QAPI Program Utilization_Manual

Improvement on Hand Hygiene analyzes Quarter: _______          Risk factors detected for poor adherence to recommended hand‐hygiene practices: Nurse status (rather than assistant) Nurse assistant status (rather than nurses) Therapist (PT, OT, ST rather that nurses) Staff sex  Working on week end (versus working during the week) Wearing gloves Missing antiseptic gel Activities with high risk of cross‐contamination Handwashig agents cause irritation and dryness Lack of soap and paper towels Insufficient time Patients needs take priority Low risk of acquiring infection from patient Beliefs that gloves use obviates the need for hand hygiene Lack of knowledge of guidelines, protocols Lack of active participation in hand hygiene training, competency Lack of administrative sanction of noncompliance/rewarding compliance Other: ________________________________________________________________________ ______________________________________________________________________________ Recommendation for improvement: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Name/Title staff completed report: ________________________________________________ Signature: _______________________________ Date: ___________________ Page 3 LEVELS OF PERFORMANCE, PATTERNS, TRENDS, AND VARIATIONS Quality Assurance, Performance Improvement Program 154