Leadership and Service Improvement: Addressing Hand Hygiene Compliance in Healthcare

This report focuses on leadership and service improvement in the context of healthcare, specifically addressing the issue of poor compliance with hand hygiene. It begins with an introduction highlighting the need for effective leadership in promoting service improvement. The report then delves into the details of the service improvement areas, emphasizing the significance of hand hygiene in preventing hospital-acquired infections. The underlying causes behind the issue are explored, including heavy workload, lack of resources, poor attitudes, and inadequate education and training. The role of integrated care and quality improvement strategies in promoting change is discussed, emphasizing the importance of ongoing quality improvement efforts. The report concludes by emphasizing the need for effective leadership and the application of theories of change to achieve quality improvement objectives.

Running head: LEADERSHIP AND SERVICE IMPROVEMENT
Leadership and service improvement
Name of the student:
Name of the University:
Author’s note

1LEADERSHIP AND SERVICE IMPROVEMENT
Table of Contents
Introduction:....................................................................................................................................2
Details about the service improvement areas:.................................................................................2
Underlying cause behind the issue:.................................................................................................4
Role of integrated care and quality improvement strategies in promoting change:........................6
Proposed plan and the application of leadership theories to improve service provision related to
hand hygiene:...................................................................................................................................8
Conclusion:....................................................................................................................................12
References:....................................................................................................................................14

2LEADERSHIP AND SERVICE IMPROVEMENT
Introduction:
With the changing dynamics of the health care system, the method of care delivery and
the way continuity of care should be maintained has changed. Rapid changes in health care
environment and evolution of health consumer’s expectation have driven health care leaders to
adapt new values and leadership skills to promote service improvement and enhance patient’s
experience in care. As many health care institutions struggle to maintain appropriate standards of
care, leadership is contemporary health care organization is regarded as a complex responsibility.
To promote organizational effectiveness, leadership in complex systems must be distributive and
collective (Boak et al. 2015). Hence, evaluation of different aspects of professional-client
relationship and identifying related improvements to current delivery structure will support in
providing more reliable and cost-effective care. Service improvement in high performing health
care systems have occurred by means of creation of effective framework and systems for
improving and making the change sustainable overtime (McSherry and Pearce 2016). With this
context, the main purpose of this report is to examine failure in quality of patient care because of
poor compliance to hand hygiene in hospital setting and use effective leadership theories and
professional identify concepts to determine the approach needed to mitigate quality issues and
promote service improvement. The report will also provide justification for the importance of
service user led improvement and the role of theories of change in achieving quality
improvement objectives.
Details about the service improvement areas:
Based on past experience of working in many health care setting, I have found that many
quality issues in patient care has emerged due to lack of compliance to basic safety protocol of

3LEADERSHIP AND SERVICE IMPROVEMENT
hand hygiene. Hand hygiene is a basic responsibility of all health care professionals while
entering into contact with patient (James et al. 2018). However, the current issue is that majority
of nurse have poor or moderate knowledge regarding hand hygiene and this becomes a vehicle
for transmission of infection among patients. Lack of knowledge related to hand hygiene also
contributes to low adherence to safety control protocols (Mahmood, Verma and Khan 2017).
Lack of implementation of proper hand hygiene guidelines among nurses has been the reason
behind high rate of hospital acquired infection (HAI), repeated hospitalization, increased medical
cost and poor health outcome of patient.
The significance of the issue is understood from the fact that over 1.4 million cases of
HAI are reported at any given time in hospitals and health care workers are the often the conduit
for the spread of such infection to other patients in care (World Health Organization 2019).
Several research studies have given evidence regarding the link between hand hygiene and
hospital acquired infection. Salama et al. (2013) established links between poor hand hygiene
and hospital acquired infection by investigating about the impact of hand hygiene compliance
rate on nosocomial infection in rates in a hospital. The study revealed that frequency of
nosocomial infection is associated with level of adherence to hand hygiene recommendations.
The review of the cause behind hospital acquired infection shows that hand hygiene is a low cost
action that could prevent spread and transmission of HAI related microbes to other patient. It is
an issue that could have been easily avoided if the nurses had adhered to hand hygiene regimen.
However, lack of adequate framework related to hand hygiene and proper scrutiny of infection
control practices among health care staffs leads to many quality issues and poor experience in
care. Hence, this form of failure in quality of patient care gives the implication to health care
leaders to critically evaluate the whole system of care and identify the cause behind the issue.

4LEADERSHIP AND SERVICE IMPROVEMENT
Underlying cause behind the issue:
The critical role of any leader in relation to realization of service improvement goals
involves focussing on problem solving from the ground level and engaging in consultation and
stakeholder engagement (Baker 2015). Therefore, to implement appropriate quality improvement
techniques to promote patient safety provisions in health care setting, there is a need to analyzed
the reasons in behind high rate of non-compliance to hand hygiene and poor practices related to
hand hygiene in clinical setting. This would provide a pathway to understand elements or
components in the health care system that is not working and plan changes that could improve
hand hygiene practices in hospitals.
Heavy workload is one of the common reasons cited by health care workers for non-
compliance to hand hygiene. A study by Anargh et al. (2013) investigating about the knowledge
and practice related to hand hygiene among health care workers (HCW) in a tertiary hospital
revealed that HCWs had adequate knowledge about hand hygiene practices and the belief that
unclean hands is the route for cross transmission of infection. However, despite this knowledge,
health care workers missed hand hygiene opportunities because of heavy workload and non-
availability of hand hygiene facilities in the hospital. Akpaka (2014) also supports that high
workload increase the frequency of non-compliance with hand hygiene. These causes behind
non-compliance reveal one major flaw in the hospital unit. This includes inappropriate
implementation of guideline and lack of complete understanding of guidelines. Low availability
of hand hygiene related resources such as alcohol, towels and disinfectants also suggest that
patient safety initiative were not properly integrated in care. This underlying cause suggest the

5LEADERSHIP AND SERVICE IMPROVEMENT
need to consider multifaceted approach to improve adherence to universal precaution of hand
hygiene in hospitals.
Poor attitude or perception about the importance of hand hygiene in preventing cross
infection is also a vital cause behind poor compliance to hand hygiene. Kim and Oh (2015) using
qualitative approach to explore reasons behind poor hand hygiene and many workers reported
that they do not find hand washing to be important because they have never found their superiors
to comply with hand hygiene. This gives the insight that lack of a positive role models hinders
staff’s action related to hand hygiene. Such evidence reveals the gap in current hospital setting
which is the perception that hand hygiene should be performed only by nurses and no one else. It
also suggests lack of system approach before implementation of the change process. Lack of
safety culture, supportive environment towards hand hygiene and inadequate resource are major
limitations existing in health care provisions today. As per the principles of integrative care, it is
vital for health care administration to implement guidelines for all health workers and the make
the process mandatory for all (Wałaszek et al., 2017). This would mitigate the impact of negative
role models on hand hygiene behaviour of staffs. It also gives implication to nurse leader to
focus on motivation aspects before bringing any change in hospital setting. This is because
positive leadership is a prerequisite for workers to adhere to hand hygiene rules. This element
should be considering while proposing solutions and achieving high hand hygiene compliance.
In response to high incidence of patient safety issues and increase in prevalence of HAI,
WHO defined 5 moments of hand hygiene to improve hand hygiene and evaluate use of hand
hygiene practices in clinical setting. The five moments included before touching a patient, before
an asceptic procedure, after body fluid exposure risk, after touching a patient and after touching
patient surroundings. By the use of ‘five moments of hand hygiene’ as a framework to monitory

6LEADERSHIP AND SERVICE IMPROVEMENT
hand hygiene behaviour, Løyland et al. (2015) revealed that hand hygiene performance is
influenced by individual’s attitude, the work setting and the general workflow at the health care
facility. Confusion among staff members existed regarding the relative effectiveness of soap and
water or hand sanitizer or confusion about isolation precaution protocols. This suggest that
proper education and training needs for staffs were not identified before imposing the need to
adhere to hand hygiene. This is a gap that needs to be addressed to achieve the goal of service
and quality improvement in care. Negligence and poor personal habit has been identified as a
cause of patient safety issues and poor hand hygiene too. It gives the insight that education and
training aspects has been ignored while engage in a patient safety initiative. It is the role of
leaders to consider systemic influence of a new practice to make the desired goal sustainable and
successful (Muiru 2018).
Role of integrated care and quality improvement strategies in promoting change:
Taking efforts for ensuring implementation of necessary quality improvement (QI)
actions is indispensable to attaining the triple aim of enhancing health outcomes, improving
patient experiences, and increasing the compliance to hand hygiene practices. Creating necessary
provisions where the healthcare providers participate in strong quality improvement practices
will facilitate continuous search for improvement of performance, thereby assisting in improving
the patient outcomes. Quality improvement (QI) strategies would typically comprise of
improving the recognition of hand hygiene practice, monitoring the already existing practices,
and taking a follow-up of the healthcare providers, in relation to following hand hygiene
practices (Ogrinc et al. 2015). Engaging in ongoing QI is likely to be a new activity for many
primary care practices, and even the most determined practice is likely to need new skills to meet
its improvement goals. The importance of obtaining data feedback and benchmarking for hand

7LEADERSHIP AND SERVICE IMPROVEMENT
hygiene practice compliance is that will provide exhaustive information on performance in the
hospitals, in contrast to external benchmarks such as, national or regional averages, thereby
facilitating recognition of target areas for improvement. In addition, implementation of QI tools
and necessary expertise will also assist the healthcare professionals and administrative staff to
troubleshoot the major barriers and challenges in practice (Johnson and Sollecito 2018).
Customer satisfaction has been recognised as a crucial parameter for arbitrating the
excellence of service being delivered by a healthcare provider to the clients (Al-Abri, and Al-
Balushi 2014). Therefore, positive feedback from the patients results in development of goodwill
of the service providers, which circuitously increases their commerce. On the other hand, failure
of the providers in adhering to proper hand hygiene practices, and poor knowledge among them
directly threatens the reputation of the institution. Currently, patients are alert of their privileges,
in relation to healthcare services and their quality that are delivered. Therefore, institutions that
are dedicated to clinical practices need to contribute greater efforts for ensuring appropriate
adherence to hand hygiene. Besides suggesting focussed techniques for hand hygiene, the
administration must also stream quantifiable enhancement in the value of healthcare services.
Furthermore, according to Chassin, Mayer and Nether (2015) streamlining necessary QI
changes into the system, will facilitate the accomplishment of a new stage of performance.
Substituting the existing inefficiencies and policies with new inventions and methodologies will
also increase awareness among the providers on hand hygiene, and reduce the spread of
pathogen. This can be accomplished by taking into consideration the concept of integrated care
whereby, due focus will be placed on coordinated forms of care provision. Three major strategies
that can be adopted for an integrated care approach are namely, (i) continuity of information, (ii)
provider continuity, and (iii) endurance across the care interface (Neo et al. 2016). Integrated

8LEADERSHIP AND SERVICE IMPROVEMENT
care seems particularly important to service provision to hand hygiene practices as it will help in
strengthening the capacity of the providers to gain a sound understanding of the importance of
hand hygiene and how it prevents nosocomial infections. Thus, integrating the concept of
cleaning hands during five essential moments will facilitate educating the staff, thereby
promoting hand hygiene practices in health-care settings.
Proposed plan and the application of leadership theories to improve service provision
related to hand hygiene:
The critical analysis of major gaps in the health care system that has lead to poor
practices in relation to hand hygiene suggest that many systemic and individual barriers is a
reason behind poor hand hygiene practice and deterioration of quality care in clinical settings. To
achieve the vision of high quality care provision, leaders in current health care organization need
to integrate the quality improvement theories with the values of integrated care so that both
managerial staffs as well as individual health care workers are on the same page while working
to engage in a change process (Siegel, Bakerjian and Zysberg 2017). Leadership styles and
proper application of quality improvement theory is the key to achieve the goal of service
improvement and high quality patient care.
The critical review of underlying cause behind poor hand hygiene and quality issues in
hospital setting revealed that lack of team based approach and lack of vision towards integrated
care resulted in high incidence of HAI and repeated hospitalizations. As the quality improvement
methods related to hand hygiene in current health care system is found to be ineffective and
inconsistent, there is a need to identify new ways to integrate quality improvement methods into
existing health care systems (Leatherman et al. 2010). To ensure that any quality improvement

9LEADERSHIP AND SERVICE IMPROVEMENT
initiative addresses all possible barriers at systemic level, there is a need to have proper
understanding of systems. The Deming’s theory of profound knowledge is based on the principle
that each organization is made of interrelated processes and people. This quality improvement
theory suggests that to achieve success of all workers within the system, leaders need to have the
skills to balance each component for the optimization of the entire system. As quality is a
systematic process, leaders need to have good understanding about the process and inter-
relationship between components of the system (Watson 2018).
For example, as Kim and Oh (2015) suggested that lack of role model was the reason
behind poor adherence to hand hygiene, this implies that hand hygiene guideline was
implemented without considering system approach. Delicate balance was not achieved as hand
hygiene was prioritized only for nursing staffs and other senior health care professionals were
not involved in the process. In addition, resource needs in relation to the change process was also
not implemented. Therefore, with a system based approach to change process, leaders can
eliminate this barrier in current health provision and ensure that universal health hygiene is
properly integrated among all health care staffs. Hence, leaders can involve physicians and other
senior staffs to demonstrate hand hygiene skills to all novice health care staffs. Systemic thinking
will ensure that leaders make efforts to ensure that all resources related to hand hygiene are
readily available for the staffs and staffs are adequately supported to achieve total hand hygiene
compliance. Leaders can take regular feedback from staffs to ensure that five moments of hand
hygiene are not missed. In addition, involvement of role models will ensure that important
components in the health care system are adequately analyzed to influence the change process.
Dombecki et al. (2015) supports that when leader is actively involved as role model, they

10LEADERSHIP AND SERVICE IMPROVEMENT
accelerate the adoption of new process and guidelines. Repeated observation and feedback
ensures that behaviour of HCW are accelerated and enhanced.
To achieve the strategy of using system based approach towards quality improvement,
having a dynamic leadership style is also critical. This will ensure that leaders seeking high
performance in clinical setting incorporate core properties needed for quality improvement work.
As the issue of poor compliance to hand hygiene suggest lack of a safety culture, appropriate
leadership style can drive changes to organizational culture. Transformative leadership style in
relevnt in such context because as per the theories of transformational leadership, such leaders
can motivate change in organizational culture and orient changes to quality improvements
values, beliefs and standards (Banks et al. 2016). Such leaders support change process through
problem solving, information sharing skills, systems level thinking and team cooperation. Hence,
the proposed plan to promote hand hygiene compliance and achieve high quality compliance
includes collaborating with health care professionals first to share information related to the
reason for complying to hand hygiene and using education and training as a strategy to motivate
them towards practice change. This action has the potential to prepared staffs towards change
process (Gould et al. 2017). This action is in relevance with the unfreezing stage of the Lewin’s
model of change process. Lewin’s model of change suggests that a successful change process
involves unfreezing, changing and refreezing stage. Unfreezing is the first stage of change which
involves the making people aware of the status quo or current factors that makes change
necessary in a organization. Hence, this will be the first step towards changing the attitude of
health staffs and give them the message regarding the importance of hand hygiene in relation to
patient safety. Birks et al. (2011) suggested that use of promotional and instructional materials

11LEADERSHIP AND SERVICE IMPROVEMENT
can be an effective step to remind staffs of the need to perform hand hygiene and change their
perception towards hand hygiene. Similar steps are needed in current health care organization.
The gap and inefficiencies in current health provision related to hand hygiene also
suggest the need to implement educational intervention for staffs. Critical thinking and broader
vision of leaders will be critical to ensure that the educational intervention or program is
effective enough to motivate staffs towards practice change process and achieve the quality
parameters needed for service improvement. According to Baker (2015), focussing on leadership
at four levels is critical to quality improvement work. This involves developing a culture that
supports learning, emphasis on development of effective teams, external accountability and
greater use of information technologies to support continuous quality improvement. High
performing organization achieved their goal through fulfilment of this type of actions.
Leaders in current organization can use transformative leadership style to improve
confidence of staffs towards hand hygiene and give them the perception that hand hygiene is not
an additional workload for them. Instead hand hygiene works to reduce their workload burden in
the long run (Muller et al. 2015). As lack of motivation and poor perception has been identified
as a common cause behind poor hand hygiene practices, transformational leadership style can be
extremely beneficial in positively improving staff’s commitment towards change. They can work
to provide the vision for change and adequately support them throughout the change process to
achieve the desired quality improvement goals. Proper communication related to change related
practices can play a role reducing resistances, eliminating uncertainties and gain support and
participation of employees (Loulas 2014). In addition, leader’s action of taking feedback at
regular interval works to mitigate role conflicts and any uncertainties related to the change. It is
also an effective team based strategy to effectively bond with employees and achieve bigger

12LEADERSHIP AND SERVICE IMPROVEMENT
change commitment. In addition, goal management can play a role in eliminating roadblocks in
the way of change. Similar steps can be followed in the context of promoting behaviour change
of employees in relation to hand hygiene (Stewardson et al. 2016).
In compliance with the above concepts of leadership theories, another step suggested to
eliminate barriers related to hand hygiene includes implementation of a holistic hand hygiene
program that includes theoretical practical workshop, reminder strategy and provision of alcohol
based solutions in the hospital setting. Evidence suggest that such comprehensive training
program are effective in developing staff’s skills in relation to hand hygiene, supporting them to
reduce missed cases of hand hygiene and appropriately use resources to promote hand hygiene
and quality care. Nour-Eldein and Eldahshan (2015) suggested the significance of such training
program is that they have the ability to address different factors linked to hand hygiene such as
lack of knowledge of the importance of preventing nosocomial infection, lack of understanding
regarding technique involves, accessibility related issues and the absence of an institutional
commitment to improve hand hygiene. Hence, by following the systematic stages of the Lewin’s
change process and using transformative leadership competencies to effective integrate vital
elements in the care process, health leaders can improve practices related to hand hygiene and
reduce the burden of nosocomial infection. Realization of the above systematic step will play a
crucial role in achieving the goals related to quality and service improvement in health care.
Conclusion:
To conclude, the critical evaluation of the issue of poor hand hygiene and its impact of
quality failure suggest that bringing systemic quality improvement in health care organization
requires positive and distributive leadership style. Leaders in health care organization need to

13LEADERSHIP AND SERVICE IMPROVEMENT
adapt a broader perspective to analyse quality issue from a broader angle and consider factors
that is needed to integrate care and enhance patient’s journey or experience throughout the care.
This report particularly identified poor attitude and compliance to hand hygiene as a major issue
affected quality improvement goals and the critical analysis revealed lack of consideration of
work culture, individuals staff’s attitude and perception and avoidance of holistic assessment of
issues as a major cause behind high rate of HAI and poor patient experience in care. The report
suggest that system wide thinking and dynamic leadership style is needed to ensure that service
improvement related activities are effectively implemented in current health setting. System
thinking is relevance in the context of quality improvement and quality improvement theories
also suggest appreciation of a system and its interconnected components to achieve quality and
continuous improvement. Transformative leadership style can help to take holistic step such as
making all resource available, providing proper training and feedback and develop a safety
culture so that all staffs comply with five moments of hand hygiene.

14LEADERSHIP AND SERVICE IMPROVEMENT
References:
Akpaka, C.C., 2014. Best practices for hand hygiene compliance by health care providers in the
inpatient setting. American Journal of Infectious Diseases, 10(2), p.84.
Al-Abri, R. and Al-Balushi, A., 2014. Patient satisfaction survey as a tool towards quality
improvement. Oman medical journal, 29(1), p.3.
Anargh, V., Singh, H., Kulkarni, A., Kotwal, A. and Mahen, A., 2013. Hand hygiene practices
among health care workers (HCWs) in a tertiary care facility in Pune. Medical journal armed
forces India, 69(1), pp.54-56.
Baker, G.R., 2015. The roles of leaders in high-performing healthcare systems; 2011. London:
The King’s Fund.
Banks, G.C., McCauley, K.D., Gardner, W.L. and Guler, C.E., 2016. A meta-analytic review of
authentic and transformational leadership: A test for redundancy. The Leadership
Quarterly, 27(4), pp.634-652.
Birks, M., Coyle, M., Porter, J. and Mills, J., 2011. Perceptions of hand hygiene amongst health
care workers in Sibu, East Malaysia. International Journal of Infection Control, 8, pp.10-13.
Boak, G., Dickens, V., Newson, A. and Brown, L., 2015. Distributed leadership, team working
and service improvement in healthcare. Leadership in Health Services, 28(4), pp.332-344.
Chassin, M.R., Mayer, C. and Nether, K., 2015. Improving hand hygiene at eight hospitals in the
United States by targeting specific causes of noncompliance. The Joint Commission Journal on
Quality and Patient Safety, 41(1), pp.4-12.

15LEADERSHIP AND SERVICE IMPROVEMENT
Dombecki, C., Shah, M.M., Eke-Usim, A., Akkina, S.R., Ahrens, M., Sturm, L., Washer, L. and
Foxman, B., 2015. The Impact of Role Models on Hand Hygiene Compliance. infection control
& hospital epidemiology, 36(5), pp.610-612.
Gould, D.J., Creedon, S., Jeanes, A., Drey, N.S., Chudleigh, J. and Moralejo, D., 2017. Impact of
observing hand hygiene in practice and research: a methodological reconsideration. Journal of
hospital infection, 95(2), pp.169-174.
James, D., Ehrstedt, F., Sundholm, J., Harel, N.N. and Egge, S., 2018. Sensitizing health-care
workers and trainees to create a nondiscriminatory health-care environment for surgical care of
HIV-Infected patients. CHRISMED Journal of Health and Research, 5(2), p.143.
Johnson, J.K. and Sollecito, W.A., 2018. McLaughlin & Kaluzny's Continuous Quality
Improvement in Health Care. Jones & Bartlett Learning.
Kim, K.M. and Oh, H., 2015. Clinical Experiences as related to standard precautions compliance
among nursing students: a focus group interview based on the theory of planned behavior. Asian
nursing research, 9(2), pp.109-114.
Leatherman, S., Ferris, T.G., Berwick, D., Omaswa, F. and Crisp, N., 2010. The role of quality
improvement in strengthening health systems in developing countries. International Journal for
Quality in Health Care, 22(4), pp.237-243.
Loulas, N., 2014. How leadership theory can contribute in quality improvement efforts, by
influencing change, teamwork and goal management. Retrieved from: http://www.diva-
portal.org/smash/get/diva2:749218/FULLTEXT01.pdf

16LEADERSHIP AND SERVICE IMPROVEMENT
Løyland, B., Wilmont, S., Cohen, B. and Larson, E., 2015. Hand-hygiene practices and observed
barriers in pediatric long-term care facilities in the New York metropolitan area. International
Journal for Quality in Health Care, 28(1), pp.74-80.
Mahmood, S.E., Verma, R. and Khan, M.B., 2017. Hand hygiene practices among nursing
students: importance of improving current training programs. International Journal Of
Community Medicine And Public Health, 2(4), pp.466-471.
McSherry, R. and Pearce, P., 2016. what are the effective ways to translate clinical leadership
into health care quality improvement?. Journal of healthcare leadership, 8, p.11.
Muiru, H.W., 2018. Knowledge, attitude and barriers to hands hygiene practice: a study of
Kampala International University undergraduate medical students. International Journal Of
Community Medicine And Public Health, 5(9), pp.3782-3787.
Muller, M.P., Carter, E., Siddiqui, N. and Larson, E., 2015. Hand hygiene compliance in an
emergency department: the effect of crowding. Academic Emergency Medicine, 22(10), pp.1218-
1221.
Neo, J.R.J., Sagha-Zadeh, R., Vielemeyer, O. and Franklin, E., 2016. Evidence-based practices
to increase hand hygiene compliance in health care facilities: an integrated review. American
journal of infection control, 44(6), pp.691-704.
Nour-Eldein, H. and Eldahshan, N.A., 2015. The Effectiveness of Hand Hygiene Education
Intervention for Medical Students in Primary Care Settings: Ismailia City, Egypt. World Family
Medicine Journal: Incorporating the Middle East Journal of Family Medicine, 99(2124), pp.1-9.

17LEADERSHIP AND SERVICE IMPROVEMENT
Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F. and Stevens, D., 2015. SQUIRE
2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines
from a detailed consensus process. The Journal of Continuing Education in Nursing, 46(11),
pp.501-507.
Salama, M.F., Jamal, W.Y., Al Mousa, H., Al-AbdulGhani, K.A. and Rotimi, V.O., 2013. The
effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti
teaching hospital. Journal of infection and public health, 6(1), pp.27-34.
Siegel, E.O., Bakerjian, D. and Zysberg, L., 2017. Quality improvement in nursing homes:
alignment among leaders across the organizational chart. The Gerontologist, 58(4), pp.e281-
e290.
Stewardson, A.J., Sax, H., Gayet-Ageron, A., Touveneau, S., Longtin, Y., Zingg, W. and Pittet,
D., 2016. Enhanced performance feedback and patient participation to improve hand hygiene
compliance of health-care workers in the setting of established multimodal promotion: a single-
centre, cluster randomised controlled trial. The Lancet Infectious Diseases, 16(12), pp.1345-
1355.
Wałaszek, M., Kołpa, M., Wolak, Z., Różańska, A. and Wójkowska-Mach, J., 2017. Poor Hand
Hygiene Procedure Compliance among Polish Medical Students and Physicians—The Result of
an Ineffective Education Basis or the Impact of Organizational Culture?. International journal of
environmental research and public health, 14(9), p.1026.
Watson, G.H., 2018. Quality Thoughts: The Theory of Profound Knowledge. Journal for Quality
and Participation, 41(1).

18LEADERSHIP AND SERVICE IMPROVEMENT
World Health Organization 2019. Clean care is safer care. Retrieved from:
https://www.who.int/gpsc/tools/faqs/evidence_hand_hygiene/en/