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The first thing you and your team notice is that Seahawk Medical Center (SMC) does not have a hand hygiene compliance monitoring program. As noted in the benchmark documentation, "hospitals should regularly monitor hand hygiene practices for everyone interacting with patients and give feedback to ensure compliance." Because SMC does not have a hand washing monitoring system, it cannot report whether providers follow hand-washing protocols when interacting with patients. It is imperative that SMC Quality Improvement & Quality Assurance (QIQA) team determine a baseline of where SMC is with hand-washing compliance, determine whether there is a need for improvement, identify any process improvement processes can be implemented, and follow up to determine whether the improvement project had an impact on hand-washing compliance. This project will require you to perform a Cost-Effectiveness Analysis (CEA) for hand hygiene process improvement implementation. To ensure compliance is measured randomly across the whole hospital - including in the Emergency Department, Oncology Unit, Medical-Surgical Units, Intensive Care Unit, Cardiac Care Unit. Step-Down Unit, and Telemetry Unity - members of your team take turns covering various shifts while observing clinical staff who enter and exit patient rooms. After making observations over a month, your team creates a.
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