The Performance Gap
Hand hygiene contributes significantly to keeping patients safe. While hand hygiene is not the only measure to counter HAI (for example effective environmental decontamination is essential), compliance with it alone can dramatically enhance patient safety, because there is much scientific evidence showing that microbes causing HAI are most frequently spread between patients on the hands of health- care workers. Many patients may carry microbes without any obvious signs or symptoms of an infection (colonized or sub clinically-infected). Microbes have an impressive ability to survive on the hands, sometimes for hours, if hands are not cleaned. This clearly reinforces the need for hand hygiene, regardless of the type of patient being cared for.
Health-care facilities which readily embrace strategies for improving hand hygiene also prove more open to a closer scrutiny of their infection control practices in general. Therefore, the impact of focusing on hand hygiene can lead to an overall improvement in patient safety across an entire organization. The hands of staff can become contaminated even after seemingly ‘clean’ procedures such as taking a pulse, blood pressure, or touching a patient’s hand.\cite{world2009guidelines}

Leadership Plan

The following is a practical guide for driving sustainable behavior change and results, starting with hospital leadership. 
●        Ensure top down leadership engagement is authentic and known by all and that leaders model the expected behavior.
●        Foster psychological safety and promote a "just" safety culture. It must be safe for everyone to be able to speak up and “stop the line” when hand hygiene does not occur as indicated.
●        Use DO for Unit Based feedback and real time barrier identification - then develop and agree on an action plans to remove them (DO’s and Secret Shoppers no longer “measure” HH.).
●        Agree on unit specific improvement goals & celebrate all successes \cite{Son_2011} (The goal is progress vs. perfection)
●        Give frequent feedback on performance – share the data daily and/or according to monitoring technology supplier’s recommendations. – front line staff engagement is essential
●        Make HHC improvement part of performance evaluation with routine reporting of results to senior leadership for facility wide feedback

Practice Plan  

Change management is a critical element that must be included to sustain any improvements. Recognizing the needs and ideas of the people who are part of the process—and who are charged with implementing and sustaining a new solution—is critical in building the acceptance and accountability for change. A technical solution without acceptance of the proposed changes will not succeed. Building a strategy for acceptance and accountability of a change initiative greatly increase the opportunity for success and sustainability of improvements. “Facilitating Change,” the change management model The Joint Commission developed, contains four key elements to consider when working through a change initiative to address HAIs. (Appendix A)
Hand hygiene improvement is not amenable to a “one size fits all” approach. It involves a complex set of interactions that requires an approach focused on measurement and understanding of root causes. The Joint Commission Center for Transforming Healthcare Targeted Solutions Tool (TST)® provides health care organizations this type of comprehensive approach and is proven to improve hand hygiene compliance.[1] However when using the tool, measurement should only be accomplished with an evidence based,  validated electronic compliance system. This combination of electronic monitoring + DO has been proven to drive sustainable improvement. \cite{al2016a}\cite{Boyce_2017}
[1] Joint Commission. (2012). Joint Commission Center for Transforming Healthcare. Joint commission resources hot topics in health care—transitions of care: the need for a more effective approach to continuing patient care. Retrieved from http://www. Joint commission. org/assets/1/18/Hot_Topics_Transitions_of_Care. pdf.