1. Addressing the Lack of
Clinician’s Adherence to
Hand Hygiene Policies
Submitted by:
Chiamaka Akunne
Submitted to:
Tefera Gezmu, PhD, MPH
President
New Jersey Public Health Association (NJPHA)
683 Hoes Lane West
Piscataway Township, NJ 08854
Date: December 4, 2011
Scientific and Technical Writing
Professor Jerald Goldstein

2. i
Abstract
The lack of adherence to hand hygiene policies by health care workers is an issue that affects
hospitals, clinics, and nursing homes throughout the United States. Despite overwhelming
evidence on the vast repercussions that noncompliance causes, the compliance rate for clinicians
has been historically low in this country. Research by the Centers for Disease Control and
Prevention (CDC) reveals that hand washing compliance rates in the United States are around 40
percent (O’Connnor, 2014). This egregious value highlights the severe nature of the lack of hand
hygiene adherence by clinicians. Noncompliance to hand hygiene policies results in numerous
undesirable effects, such as the spread of healthcare-associated infections (HAIs). It is estimated
that two million Americans contract a healthcare-associated infection yearly, and of these
individuals, an alarming 22% die as a result of the infection (Gawande, 2007). Healthcare-
associated infections pose dire consequences on clinicians and patients, such as an increased
propensity towards death, longer hospital stays, and increased healthcare associated cost.
The negative effects caused by the lack of compliance are grand in nature, resulting in the need
for elaborately designed intervention programs. Past successful interventions aimed at increasing
compliance rates have incorporated multidisciplinary approaches that address the individualistic
and environmental factors that shape behavioral change. This proposal aims to increase hand
hygiene compliance amongst healthcare workers through the implementation of a multifaceted
plan, modeled after past successful multidisciplinary intervention programs. This plan includes
increasing access to hand hygiene materials, monitoring and providing feedback to clinicians,
and providing monetary rewards to clinicians who comply to hand hygiene standards. This
approach addresses the individualistic and environmental factors that cause noncompliance. The
success of past multidimensional intervention programs indicates that this plan will undeniably
increase hand hygiene compliance.

3. ii
Table of Contents
Abstract .............................................................................................................................................i
Table of Figures ...............................................................................................................................ii
Introduction..................................................................................................................................... 1
Factors that Influence Hand Hygiene Noncompliance ............................................................... 1
Link between Hand Hygiene Compliance and HAIs .................................................................. 1
Repercussions of Noncompliance for Staff and Medical Facilities ............................................ 2
Repercussions of Noncompliance for Patients............................................................................ 3
Literature Review............................................................................................................................ 5
Ineffective Single Approach Interventions ................................................................................. 5
Effective Multimodal Approaches .............................................................................................. 6
Plan of Action ................................................................................................................................. 8
Overview ..................................................................................................................................... 8
Addressing Environmental Factors ............................................................................................. 8
Addressing Individualistic Factors.............................................................................................. 9
Budget ............................................................................................................................................. 9
Justification ............................................................................................................................... 10
Discussion..................................................................................................................................... 11
Table of Figures
Figure 1: Costs of the Five Most Common HAIs in the US 2
Figure 2: Schematic Representation of the Five Most Common HAIs 3
Figure 3: Impact of HAIs on Length of Stay 4
Figure 4: Hand Hygiene Compliance at Johns Hopkin Before and After the Implementation of
the WIPES Infection Prevention Program 7
Figure 5: Budget 10

4. 1
Introduction
Factors that Influence Hand Hygiene Noncompliance
Hand hygiene is defined as the act of washing ones’ hands or using alcohol-based antiseptics for
the purpose of eliminating dirt and microorganisms. Historically, the average compliance rate for
health care workers in the United State has been low, despite astounding evidence of the negative
effects induced by the lack of compliance. The latest findings documented by the CDC indicate
that hand washing compliance rates in the United States are around 40 percent (O’Connor,
2014). This abysmal value highlights the severity of the overwhelming lack of hand hygiene
compliance by health care workers. Noncompliance leads to severe consequences, which include
the spread of nosocomial infections, also known as healthcare-associated infections (HAIs).
Analysis conducted by U.S. Centers for Disease Control (CDC) indicates that two million
Americans nationwide contract infections yearly while in a hospital (Gawande, 2007). The
negative effects of HAIs ultimately pose severe challenges to patients and clinicians.
Researchers, in their attempt to implement intervention methods aimed at increasing adherence,
have pinpointed individualistic factors that influence noncompliance. Studies reveal that being a
doctor, rather than a nurse, leads to greater noncompliance, and that being a male clinician,
rather than female, also results in an increase in noncompliance (Pittet & Boyce, 2001). In
addition, clinicians’ lack of sufficient knowledge on proper hand hygiene practices and their
importance reduces hand hygiene compliance. Other factors linked to greater hand hygiene
noncompliance include forgetfulness and the lack of time as a result of busy workloads (2001).
Research reveals that environmental factors also pose a threat to hand hygiene adherence. For
example, inconveniently located sinks and anti-bacterial gel dispensers, or the scarcity of these
items, induces poor adherence with hand hygiene (Pittet & Boyce, 2001). Other environmental
factors include understaffing or overcrowding in medical facilities, and the failure of facilities to
prioritize hand hygiene adherence (2001). The factors that influence hand hygiene
noncompliance ultimately result in detrimental effects, notably the spread of HAIs.
Link betweenHand Hygiene Compliance and HAIs
The relationship between hand hygiene compliance and healthcare-associated infections has been
studied by individuals in healthcare for many decades. Healthcare-associated infections are
defined as ailments an individual acquires in a healthcare facility that were not present during
his/her initial admittance. The first indication of the correlation between hand hygiene and
nosocomial infections was revealed through the works of Viennese obstetrician Iganaz
Semmelweis in 1847. Semmelweis deduced that the poor hand hygiene of doctors, resulting from
their inability to wash their hands correctly or at all, led to the spread of childbed fever
(Gawande, 2007). Childbed fever, which is caused by the Streptococcus bacteria, was the main
cause of maternal death during the time. Semmelweis noticed that 20 percent of mothers who
delivered babies at his hospital died from childbed fever, while only 1 percent of women who
underwent home birth died from the illness. Attributing the high maternal death rate of mothers
in his hospital to the poor hand hygiene of doctors, Semmelweis enforced measures that
mandated hand washing compliance. As a result, the maternal death rate diminished to 1 percent,
a clear indication of the strong link between hand hygiene and nosocomial infections (2007).

5. 2
Repercussions ofNoncompliance for Staff and MedicalFacilities
Research by the World Health Organization (WHO) reveals that the prevalence of HAIs in the
United States can be attributed to the poor hand hygiene of clinicians. The primary route of
transmission of health-care associated pathogens is through the contaminated hands of clinicians
(World Health Organization, 2009). After a clinician makes contact with the skin of an infected
patient, pathogens from the patient are transferred to the hands of the caregiver. The pathogens
remain on the healthcare worker’s hands, a result of his/her failure to engage in proper hand
hygiene behaviors or the complete omission of such acts. Subsequent encounters with uninfected
patients results in in the transmission of pathogens (2009).
The spread of healthcare-associated infections poses great challenges to clinicians and healthcare
facilities. Reports indicate that as HAIs spread, a growing amount of clinicians and hospitals are
faced with lawsuits (“Hospital Infections”, 2008). This is due to the fact that many patients seek
out compensation for complications arising from HAIs, especially since growing evidence
reveals that almost 50% of HAIs are preventable (Burns, 2014). In addition, as a result of the
growing prevalence of HAIs, Medicare no longer pays hospitals for the costs associated with the
treatment of HAIs (“Hospital Infections”, 2008). This negatively affects hospitals as the costs
associated with treating HAIs increase annually. The average cost of treating the five most
common HAIs in the United States is currently at a staggering $10 billion (Burns, 2014). Figure
1 below illustrates costs associated with treating each of the five most common HAIs and how
these infections contribute to the total annual cost. Through the visual representation below, it is
evident that healthcare facilities, and even patients, are financially burdened as a result of
clinicians’ noncompliance. The lack adherence to hand hygiene policies not only negatively
impacts clinicians and healthcare facilities, but also affects patients.
Figure 1: Costs of the Five Most Common HAIs in the US
Source:Overall and Unit Costs of the Five Most Common Hospital-acquired Infections (HAIs) in the US (n.d)

6. 3
Repercussions ofNoncompliance for Patients
Many centuries after the ground breaking findings of Semmelweis, hand washing noncompliance
still plagues hospitals, clinics, and nursing homes in the United States. Unfortunately, patients
are the individuals that suffer the most as a result of the dire consequences of noncompliance.
Research by the World Health Organization (WHO) reveals that the prevalence of HAIs in the
United States can be attributed to the poor hand hygiene of clinicians; clinicians spread
infections through direct contact with patients (World Health Organization, 2009). Nosocomial
infections lead to increased mortality and morbidity. Research by the CDC indicates that two
million Americans nationwide contract infections yearly while in a hospital setting (Gawande,
2007). Of these two million individuals, a staggering 22.2%, or approximately 90,000
Americans, succumb to the infection (2007). Further evidence in support of the overwhelming
presence of HAIs is research by Magill et al. (2014) which revealed that on a day-to-day basis,
approximately 1 out of 25 patients in hospitals throughout the country suffers from a healthcare-
associated infection (Magill et. al, 2014).
Several HAIs have been attributed to the lack of hand hygiene compliance, the most common of
these being ventilator-associated pneumonia (VAP), central line-associated bloodstream
infections (CLABSIs), surgical site infections (SSIs), clostridium difficile, and urinary tract
infections (UTIs) (Zimlichman et. al, 2013). Figure 2 below provides a breakdown of the five
most common HAIs. VAP and SSIs each account for 22% of total HAIs, UTIs account for 14%
of nosocomial infections, CLABIs accounts for 11% of HAIs, while the pathogen clostridium
difficile causes 12.1% of health care-associated infections (Magill et. al, 2014).
Figure 2: Schematic Representation of the Five Most Common HAIs
Source: Magill et. a, 2014
22%
11%
22%
12.1%
14%
18.9%
Ventilator-associated pneumonia
(VAP)
Central line-associated bloodstream
infections (CLABSI)
Surgical site infections (SSI)
Clostridium difficile
Urinary tract infection (UTI)
Others

7. 4
In addition to dealing with the negative health effects caused by HAIs, patients are also burdened
by the economic effects associated with these infections. Patients incur additional medical costs
as a result of the prolonged hospital stays and the additional treatments that accompany these
infections (Zimlichman et. al, 2013). On average, the acquisition of an HAI costs an individual
an additional $23,228 and raises the average hospital stay from about five days to 22 days, as
illustrated in Figure 3 below (Savage, Segal, & Alexander, 2011).
Figure 3: Impact of HAIs on Length of Stay
Source: Savage, Segal, & Alexander, 2011
Further compounding the issue of nosocomial infections resulting from hand hygiene
noncompliance is the increasing number of pathogens that are resistant to antimicrobial agents.
The overreliance and misuse of antibiotics in treating patients results in greater resistivity.
Concerns in regards to the growing presence of antibiotic resistant bacteria unfortunately results
in the premature discharge of patients from hospitals and clinics within days of a medical
procedure. Amongst the most prevalent antibiotic resistant bacteria is methicillin-resistant
Staphylococcus aureus (MRSA), which causes life-threating infections such as CLABIs. MRSA
infections account for a staggering 6.5% of all nosocomial infections nationwide (Burns, 2014).
The CDC reports that infections caused by MRSA increased from 22% in 1995 to 63% in 2004
amongst intensive care unit (ICU) patient (Cummings, Anderson, & Kaye, 2010). This trend is
rather troublesome as infections caused by MRSA and other antibiotic resistant pathogens results
in the undesirable effects of increased mortality and higher hospital costs for patients (2010). The
aforementioned evidences of the detrimental effects of HAIs on patients indicate that individuals
seeking medical attention throughout the United States are affected by clinicians’ noncompliance
to hand hygiene standards. As Americans seek medical attention in hospitals, clinics, and nursing
homes, they become susceptible to contracting infections, prolonged hospital stays, greater
hospital costs, and death as a result of clinicians’ noncompliance to hand hygiene standards. The
detrimental effects of noncompliance have ultimately resulted in the implementation of

8. 5
numerous intervention programs aimed at increasing adherence rates amongst health care
personnel.
Literature Review
Ineffective Single Approach Interventions
Numerous interventions have been implemented by healthcare facilities to increase clinicians’
hand hygiene compliance, and thus halt the negative consequences that result from the lack of
such compliance. Didier Pittet, director of the Infection Control Program at the University
Hospital of Geneva, notes that, “Hand hygiene by hand washing or hand disinfection remains the
single most important measure to prevent nosocomial infections” (Pittet et al., 2000). However,
with many failed interventions at increasing compliance rates, poor hand hygiene compliance
still remains an issue. Traditional intervention methods have aimed at improving compliance
through the use of single interventions. These approaches involve the introduction of a single
component, such as an educative program or the use of posters to remind clinicians to wash their
hands. Unfortunately, these approaches often fail to yield the desired outcome of raising hand
hygiene compliance, and are thus ineffective. This is especially evident through a study by C.
Muto, B. Sistrom, and B. Farr (2000) in which the introduction of a single intervention not only
failed to increase compliance, but resulted in its decrease. The study, which lasted for two
months, was conducted by members of the University of Virginia Health System. The
intervention program involved the use of a weekly educative program that instructed and
reminded clinicians to use alcohol-based antiseptics to improve hand hygiene. At the end of this
two-month intervention, hand hygiene rate was reported at 52%, a shocking 8% decrease from
the initial rate of 60% (Muto, Sistrom, & Farr, 2000).
The ineffectiveness of traditional intervention programs is also evident through an intervention
implemented by researchers at the Medical College of Virginia Hospital/Virginia
Commonwealth University School of Medicine in Richmond, Virginia. The six-month long
study involved the introduction of an educational program, similar to that used by the researchers
at the University of Virginia Health System. The study required that clinicians attend six
educational sessions that taught the importance of hand hygiene. Prior to the introduction of the
intervention, compliance rate was at 34% (Bischoff et al., 2000). At the end of this six-month
intervention, compliance was reported at 30%, a reflection of the inadequateness of traditional
interventions (2000).
The ineffectiveness of traditional intervention methods stems from their failure to address both
the individualistic and environmental factors that influence noncompliance (Pittet, 2001).
Traditional intervention methods, in attempting to increase hand hygiene compliance, only focus
on the individual. These interventions only address the individualistic factors that cause
noncompliance to hand hygiene policies, such as clinicians’ lack of knowledge on the proper
hand hygiene practices and their importance. Traditional interventions neglect factors that are
external to the individual and shape non-adherence. These factors include inconveniently located
sinks and overcrowding of medical facilities. Thus, the intervention implemented by C. Muto, B.
Sistrom, and B. Farr (2000) and individuals at the Medical College of Virginia Hospital/Virginia
Commonwealth University School of Medicine failed to increase hand hygiene compliance as
they focused only on educating clinicians, and disregarded external factors that cause

9. 6
noncompliance. Results of these studies challenge the effectiveness of traditional interventions,
and suggest the need for multifaceted approaches that address the individualistic and
environmental factors that impact non-adherence.
Effective Multimodal Approaches
Although many approaches have been introduced to increase hand hygiene compliance rates,
these interventions have often resulted in failure or minimal improvements. The ineffectiveness
of traditional interventions results from their inability to address the multiplex nature of
behavioral change (Pittet, 2001). In addressing the behavioral components that hinder hand
hygiene compliance, research suggests that the use of multidisciplinary strategies is vital.
According to findings by Didier Pittet, “Interventions aimed at improving compliance with hand
hygiene must be based on the various levels of behavior interaction. Thus, the interdependence
of individual factors, environmental constraints, and institutional climate should be considered in
strategic planning and development of hand hygiene promotion campaigns… The complex
dynamic of behavioral change involves a combination of education, motivation, and system
change” (Pittet, 2001). Thus, successful interventions aimed at increasing hand hygiene
compliance must incorporate multifaceted approaches that address both the environmental and
individualistic factors that generate noncompliance.
Numerous multimodal approaches, shaped significantly by behavioral change theories, have
drastically increased hand hygiene compliance rates in healthcare facilities in this nation. For
example, a multifaceted intervention, known as the WIPES Infection Prevention program, was
successfully implemented by researchers at The Johns Hopkins Hospital in November 2007.
Researchers theorized that addressing both the environmental and individual factors that cause
noncompliance, aspects which single interventions such as that implemented by C. Muto, B.
Sistrom, and B. Farr (2000) and individuals at the Medical College of Virginia Hospital fail to
address, would result in increased hand hygiene compliance. The research design “included the
following components: a communications campaign, education, environmental optimization,
leadership engagement, performance monitoring, and timely feedback system” (Aboumatar et
al., 2012). This intervention program also included the provision of rewards to clinicians who
consistently adhered to hand hygiene policies. The environmental optimization component of the
program involved the introduction of 2,500 anti-bacterial gel dispensers. Researchers theorized
that the environmental optimization would result in greater accessibility to hand hygiene
materials, and thus combat the environmental barriers of hand hygiene. The other components of
the program were aimed at addressing the individualist factors that hinder adherence to hand
hygiene standards.
After the program was fully implemented in the hospital, overall compliance rose by 2-fold, with
researchers observing an increase in compliance among all units of the hospital. Researchers also
observed an increase in compliance amongst varying healthcare personnel. For example, in the
last six months of the three-year study, compliance had risen from 77% amongst nurses and 62%
amongst physicians, a significant increase from the 36% compliance rate for nurses and 38%
compliance rate for physicians that researchers had observed six months into the study
(Aboumatar et al., 2012). Figure 4 below depicts hand hygiene compliance at the Johns Hopkins
Hospital during differing time periods. Prior to the implementation of the WIPES Infection

10. 7
Prevention program (t0), overall hand hygiene compliance was recorded at 34%. After the
program was fully implemented in the hospital (t1), hand hygiene compliance had risen to 67%,
and thus had increased by 2-fold from the initial value. Researchers also observed an increase in
hand hygiene compliance, from 67% to 72%, during the follow-up period (t2) of the program.
The positive results of the WIPES Infection Prevention program indisputably highlight the
effectiveness of multidisciplinary approaches.
Figure 4: Hand Hygiene Compliance at Johns Hopkins Hospital Before and After Implementation
of the WIPES Infection Prevention Program
Source: Aboumatar et al., 2012
The success associated with multidisciplinary interventions is also evident through a 2005 hand
hygiene promotion campaign launched by individuals at the University of Pittsburg Medical
Center (UPMC). The campaign, known as the Joseph Hardik Hand Hygiene Project, consisted of
an educational program, performance monitoring, poster reminders, and the installation of anti-
bacterial gel dispensers. Thus, this intervention was designed to address both the individualistic
and environmental factors that influence noncompliance, similarly to the WIPES Infection
Prevention program. At the end of this four-month campaign, researchers reported compliance
rate at 60%, an astonishing 43% increase from the initial value of 17% (“The Sound”, 2014).
Therefore, the results of this campaign also highlight the effectiveness of multimodal
approaches.
In comparison to the traditional interventions implemented by C. Muto, B. Sistrom, and B. Farr
(2000) and individuals at the Medical College of Virginia Hospital/Virginia Commonwealth
University School of Medicine, the multifaceted WIPES Infection Prevention program and the
Joseph Hardik Hand Hygiene Project both succeeded in increasing hand hygiene compliance.
These two interventions are testaments to the effectiveness multidisciplinary approaches. The
ability of multifaceted approaches to address both the individualistic and environmental factors
that influence noncompliance results in success. This is ultimately what sets the WIPES Infection
Prevention program and Joseph Hardik Hand Hygiene Project apart from the aforementioned
traditional interventions. The positive results of the WIPES Infection Prevention program and the
Joseph Hardik Hand Hygiene Project irrefutably illustrate the effectiveness of multidisciplinary
approaches, and prompt the implementation of similar interventions.

11. 8
Plan of Action
In combating clinicians’ hand hygiene noncompliance, the adoption of a multimodal approach is
key. The outcomes of the previously mentioned multimodal interventions reveal a striking trend:
hand hygiene compliance rates tend to increase. As a result, my plan of action to increase hand
hygiene compliance rates involves a multifaceted intervention that considers both the
individualistic and environmental factors that perpetuate noncompliance.
Overview
This plan involves a three-month intervention program that will be first implemented at Robert
Wood Johnson University Hospital (RWJUH), which is located in New Brunswick, New Jersey.
RWJUH will serve as the pilot site for this program as its low hand hygiene compliance rates
have often resulted in numerous repercussions, such as the spread of HAIs (“Many Hospitals”,
2010). Prior to the implementation of this plan, the baseline hand hygiene compliance rate at
RWJUH will be measured. This baseline will be used for comparison purposes at the end of the
three-month intervention to detect the effectiveness of this program. If this program is proven to
be successful, it will be expanded to other hospitals, clinics, and nursing homes in New Jersey.
This intervention consists of components that address the environmental and individualistic
aspects that influence noncompliance.
Addressing Environmental Factors
The focus on the environmental factors that result in noncompliance will involve the strategic
placement of anti-bacterial gel dispensers throughout RWJUH. These anti-bacterial gel
dispensers will be primarily placed in locations in which noncompliance is frequently observed,
such as the intensive care unit (ICU). The researchers who introduced the WIPES Infection
Prevention program at the Johns Hopkins Hospital credit the success of their intervention
program to the installation of 2,500 dispensers in patient rooms and other areas of the hospital
(Aboumatar et al., 2012). The introduction of anti-bacterial gel dispensers allows for greater
accessibility to hand hygiene materials, and will undeniably lead to greater hand hygiene
compliance.
Another component of this plan involves the installation of surveillance cameras near sinks and
hand sanitizer dispensers throughout the hospital. These surveillance cameras will be used for
monitoring purposes. The initiators of the WIPES Infection Prevention program took a similar
approach in monitoring clinicians’ compliance rates; however, rather than using video
recordings, “trained undercover observers conducted direct observations of hand hygiene
compliance throughout the institution…” (Aboumatar et al., 2012). The initiators of the Joseph
Hardik Hand Hygiene Project also used trained observers in monitoring hand hygiene
compliance, and credit this to the success of their intervention (“The Sound”, 2014). The use of
cameras to monitor clinicians, rather than observers, will efficiently increase compliance without
the use of additional manpower. The acquired footages will be used to give clinicians feedback
on how well they comply to hand hygiene policies and on the areas they need to improve on. The
provision of feedback will be accomplished through the hiring of five trained surveillance
operators. The video footages these individuals observe will be reported back to the clinicians.

12. 9
The researchers of the WIPE Infection Prevention program credit the observed 42% increase in
hand hygiene compliance for nurses and the 32% increase in compliance for medical providers at
the Johns Hopkins Hospital to the provision of performance feedbacks (Aboumatar et al., 2012).
Such success indicates that monitoring clinicians with cameras and giving them feedback will
decrease hand hygiene noncompliance. This intervention program will also concentrate on the
individualistic variables that induce noncompliance.
Addressing Individualistic Factors
In addressing the individualistic factors related to hand hygiene noncompliance, education and
the provision of incentives will be vital. This plan involves the use of an interactive online course
to educate clinicians on the importance of hand hygiene. This online course will consist of a 20-
minute long video that teaches clinicians how to properly engage in hand hygiene behaviors.
After watching this video, clinicians will be subjected to questions that test their mastery of the
contents displayed in the video. Individuals who fail to acquire a satisfactory test score must
retake the online course until they attain passing grades. An online course, rather than the
traditional classroom courses used in the WIPES Infection Prevention program and the Joseph
Hardik Hand Hygiene Project, will be implemented as a result of the convenience and flexibility
that are associated with online courses. Clinicians can access the course at any location and at
varying times, rather than being subjected to assigned course sessions. Through the use of an
online course, clinicians will become more educated on proper hand hygiene standards, which
will undeniably result in increased hand hygiene compliance.
As behaviors are often shaped by incentives, the provision of rewards for compliance will also
reinforce hand hygiene behaviors. For example, researchers who designed the WIPES Infection
Prevention at the Johns Hopkins Hospital credit the 2-fold increase in hand hygiene compliance
to the provision of rewards (Aboumatar et al., 2012). Clinicians who consistently adhered to
hand hygiene standards were publicly recognized as their pictures were showcased throughout
the hospital and on computer screensavers (2012). The success of this rewards system indicates
that similar systems will also be effective. As a result, this plan involves rewarding clinicians
who demonstrate exceptional adherence to hand hygiene policies with a feature in the healthcare
facility’s monthly newsletter. The ability to gain public recognition will motivate clinicians to
comply to hand hygiene policies, resulting in increased hand hygiene compliance. The success of
past multimodal interventions suggests the efficacy of this intervention program, which will be
implemented at a minimal cost.
Budget
The following budget has been designed for a three-month intervention program. The execution
of this intervention program requires the purchasing of hand hygiene materials, such as hand
sanitizers, the development of an online course, and the purchasing of surveillance cameras for
monitoring purposes. The budget also includes the wages for the five surveillance operators that
will be hired and additional labor costs. The costs associated with these features are summarized
in Figure 5 below.

13. 10
Figure 5: Budget
Item Cost
1000 Alcohol-based Hand Sanitizer Refills $22,000
100 Hand Sanitizer Dispensers $2,200
100 Hand Sanitizer Stands $7,000
20 Surveillance Cameras $3,200
Educative Program $6,525.00
Surveillance Operators’ Salaries $41,512.50
Labor Cost for Installing Surveillance Cameras
and Hand Sanitizer Dispensers
$1,320
Total $83,757.50
Justification
1. Hand Hygiene Materials
 1000 hand sanitizer refills will cost $22,000 at $22 each
 100 dispensers will cost $2,200 at $22 each
 100 hand sanitizer stands will cost $2,200 at $70 each
 20 surveillance cameras will cost $3,200 at $160 each
2. Online Interactive Educational Program
 According to researchers at Old Dominion University, the cost of designing and
producing an online educational course is $6,525 (Gordon, He, & Abdous, 2009).
This price consists of the wages for the producers, designers, and technologists
that will plan, digitize, edit, and encode the online course.
3. Surveillance Operators’ Salaries
 Annual wages of surveillance operators is $2,767.50 (Aurelio, n.d). For a three-
month period, the five surveillance operators that will be hired will each make
$8,302.50, bringing the total to $41,512.50.
4. Labor Cost for Installing Surveillance Cameras and Hand Sanitizer Dispensers
 10 individuals will be hired to install the surveillance cameras and hand sanitizer
dispensers. These individuals will each work 8-hour shifts over the course of two

14. 11
days. Each will be paid the current minimum wage of $8.25 an hour, bringing the
total amount to $1,320.
Discussion
The lack of adherence to hand hygiene policies by clinicians is an issue that affects hospitals,
clinics, and nursing homes throughout the United States. The compliance rate for clinicians has
been historically low in this country, despite vast evidence on the detrimental effects that
noncompliance perpetuates. The repercussions posed by noncompliance are immense, and
include the unfortunate development and spread of healthcare-associated infections (HAIs).
HAIs result in increased mortality, prolonged hospital stays, and higher healthcare cost. Thus,
the lack of hand hygiene compliance poses adverse consequences on patients, clinicians, and
healthcare facilities.
The current hand hygiene compliance rate, which is estimated at 40 percent, is simply
unacceptable (O’Connnor, 2014). Carefully designed hand hygiene intervention programs must
be implemented to increase hand hygiene adherence, and thus halt the negative effects that the
lack of compliance generates. In the attempt to increase the hand hygiene compliance rate
amongst health care workers, the results of past intervention programs suggest the abandonment
of traditional approaches and the adoption of multidisciplinary interventions.
This proposed plan, modeled after past successful multimodal interventions, will combat the
individualistic and environmental factors that promote non-adherence, yielding the desired
outcome of successfully increasing hand hygiene adherence. The components of this plan, which
include the introduction of hand hygiene materials for greater accessibility, the provision of
incentives, the creation of an educational online program, and the introduction of a monitoring
and feedback system, target the multiplex factors that hinder hand hygiene adherence and will
ultimately motivate clinicians to abide to hand hygiene policies. In addition to increasing hand
hygiene compliance, this proposed 3-month intervention program will halt the adverse effects
produced by non-adherence. The success of past multifaceted approaches suggests the success of
this plan. Its implementation is thus crucial in the effort to increase hand hygiene compliance
rates amongst clinicians.

15. 12
List of References
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precede model: Improving hand hygiene behaviors among healthcare personnel. Infection
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Aurelio, L. (n.d). The salary of surveillance officer. Retrieved from
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Bischoff, W.E., Reynolds, T.M., Sessler, C.N., Edmond, M.B., & Wenzel, R.P. (2000).
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acquired-infections
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16. 13
Magill, S., Edwards, J., Bamberg, W., Beldavs, Z., Dumyati, G., Kainer, M., & ... Fridkin, S.
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