NURS FPX 9000 Assessment 3 Topic Report With CITI Training

NURS FPX 9000 Assessment 3

Topic Report with CITI Training

Student name

NURS-FPX9000

Capella University

Professor Name

Submission Date

Topic Report With CITI Training

CITI is a collaborative institutional training program that offers the required training in healthcare quality improvement projects that entail human subjects research. The CITI training makes the practitioners aware of ethical principles, regulations, and protection of participants that are needed to undertake evidence-based practice endeavors. Completion of the CITI modules is evidence of knowledge of research ethics, informed consent processes, and risk-benefit analysis, which are essential to healthcare improvement initiatives. An expanding literature base documents the CITI training as a means of preparing clinicians to conduct ethical and compliant research practice (Nguyen & Hirsch, 2025). The ethical implementation of quality improvement interventions is based on the standardized training foundation to ensure patient safety and regulatory compliance throughout the project life cycle. The primary aim of the assessment is to prepare a topic report on the details of the DNP project and CITI training.

Project Problem and Relevant Evidence

The problem of Healthcare-associated infections is a serious safety issue that should receive urgent resolution due to the systematic quality improvement initiatives. The present hand hygiene compliance rates of nursing staff at the site are at an average of 45-50%, which is far below the standards that are needed to secure effective infection prevention (Infection prevention manager, personal communication, May 15, 2025). The non-optimal compliance has a direct effect on the patient outcomes, with 7 cases out of every 100 patients in acute care hospitals in developed countries developing healthcare-associated infections (World Health Organization, 2022). There is a lack of uniformity in the compliance with the established protocols among all the members of the nursing staff, including registered nurses, licensed practical nurses, and nursing assistants of all shifts. Internal audits of the last 6 months have indicated inconsistency in adherence to the WHO “my 5 moments” framework among nursing units (Quality improvement director, personal communication, January 18, 2025). Healthcare-related infections cost the healthcare system US$28-45 billion each year in direct costs, so it is financially urgent to intervene (Gidey et al., 2023). The compliance levels at the facility are lower than the average of 59.6% of adherence recorded in critical care departments across the world (WHO, 2022). The effective implementation of evidence-based hand hygiene policies is an important measure against healthcare-associated infections and patient outcomes in acute care facilities.

• Evaluating the Adequacy of Metrics Used

Monitoring hand hygiene is a key component of preventing healthcare-associated infections and patient safety. The hospital currently applies direct observation measures to evaluate the compliance rates in hand hygiene that stand at 45-50 percent among the nursing staff region (Quality improvement director, personal communication, January 18, 2025). The baseline data is in line with WHO recommendations concerning healthcare-related infections surveillance and allows for quantifying improvement. The facility will use the WHO My 5 Moments framework as the evaluation criterion, which will provide a systematic evaluation of important hand hygiene opportunities. The integration of electronic monitoring systems, including sensor-based dispensers or RFID tracking, may allow objective data collection that can be used to supplement direct observation and eliminate the Hawthorne effect and observer bias (Wang et al., 2021). Other cost-effectiveness indicators, e.g., the level of sanitizer consumption, may add to the thoroughness of compliance analysis.

• Recognizing Potential Areas for Improvement or Additional Knowledge

The existing evaluation tools need to be extended to cover patient outcome correlation and sustainability measures of longer-term sustainability after the 12 weeks of implementation. The incorporation of real-time feedback systems, automated monitoring systems, and technologies can give more accurate and ongoing compliance data. Surveys of staff perceptions and assessments of behavioral changes would provide good information about the success of interventions and acceptance levels (Huebner & Zacher, 2021). There are knowledge gaps in terms of the best training frequency, reinforcement approaches, and cultural differences in relation to hand hygiene practices among various nursing populations. Future studies are needed to study the economic side of different intervention modalities and their effects on the rate of reduction of healthcare-associated infections.

The Project Site

The project hospital is an acute care facility in upstate New York, which is a part of a larger healthcare system that offers a full range of medical services, including medical-surgical units and emergency care, as well as specialty services. The site is a large-scale healthcare network with more than 2,000 healthcare providers of various specialties with a diverse patient population serving the capital region (Quality improvement director, personal communication, January 18, 2025). The facility has emergency departments, inpatient units, and outpatient clinics, and it is dealing with thousands of patient encounters on a weekly basis within the healthcare network in an urban location. The healthcare system offers the entire range of medical services, namely, primary care and specialized tertiary services, which include cardiac surgery, oncology, and neurology. The facility has in place comprehensive quality improvement programs and clinical education programs, with sufficient infrastructure, resources, and institutional support.

• Potential Implications of the Project Site for the Project

The acute care hospital setting is an optimal place where hand hygiene improvement intervention can be implemented because patients are highly acute, and the care transitions occur frequently, thus requiring the use of infection prevention protocols. The quality improvement initiatives of the facility will comprise comprehensive programs that will provide the facility with the infrastructure to support systematic changes in evidence-based practices. The massive reach of the healthcare network allows for a wide-reaching scope of intervention and possible system-wide effects. Its urban set-up has adequate patient traffic to extract meaningful data. The digital platforms that are currently used by the institution support the incorporation of performance improvement indicators.

• Additional Information to Enhance Understanding

The practicum site has thorough infection control measures with the presence of ethanol-based sanitizing stations that are accessible to all clinical service areas. Training materials on the personnel are already in place, but direct observation training will require dedicated personnel and standardized evaluation tools. The WHO hand hygiene self-evaluation tool will present methodical evaluation criteria in terms of institutional readiness. Direct observation methods can be supplemented by electronic monitoring systems to collect all possible data. Budget considerations will include training materials, monitoring equipment, and time allocation of staff to the auditing processes.

Project Support at the Project Site

The project site has a good institutional support in terms of quality improvement infrastructure and involvement of stakeholders at various levels in the organization. Preliminary collaboration with the quality improvement director confirmed the hand hygiene compliance as one of the priority projects after the recent internal auditing results provided a direct organizational alignment with the intended WHO My 5 Moments framework implementation (Quality improvement director, personal communication, January 18, 2025). The infection prevention manager also acknowledged that the current compliance is about 45-50% and supported the idea of evidence-based interventions in order to eliminate the gap (Infection prevention manager, personal communication, May 15, 2025). Collaborations with stakeholders were done through stakeholder meetings with nursing leadership, infection prevention specialists, and frontline healthcare workers who were consulted on the current facilities and training materials (Laurisz et al., 2023). The broad-based infection control plans and the quality improvement frameworks that have been proven successful make the facility an ideal place to introduce systematic implementation plans.

• Areas for Preparation Enhancement

Further stakeholder engagement meetings with nursing unit managers would enhance project implementation planning and single out barriers to hand hygiene compliance specific to each unit. The protocols of detailed baseline data collection need to be elaborated in order to determine pre-intervention metrics other than compliance rates. The decisions concerning budget allocation with administrative leads should be expanded to specify the resources needed to run training materials, monitoring equipment, and staff time to be used on auditing activities (Homauni et al., 2023). The flexibility of electronic monitoring systems to integrate should be further investigated to support the direct method of observation to improve the accuracy of data collection. Formal timeline coordination with other quality improvement initiatives also needs more work to make sure that it does not conflict with other organizational priorities.

Proposed Interventions

Interventions that are evidence-based form the basis of successful quality improvement initiatives in health care facilities, and thus systematic methods of implementation are needed to ensure the best patient outcomes. The primary overall intervention will be the implementation of the WHO My 5 Moments of Hand Hygiene intervention, which includes a multimodal intervention, including system change, training and education, evaluation and feedback, workplace reminders, and institutional safety climate elements (WHO, 2021). The implementation will involve the use of structured monitoring procedures with the hand hygiene self-assessment tool (HHSAF) to identify systematic assessment and track the progress in time (Suzuki et al., 2020). A study by Loyland et al. (2020) indicated that students of nursing watched the hand hygiene practices under the WHO framework and scored 57.2 percent on their compliance levels, with their understanding of the complexity of infection prevention. Suzuki et al. (2020) reported that the consumption of alcohol-based hand sanitizer increased eightfold (4.0 to 34.4 L/1000 patient days) after the implementation of a multimodal strategy to reduce HAIs over a period of 5 years. Saito et al. (2023) proved the long-term effectiveness of Train-the-Trainers initiatives, as 158 healthcare professionals exhibited high knowledge gains and even changes in the climate of these institutions after education on the WHO framework. Garlasco et al. (2021) found positive relations between the scores of the self-assessment framework of hand hygiene and alcohol-based hand rub consumption, which indicates that the framework is accurate in predicting hand hygiene performance. WHO guidelines were effectively applied to operating room operations by Smith et al. (2020), who developed unique patient zone identification tools that increased staff awareness and maintained consistent hand hygiene compliance. Studies have proved that the right hand hygiene can prevent infections acquired in health care delivery, which should be avoided.

• Educational Interventions

Nursing staff, including registered nurses, licensed practical nurses, and nursing assistants, will be the target population of the educational intervention, working all shifts in medical-surgical units. Substantial education will emphasize the five critical times of the WHO framework of hand hygiene, including how, when, and why each moment should be performed (Bale et al., 2021). The educational element will employ various modes of delivery, such as interactive lessons, visual aids, and practical simulations to support a variety of learning styles and shift patterns (Ward et al., 2024). The intervention reinforces the WHO implementation through the assurance of the staff’s knowledge of evidence-based protocols and the establishment of the knowledge foundation on which sustained behavior change can be achieved. Educational interventions through the development of staff competency and organizational commitment to evidence-based hand hygiene practices increase the effectiveness of quality improvement.

Comparisons

The comparison of the quality improvement intervention consists of reflecting upon the desired state of care implementation of the WHO My 5 Moments framework with regard to the current state of hand hygiene practices at the site. The present-day practices indicate poor adherence rates of 45-50% of nursing staff on average, which is the point of comparison when evaluating the improvement (Infection prevention manager, personal communication, May 15, 2025). The current status is variability in the compliance with the established hand hygiene practice, lack of systematic monitoring, and organized intervention strategies. The existing hand hygiene practices are not comprehensive in terms of multimodal elements of strategy, such as standardized education, continuous feedback, and reminders in the work setting. The ideal state will include an increase in compliance rates due to a systematic deployment of evidence-based WHO guidelines in all nursing units (Bajunaid et al., 2024). The intervention will be given to all the nursing staff participants as part of the quality improvement project with no control group isolation. The comparison will be done on the pre-implementation and post-implementation compliance rates to show the effectiveness of the intervention and the long-lasting results of the behavioral change.

Desirable Outcomes

The primary outcomes are decreased healthcare-related infection rates as obtained through facility infection surveillance data during pre-implementation and post-implementation periods. Objective measures will be the consumption of alcohol-based hand sanitizer (Saha et al., 2021). The secondary outcomes would be the realization of an enhanced level of hand hygiene compliance amongst nursing staff of more than 80 percent in line with the WHO My 5 Moments framework. The results will be quantified through direct observation audits with the help of standardized WHO monitoring tools and tracking compliance with all five critical moments of hand hygiene (Bale et al., 2021). All results will be measurable and will be evaluated with regard to evidence-based quality improvement metrics.

• Potential Impact

Possible implications of the project implementation are that patient safety will be increased significantly due to the limited number of healthcare-associated infections. The financial advantages can be significant cost reductions due to reduced infection-related interventions, bearing in mind that healthcare-related infections cost the United States a total of US$28-45 billion in direct healthcare costs (Gidey et al., 2023). Enhanced staff adherence will result in sustainable organizational culture change that will make evidence-based hand hygiene practices the normal form of care (Douno et al., 2023). The intervention could be used as an example of a system-wide implementation in a hospital that has various facilities and specialties. Long-term outcome is improved institutional reputation regarding patient safety excellence and improved quality measures that support accreditation/regulatory compliance demands.

• Areas of Additional Information or Knowledge to Enhance Preparation

Further data on the baseline hand hygiene compliance data per individual nursing units would be of use in preparation for the project and the relevance of the targeted intervention strategies. Existing workforce patterns, rotation of shifts, and workload may help plan the best time to train staff and the most appropriate scheduling. Appreciating the current infection prevention policies and the audit process would make it easier to integrate them into organizational systems (Ștefan et al., 2024). Understanding of prior hand hygiene improvement programs would inform intervention fine-tuning strategies. Specifics of available technology resources and budgetary allocations would aid in overall implementation planning.

Learner’s Role for the Project

The doctoral student as the project leader will take the lead role in the design, implementation, and management of the entire WHO My 5 Moments hand hygiene improvement initiative and work closely with the preceptor as a master strategist and mentor. My responsibilities include coming up with a detailed implementation schedule, organizing stakeholder consultations, and holding education sessions with all the nursing units to provide a systematic implementation of the project. Project leadership demands clarity of communication, planning, and flexible management to lead in the complex healthcare setting (Singh et al., 2024). The quality improvement projects can gain an advantage by using collaborative efforts that consider the combination of academic and clinical skills to realize the best results in terms of evidence-based intervention (Hempel et al., 2022). I will complete direct observation audits, review compliance data, and provide periodic progress reports to organizational leadership, and continue open communications with the preceptor on project changes and how to resolve issues. The preceptor will act as a clinical advisor, including site-specific knowledge, introductions to key stakeholders, and advice about organizational culture and policy within the context of implementation. In implementation, I will organize training programs, control data collection procedures, and keep to the project schedules, and overcome any arising challenges and obstacles. The leadership style will focus on evidence-based decision making, continuous quality improvement concepts, and working in collaboration with the nursing staff to encourage long-term behavioral change and organizational commitment to better hand hygiene practice.

Project Question

In an acute care hospital (P), when compared to current practice (C), how does the implementation of the World Health Organization (WHO) My 5 Moments of Hand Hygiene framework (I) impact on the rate of healthcare-associated infections (HAIs) (O) over 12 weeks (T)?

The Population (P) is the nursing personnel who are registered nurses, licensed practical nurses, and nursing assistants who directly attend to patients in acute care hospitals on all shifts and in medical-surgical units. The Intervention (I) is the introduction of the World Health Organization’s “My 5 Moments for Hand Hygiene” strategy, which is a multimodal intervention that includes aspects of system change, training and education, evaluation and feedback, workplace reminders, and safety climate in an institution. The Comparison (C) reflects the current hand hygiene practice at the facility, which represents the sub-optimal hand hygiene compliance rates with averages of 45-50% among the nursing staff, with no systematic monitoring and structured interventions. The Outcome (O) is the increased compliance rate with hand hygiene as measured by direct observation audit using standardized monitoring tools developed by WHO, and alcohol based hand sanitizer consumption per 1000 patient days. The time (T) includes a 12-week implementation phase of the primary intervention procedures, which should give enough time for the behavioral change and measurable compliance enhancement, and fit the evidence-based quality improvement cycles.

Conclusion

The quality improvement project highlights the urgent necessity to conduct systematic interventions in terms of hand hygiene in acute care facilities where the level of compliance remains lower than the most desirable levels. The introduction of the WHO framework of the 5 moments helps to fill the gap with a multimodal approach that engages all nursing personnel on all shifts. The intervention can dramatically decrease the healthcare-associated infections and produce massive savings to the healthcare system. Success is ensured by long-term organizational commitment, sufficient resource allocation, and constant monitoring to make sure that it is effective. Sustained behavioral change and patient safety outcomes will need reinforcement and constant evaluation of evidence-based methods of hand hygiene practices.

Appendix A: Terms and Definitions

Note: The appendix provides definitions for key terms and abbreviations used throughout the hand hygiene quality improvement practicum project to ensure clarity and understanding for all readers.

Appendix B: Evidence Matrix Table

Note: The evidence matrix organizes key literature supporting hand hygiene improvement initiatives based on the WHO multimodal strategy. The selected studies represent diverse healthcare settings (nursing homes, acute care hospitals, operating rooms) and various implementation approaches (student observers, long-term initiatives, train-the-trainer programs, surveillance systems). All studies demonstrate the effectiveness of structured, evidence-based approaches to hand hygiene improvement, with particular emphasis on the WHO “Five Moments for Hand Hygiene” framework and the Hand Hygiene Self-Assessment Framework (HHSAF) as reliable monitoring tools. The evidence supports multimodal interventions that combine education, system changes, feedback mechanisms, and sustained implementation strategies to achieve meaningful improvements in hand hygiene compliance and patient safety outcomes.