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Culture Change and Managing Infection Risk (MIR) Program Implementation

Research Domain: 
Systems Engineering
Community Partner: 
Iasis Healthcare
Student Researchers: 
Haroon Kisana; Unity Funfe
Faculty Mentor: 
William Riley

The issue of hand washing in medical facilities has come under severe scrutiny in recent years. This was after the realization of the fact that many health care providers do not comply with proper hand hygiene guidelines thereby ending up exposing themselves and others to potential health infections. The content of this project outlines the main issue of hand hygiene and what can be done to raise awareness on the matter. In this context, a secret shopper program was used to monitor how regularly health care workers washed their hands. The focus in this project was specifically on the implementation of a Managing Infection Risk (MIR) Program in St Luke’s Medical Center (SLMC).

In other to evaluate and improve hand hygiene compliance at SLMC, data collected by members of the Environmental Services (EVS) was analyzed using statistical process control. An annual physician infection prevention orientation PowerPoint was developed which will be reviewed annually.

The data collected by EVS employees was analyzed using statistical process control (P-Chart), and the charts were examined for possible process variation to determine the process stability, capability, and predictability. The analyzed data showed the process was not in control due special cause variations. Conclusions: Although the secret shopper program has helped improve hand washing at SLMC, there is the need for a change of attitude towards the whole aspect of hand hygiene to increase overall performance. Some units at SLMC had several hand hygiene audits per month with high variations while others had fewer audits each month. This is evidence that the secret shopper program is not very effective in managing infection risk at SLMC. It would benefit the hospital if they use volunteers, and eventually consider the use of electronics such as SwipeSense to monitor hand washing.