Healthcare Program-Policy Evaluation Analysis Template

Healthcare Program/Policy Evaluation Analysis Template

Use this document to complete the Module 6 Assessment Global Healthcare Comparison Matrix and Narrative Statement

Healthcare Program/Policy Evaluation Hand Hygiene Policy- I chose this particular policy because after carefully reviewing many different policies hand hygiene kept sticking out to me as the most crucial and most important when it comes to patient care and ultimately patient outcomes. This is also a policy that all healthcare professionals can be familiar with no matter what facility, hospital, or community you are working with.
Description All healthcare worker’s who come into contact with patients should know how to preform hand hygiene. Contact with patients includes directly or indirectly through the equipment or the environment. Hand hygiene is crucial to the safe and sanitary delivery of patient care. Hand Hygiene can also “make or break” the outcome of the patient’s healthcare. With this particular healthcare policy at my workplace all healthcare workers are required to use hand hygiene practices according to the “5 moments of hand hygiene principles.” They must apply these to their everyday work environment and work day. The 5 moments of hand hygiene principals states that a healthcare worker must:1. Before patient contact2. Before a procedure3. After a procedure or contact with body fluid exposure risk4. After patient contact 5. After contact with patient surroundings. Other precautions are also included in the policy which include not only the 5 moments of hand hygiene but also examining your fingernails to ensure they are short and clean, inspecting your hands for cuts, scrapes, abrasions, and hangnails, and removing jewelry from your hands and forearms.
How was the success of the program or policy measured? There are many ways that this policy is measured throughout the hospital setting. We have audit reports that are run weekly in regard to infection percentages throughout the hospital. These percentages are monitored closely and if there is a spike or changes then there is a full-on investigation as to the root cause. Managers on the unit also ensure that each employee does annual compliance training with this policy.
How many people were reached by the program or policy selected? How much of an impact was realized with the program or policy selected? Everyone in healthcare and who is involved in patient care is technically reached by the hand hygiene policy since this is the number one way to prevent infection in our patients. By this hand hygiene policy in particular for my hospital, everyone is affected. Since everyone who is employed by the hospital is either in direct contact with the patient or they are in contact with the supplies that will be in contact with the patient they are required to follow the hand hygiene policy. Infection rates have dramatically decreased with the implementation of this policy. The assurance that everyone will follow this policy is critical in keeping the rates of hospital-acquired infections at a minimum.
What data was used to conduct the program or policy evaluation? The audits that the hospital runs as a whole that tracks infections, more specifically, hospital acquired infections is how they collect data and conduct the policy evaluation. The testing that each employee is required to do at their hire date, and yearly, is another way that the hospital can conduct policy evaluations. Comparing and contrasting these percentages and results is how they can see how well the hospital is doing.
What specific information on unintended consequences were identified? There are consequences that can occur if this hand hygiene policy is not followed when working in the healthcare setting. First and foremost, patient care and patient safety can be compromised. The spread of infection to yourself as well as other patients on the units throughout the hospital is a high risk if you do not follow the hand hygiene policy.
What stakeholders were identified in the evaluation of the program or policy? Who would benefit most from the results and reporting of the program or policy evaluation? Be specific and provide examples. I think that the patients that the healthcare workers are treating and taking care of would benefit the most from the results and reporting of the policy evaluation. Secondly, the units of the hospital would benefit in the breakdown of the compliance audits of this policy to see how they are doing in preventing infections throughout the unit. I think that if this would be something that the nurses and CNA’s were more aware of on my unit then there would be better compliance and better patient outcomes. There are signs all over the unit reminding people to wash their hands, especially with isolation rooms but this does not necessarily mean that everyone follows the 5 steps like they should. By making a heightened awareness of the outcomes and consequences of not following this policy could increase the positive patient outcomes as a whole.
Did the program or policy meet the original intent and objectives? Why or why not? The hospital that I work for has a very low infection rate and a low hospital acquired infection rate so I would say that the policy does meet the original intent and objectives.
Would you recommend implementing this program or policy in your place of work? Why or why not? This policy is currently implemented in my place of work. I think that a hand hygiene policy such as this one should be implemented in every hospital, facility, or anywhere else where healthcare professionals are taking care of patients. Implementing this policy in every healthcare setting would keep infection rates and spread of infections at a low and keep patients outcomes higher.
Identify at least two ways that you, as a nurse advocate, could become involved in evaluating a program or policy after one year of implementation. Nurses are the biggest patient advocates of all the healthcare workers that are involved in the patients careplan. There are many ways that nurses can be involved in this particular policy implementation and evaluation. First off, we can make sure that we, as nurses, are ensuring that our aides and anyone else that comes into or out of our patient rooms is preforming hand hygiene like they should. As nurses, particularly charge nurses, can look at the results of the infection audits on our particular unit daily to ensure that we are doing everything we can to prevent further infection or illness to the patients.
General Notes/Comments It is important to ensure that when working in healthcare you are reading policies and abiding by them everyday. REFERENCES:A to Z (All Policies and Guidelines). (n.d.). Retrieved May 5, 2019, from Login Portal. (n.d.). Retrieved May 5, 2019, from

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