Date of Award


Degree Type


Degree Name

Doctor of Philosophy in Industrial and Systems Engineering


Mechanical, Industrial and Systems Engineering

First Advisor

Valerie Maier-Speredelozzi


Hand hygiene is the first line of defense against the prevalence of infectious diseases in healthcare settings. Therefore, healthcare costs can be reduced. However, having rare incidents of healthcare-associated infections (HAI) does not always mean that hand hygiene compliance is high and at its desired level. This research study aims to develop multi-statistical measurements to assess hand hygiene compliance of the medical and nursing groups at the inpatient wards, 5B, 6B and ICU at the Providence Veterans Affairs Medical Center (PVAMC). The PVAMC was trying to identify whether the few cases or rare incidents of HAI that have been reported in the past few years was caused by or linked to poor hand hygiene practices. Healthcare worker (HCWs) subgroups of nurses and hospitalist doctors were asked to self report their patient contact over one complete week. The URI research team and 25 other secret observers were asked to directly observe the medical and nursing groups’ hand hygiene behavior over two complete months including all working shifts: night, day and evening. These two months were overlapped with the one complete week of self reporting patient contact. The results indicated that the monthly hand hygiene compliance mean estimation was not as expected by the PVAMC. The monthly hand hygiene compliance mean estimation was around 50%. The results also indicated that as bed days of care (BDOC) increased, hand hygiene compliance decreased. In contrast, the results did not indicate any strong correlation between hand hygiene compliance and HAIs. However, the possibility that the PVAMC has been adopting other infection prevention methods that are associated with the rare HAI incident (for example zero MRSA for the past five years) cannot be eliminated or ignored. Hand hygiene compliance was higher after touching a patient than before, even though both are recommended in the World Health Organization’s 5 moments of hand hygiene. Risk factors for poor adherence to recommended hand-hygiene practices were observed and found to be statistically significant, including being a male patient, working in a step-down unit (5B) and working on weekdays and working in night shift. In addition, an attempt was made to indirectly estimate hand hygiene compliance over a 10 month period by measuring how many times Purell and Soap cartridges were replaced at inpatient wards. Similarly, an attempt was made to indirectly estimate personal protective equipment (PPE) compliance over a three year period using PPE inventory data. In the indirect methods, patient contact data was used to average how many times a patient was seen by the medical and nursing groups. This estimation was used to indirectly estimate the hand hygiene compliance. The indirect hand hygiene compliance via measuring product use (Purell and Soap) was very low compared to the hand hygiene compliance estimated via the direct hand hygiene observation method when the same two months were compared in all inpatient wards. The actual Purell and Soap replacement was not equal to or close to the targeted replacement at any of the inpatient wards. The research study did not find any correlation between BDOC and hand hygiene compliance under such a method. The source of error on the indirect PPE compliance method forced the compliance to go beyond 100% in several months. The research study did not find any correlation between BDOC and PPE compliance. Such methods need more validation, but is an interesting first step for a new proposed method.



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