Date of Graduation

Spring 5-20-2021

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


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First Advisor

Shirley Kedrowski


Problem: Compared to inpatient units, ambulatory care clinics have differences in staffing available and frequency to perform room turnover (RTO). Pre-intervention data revealed poor Hand hygiene (HH) and high-touch surface cleaning (HTSC) knowledge and low RTO compliance reliability. Currently, there is no process for objectively monitoring RTO compliance and staff self-evaluation of HH, HTSC, and RTO performance is incongruent with observations.

Context: HH and HTSC are a crucial component of preventing healthcare-associated infections (HAIs). Estimated loss of revenue for one northern California tertiary university hospital system (HCO) campus was nearly $1.8 million dollars in Medicare penalties for 2018.

Intervention: This project used fluorescent marker and provided performance feedback and education to staff on HH and HTSC that was specific to their clinic. Clinic leadership implemented the use of the checklist tool within their clinics. Planned interventions are also described.

Measures: HH scores, HTSC scores, and staff self-perceived performance on HH, RTO, and HTSC were averaged and measured for significant change. Percentage of surfaces cleaned adequately by end of shift were tallied (surfaces cleaned / surfaces inoculated).

Results: Significant improvement was observed in HH knowledge from baseline. HTSC knowledge improvement was not significant. Self-evaluation of HH, RTO, and HTSC was not significantly changed compared to baseline.

Conclusions: Clinic-specific education on HH, RTO, and HTSC may improve compliance to HCO guidelines and reduce HAIs. Self-evaluation of HH, RTO, and HTSC performance is incongruent with observations, suggesting the need to have internal or external compliance monitoring.