hygiene compliance data increased from three to five reporting departments. Accountability from leadership appears to have provided the framework for a systematic approachfor improvement in documenting hand hygiene practices. Therefore, the objective to modify the current hand hygiene data collection process to reflecta more accurate representation of hand hygiene practices at the organization was met. Due to the limited timeframe for this project, it is difficult to assess whether or not the multi-modal hand hygiene project had a sustainable impacton organizational hand hygiene compliance. Time only allowed for data collection for a three-month period, which made it difficult to determine any trends in improvement. However, hand hygiene compliance did improve after implementing the project and continues to do so. There is optimism that hand hygiene compliance among healthcare workers at BEMC will continue to improve over time and as the project evolves.