Putting in place the rules for hand hygiene in the operating room

Putting in place the rules for hand hygiene in the operating room
Implementation steps:
In the operating room, the hand hygiene protocol was put into place through a number of steps that helped the staff clean their hands well. The first step was to ask the hospital’s staff for permission to make a new change in the organization. Administrators were given a first draft that explained why the new change was important. The draft laid out the steps for making the change, as well as the resources that would be needed before and after the change. The second step was to look at the WHO guidelines for hand hygiene and figure out where healthcare workers in the OR were falling short. With the help of the clinical nurse trainer, the hospital’s hand-washing rules were looked over to make sure they covered everything. The end result was a full hand cleanliness guideline that took into account both hospital rules and WHO rules.

Changes in the healthcare organization had to be made with the help of nurse leaders and workers. The third step was to tell the OR charge nurse and the clinical nurse trainer about the new rules. This step had to be taken because the nurse leaders had the power and influence to help reach the goals. After the administration and other leaders gave their approval to the whole plan, the next step was to figure out who the important people were and what their jobs would be during the change. Along with the doctors, surgical technicians, and subordinate staff, the OR nurses were the most important people in the situation.

The first intervention plan for hand hygiene compliance was to create a multimodal plan that included teaching in the classroom, simulation training with hands-on practice, and professional modeling. The next step was to use WHO standards to make a hand hygiene education program for nurses. During education, practice training was given to make sure that the staff learned how to wash their hands properly. For example, the nurse trainer showed the group how to wash their hands in six steps, and they were told to wash their hands for 20 to 30 seconds. During the new change’s introduction, there was a lot of focus on professional modeling to make sure that nurse leaders were involved in the process. The last step was to print the new hand cleanliness rules and make sure they were at every hand washing station in the operating room. The staff was told about the four-week monitoring time and how to prepare for the handwashing exercise.

Changes Talked About

In any health care center, the operating room is a busy place, and making changes takes time. The original plan was for staff to learn in class and train using simulations. But because the staff was so busy, the two drills were put together to save time. Second, it was hard to give education and training to both day and night shift workers. As a result, staff education in the classroom was split so that staff on the night shift could also learn. This change made sure that everyone on staff could get training and see how well people washed their hands. The clinical nurse educator also brought in people from outside the organization to help teach the OR staff about how important hand hygiene is to the organization and how it affects HCAHPS scores. There was also the use of online sharing of educational tools like videos and sessions for both day shift and night shift workers. Because of these changes, an extra week was added to the original time of implementation to make sure all activities were done.

Talking about the problems

Even though many changes have been made, preventing and controlling infections in healthcare organizations has remained a struggle. The first problem was getting the staff in the OR to accept the new change. Most people said that the new WHO hand-washing rules were not that different from the CDC rules. Second, because the OR didn’t have enough staff, it was hard to find time for education and training for the staff. Because the OR was so busy, workers had to go to school at different times. Also, it was hard to train people who worked the night shift, so an extra schooling program was started at night.

Getting Past Obstacles

The first problem was getting the staff in the OR to accept the new change. Some people said that the CDC guidelines and the WHO rules were the same. This problem was solved by putting together a thorough program to teach people about the WHO guidelines. For example, the staff was told that hand-washing should take between 20 and 30 seconds, as recommended by the WHO. The staff was also told more than once in the operating room that hand washing was done according to WHO rules for hand hygiene. Through the education and training program, most professionals knew how important the new change was and how the CDC and WHO standards for hand hygiene were different.

The second problem was that there wasn’t enough time for training and teaching because there wasn’t enough staff. To get around this problem, staff on the day shift were taught different things at different times so that the OR could handle other operations. Before the day’s events started, it was also suggested that people train in the morning. During the night shifts, the nurse educator made sure the nurses were ready for the exercise by giving them a training lesson. Online groups, which were used to share training and simulation movies, was another method. This plan made sure that everyone on staff learned the same way to wash their hands using the new WHO method.

Identifying the Relationships Between Professionals

Several professional teams, such as nurses, surgeons, surgical technicians, and clinical trainers, worked together to put the new change into place. These people worked together to make sure that the new change worked and that the project would last. The hospital’s management and the nurse educator set up for outside people to be there to help with education and training. Interprofessional teamwork is important for putting evidence-based practice into action because it makes it easier for people to share ideas and makes changes last longer.

Talk about relationships

Nurses. Nurses are the most important people in change processes because they make up the largest group of health care workers in any business. When a new change was made to the building, the staff nurses in the operating room (OR) were involved in making it happen. First, the team taught and trained people on how to wash their hands according to WHO standards. During the implementation phase, the nurses worked closely with the surgeons and surgery techs to keep an eye on hand hygiene and report any problems to the nurse leaders. The new change went well because the nurses and the other people working in the OR got along well.

Surgeons. Surgeons took part in training and education to learn about the new change and help put it into place. The surgeons and surgical technicians needed to be taught about the WHO standards because they work with patients every day. The team also gave comments to the administration about how well the new change worked and any problems that came up during the implementation phase. Having good relationships with nurses and other staff made it easier to communicate and find gaps, which helped the project succeed.

Nurse Educator. The clinical nurse trainer was a very important part of putting the new change into place. The nurse educator was in charge of making sure that everyone in the operating room (OR) got the education and training they needed to make the change happen. During the practice, the nurse educator served as a link between the nurses and the surgical team to make sure everyone understood and worked together. The clinical nurse educator and the administration worked together to bring in outside people who stressed the importance of hand hygiene for both the patients and the healthcare group. Lastly, the nurse educator made sure that both day shift and night shift workers got the education and training they needed. This included making sure that online education was available and that materials were shared. Staff on night shift were given a chance to learn more, which helped the project succeed.

Team for Information Technology. Health care quality and patient safety have both gone up since health information technology has been used in it. The IT team helped put the new change into place by making sure computers were available during the teaching process. Second, the team helped organize the events that led to the creation of the OR online group and the sharing of educational movies.

Chapter 4: Things to think about after the capstone project

Talking about what went well

Improving the quality of healthcare is a process that needs education, training, and tracking to get better results. When the new change was put into place, it made the company better in many ways. For example, the nurses and other members of the healthcare team knew how important hand cleanliness was and how it affected how well patients did. Understanding these effects has made it easier for OR workers to wash their hands. By making sure people wash their hands, there is also evidence of teamwork and working together to reduce diseases. Today, nurses, doctors, and surgical techs wash their hands according to the WHO’s “five moments of hand hygiene” recommendations.

The second part of an organization’s success is being able to show that evidence-based practices are being used well. Research shows that following WHO standards for hand hygiene helps cut down on infections that people get in hospitals. The project shows that using evidence-based practices can help healthcare organizations improve both the level of care and how well patients do. For example, the use of WHO hand hygiene standards has led to a gradual drop in the number of HAIs in the hospital. Some of the ways that hand cleanliness was put into place in the unit were through education and training. The use of these methods shows that the project was a success because nurses and other health care workers now know how important it is to wash their hands for both the patients and the business.

How Past Projects Will Help Plan Future Ones

The success of this project shows that evidence-based practices can be used to make changes in healthcare groups. There is proof that following WHO guidelines for hand hygiene will help cut down on hospital-acquired infections. Evidence-based methods should also be used in future projects to improve quality and the health of patients. Collaboration between people from different fields was another way the project was run to get good results. The project was successful because nurses, surgeons, surgical technicians, and the clinical nurse trainer all worked together. In the future, interprofessional teamwork should be one of the ways that institutions try to get good results. Lastly, education and training were very important in teaching staff how important it is to wash their hands. Before making changes in any company, future projects should use this method. Lastly, the new change shows that you need a good plan to get past problems.

Things That Didn’t Work Out

During the change’s execution, there were a lot of problems that made it hard to reach the goals on time. Due to a lack of staff, it caused the nurse educator to set up two separate education programs. To make sure that everyone who worked in the OR was educated, it was also important to set up a different education program for night shift staff. Time was another thing that slowed down the process of change. Because changes were made to the original plan, it took an extra week to finish the job. The CDC standards that were already in place made it hard for the OR staff to accept the new change at first. Nurses didn’t start to understand how important the new change was until they were given education and training.

Understanding What Did Not Go Well

The use of WHO hand hygiene standards in the operating room has helped me understand how change happens and how to get past obstacles to change. I’ve learned that education is a key part of bringing about change and getting people to accept new projects in healthcare groups. Education and training for healthcare workers should be thought of for future projects. The new change has helped me learn more about how change happens, what gets in the way of change, and how to get around these problems. For example, I know that time is important when making a change and that enough resources should be set aside before starting a new change. I think this change process has helped me learn more about how to improve healthcare quality and how to handle change.

Details on how the gap was closed

The WHO hand hygiene standards look at the evidence about how to wash your hands to tell healthcare workers how to wash their hands well (WHO, 2009). The healthcare group wasn’t following the CDC’s hand hygiene rules, which was found to be a problem. There was a lack of people washing their hands the right way, at the right time, and in the right way. Random audits in the OR showed that it was hard for nurses, surgeons, and surgical techs to wash their hands properly. Also, nurse leaders and top staff didn’t set a good example, so people didn’t wash their hands well in the OR. As part of the new change, staff were educated and trained on the WHO standards so that they could be followed correctly.

Using teaching to bring about the new change made sure that nurses and other health care workers knew how to wash their hands properly. Staff in the OR were able to learn how to wash their hands using the six steps that the WHO recommends. The second part was using a team-based method to cut down on HAIs in the operating room. Nurses, doctors, and surgical workers all worked together to make sure that hand hygiene was done. The end results showed that staff washed their hands more often and knew more about how important it is for the health of patients to wash their hands.

Getting behind the plan

The plan for help after implementation includes routine monitoring of hand hygiene in the OR, regular reports about hand hygiene, and the creation of rules for hand washing in the OR. The charge nurse and other top staff will make sure that all nurses, surgeons, and surgical technicians follow the WHO standards for hand washing. People who don’t wash their hands well enough will get in trouble or have to deal with the results. The new change will hold nurse managers accountable by having them send weekly reports to the management about how they clean their hands in the OR. These reports will also tell what to do when people don’t wash their hands well enough or when changes need to be made.

Another plan for longevity is to make rules about how to keep your hands clean in the OR and other parts of the hospital. For example, there should be printed WHO guidelines at every hand-washing station to tell staff how to wash their hands properly. Last but not least, ongoing education and training for staff and new workers should focus on hand hygiene to make sure the new change works. Nurse leaders should be at the front of the line to set up education classes and practice role modeling to make sure that the new way of doing things sticks around.

Resources for Post-Implementation

To follow WHO standards for hand hygiene in the operating room (OR), you will need education, training, and money to keep doing it. There will be education rooms and audio-visual technology for training as part of the change. Second, there will be a need for writing supplies during the education sessions and regular reports to the office. The unit will need help paying for things like printing the WHO guidelines and getting soap and sanitizers. People who work in health care, like the clinical nurse educator, will have to teach and train new employees and those who are finishing their education.

Chapter 5: Looking back

Integration of Results

The first program result I think I showed in the project is how to plan, deliver, and evaluate evidence-based practice by combining clinical reasoning with organizational, patient-centered, and culturally appropriate strategies. The change in practice involved following the WHO’s hand hygiene standards, which are backed up by evidence. In the last part, I gave a full review of the research on how the WHO hand hygiene guidelines have helped healthcare organizations cut down on infections that people get in hospitals.

The second program result I was able to include was the creation of interprofessional teams that can communicate, coordinate, work together, and consult with other health professionals to promote a culture of excellence. People from different professions, like nurses, surgeons, and surgical technologists, were part in the new change. These teams worked together to make sure that the change in the OR went well.


Healthcare-associated infections (HAIs), like skin infections after surgery, have been on the rise, which has led to more people getting sick and dying after surgery. The CDC, WHO, and other expert groups agree that washing your hands is the most basic thing you can do to stop these infections. Compliance with hand hygiene in the OR was found to be a problem at my healthcare center, which led to a recommendation for a change in practice. After looking at the research, it was found that following the WHO’s standards for hand hygiene was the best way to get good results. The plan for changing the way things were done was to do it through teaching in the classroom, hands-on simulation training, and professional modeling. To make this change happen, nurses, surgeons, and surgical technicians in the OR were taught how to clean their hands according to WHO standards. During the execution phase, simulation training and role play were also used. At the end of the project, it was seen that the OR staff was more aware of the value of hand hygiene and did a better job of keeping their hands clean.


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 https://www.who.int/gpsc/5may/tools/who_guidelines-handhygiene_summary.pdf

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