BUSINESS CASE

INTRODUCTION & BACKGROUND

Hand Hygiene is one of the most effective tool in prevention of healthcare associated infection.
As it was first developed during 1840s by Ignaz Semmelweis, it was noted that hand washing with water
and antiseptic solution has reduced significantly the maternal mortality after delivery in Vienna
Maternity Institution. In his study between two subjects, first subject as medical students versus subject
b as midwives, he observed that in the midwife clinic, there are far less maternal mortality due to the
hygiene practices.

Currently, Hand hygiene is one of the most promoted best practices in the healthcare as most of
the healthcare workers are exposed to blood and bodily fluids. The risk of transmitting disease or
infection in a healthcare institution is very high and hand hygiene is the single best tool to ensure
transmission of infection will be little or eliminated. Moreover, over the period of time concentrating on
patient centeredness, quality, cost control and other factors in the healthcare, hand hygiene practice
has become a benchmark of excellence in delivery of quality care. In 2006, JCI (Joint Commission
International) has developed and included the reduction of the risk of health care associated infection as
number 5 in the international patient safety goal. With that being said, through hand hygiene there is a
big fulfillment in the fifth international patient safety goals along with other measures.

Needless to say, hand hygiene is not just historically accurate to control or prevent HAIs nor just
a trendy way in executing a quality health care but the most practical way to minimize acquiring health
care associated infection.

BUSINESS OBJECTIVES

A main part of the mission of Mukhtar A. Sheikh Hospital is to align the process and the facility
to achieve international healthcare accreditation from many institutions such as Joint Commission
International. To achieve this in MASH, we need to ensure that IPSGs are met. As mentioned, one of the
IPSG is to reduce the risk of healthcare-associated infections. With that being said, one of the basic and
evidence based way is to ensure and promote hand hygiene. In order for this institution to do that,
availability of hand hygiene facility, promotion of hand hygiene and monitoring of hand hygiene
practices will be the basic three objectives. Moreover, the improvement of hand hygiene in MASH will
definitely improve healthcare quality outlook and also the overall patient outcome.

CURRENT SITUATION AND PROBLEM/ OPPORTUNITY

During the MASH commissioning program, the Infection Control department made a gap
analysis in order to counter check the pre-commissioning hospital status. As per checking, in accordance
to hand washing, the result is not promising. On all fully constructed areas which are the following; 4
ambulatory departments, 11 IPD units and 5 restricted but non patient care units, only 3 areas have
hand washing facility. Areas such as Emergency Department, IPD wards, ICU, SICU, PICU, NICU, Gyne, OT
units has few to none hand washing facility. Additionally, there was no even water provision in the most
units for construction of hand wash basin. Moreover, alcohol hand rub is nowhere available at that
point. In short, hand hygiene facility presents a very dissatisfying current outlook at the point of
commissioning phase of MASH.

Additionally, as OPD has already started 2 clinics, it has been found out that the hand wash
basin sinks are not up to standards in which the faucet is too low, close to sink and sink is not deep
enough which causes water splashes. In this regard, the hand wash basin recommendation from
International Health Facility guidelines were not met.

CRITICAL ASSUMPTIONS AND CONSTRAINTS

The Director of Nursing, the Deputy Medical Director and the Infection Control Committee has
agreed that this is a critical problem and needs urgent planning and action as the opening of other areas
such as Emergency Department, IPD, Operating Theater, OBs and Gyne Department, Nursery and other
non-patient but critical areas will be soon. Without the hand washing facility and hand rub facility, it is
difficult for good hand hygiene compliance and also there is a high risk of transmission of infection. The
issue has been raised to COO nevertheless, due to financial and engineering issues the concern has been
forwarded to the Chairman of Mukhtar A. Sheikh Hospital.

ALTERNATIVE ANALYSIS & RECOMMENDATION

There are the following ways to fix the gap on hand hygiene in Mukhtar A. Sheikh Hospital:

1. Install sinks in all important areas as much as aligned to AIA guidelines in conjunction of CDC
requirements. (Example: 1 ICU bed is to 1 Hand Hygiene sink and 1 Alcohol Hand rub)
2. Place a single movable sink with the areas or units with no water provision.
3. Place alcohol hand rub in required areas as per WHO requirement.
4. Hand Hygiene awareness, promotion and continuous monitoring for compliance after hand
hygiene facility completion must be done by Infection Control Department.

After review of available options along with Chairman, Senior Leadership team and Infection
Control Committee it is decided that the best way to improve hand hygiene status of Mukhtar A. Sheikh
Hospital it is to follow options #1, #3 and #4. To begin with, since JCI and other international
accreditation will be pursued by the institution it is best to align the wash basin facilities as per
international standard. On the other hand, while option #2 suggests for a cheaper way to provide for
hand washing sinks, it is nevertheless inconvenient due to its limitations such as water source would be
inside the moveable sink cubicle which will require refilling of water from time to time and also water
drainage will be going to a reservoir which is also inside the moveable sink cubicle. Moreover, both
mentioned limitations in option # 2 will also be a possible risk of source of infection in the special care
units due to possible water contamination in the water storage in the moveable sink cubicle.
Furthermore, since there are two types of hand hygiene practice in a healthcare setting, option # 3
needs to be attained. Lastly, option # 4 is a required process to ensure that hand hygiene will be
practiced by all healthcare workers.
This combination of 3 options (option #1, option #3 and option #4) will strengthen and also
standardized the hand hygiene practice in this new facility. Moreover, as early as commissioning phase,
these things will be settled and not contributing to bad patient outcome due to infection in the
operational phase.

PRELIMINARY REQUIREMENTS

This project is being undertaken to meet the following requirements:

1. Install hand washing sinks in the IPDs, ambulatory areas and non-patient but critical areas as
aligned to AIA guidelines, CDC and health facility guidelines.
2. Install alcohol hand rub in the IPDs and ambulatory areas and non-patient but critical areas as
aligned to AIA guidelines, CDC and health facility guidelines.
3. Organize a hand hygiene awareness and campaign.
4. Develop and deliver training for new joining healthcare workers.
5. Monitor and ensure compliance of hand hygiene in accordance with WHO hand hygiene
compliance and protocol.
6. Develop a hand hygiene KPI and ensure to achieve target of hand hygiene performance in each
unit and areas in MASH.

BUDGET ESTIMATE AND FINANCIAL ANALYSIS

The preliminary costs estimate for this project is divided into 5 phases which has the grand total
of 1,670,000 PKR (baseline) and of 2,132,000 PKR (including contingency). The diagram shows the
project costs per phase:

Phase Cost Contingency Contingency Notes

Estimate Estimate
1- Core cutting, Construction 730,000 PKR 200,000 PKR Core cutting requires new bricks and
and installation of wash paint. There are some existing materials
basin- ED, Rehab, Dialysis, however maybe insufficient
Endoscopy, OT, CSSD,
SICU, G2 Ward, Obs and
Gyne, Nursery (All areas
to be opened at 1st phase)
2- Installation of Hand 330,000 PKR 70,000 PKR Hand sanitizer at first installation needs 2
Sanitizer- ED, Rehab, to 3 packs per unit as a backup before it
Dialysis, Endoscopy, OT, will become a ward/ unit area cost
CSSD, SICU, G2 Ward, Obs
and Gyne, Nursery (All
areas to be opened at 1 st
phase)
3- Core cutting, Construction 352,800 PKR 100,000 PKR Core cutting requires new bricks and
and installation of wash paint. There are some existing materials
basin- PICU, CICU, MICU however maybe insufficient
Executive Ward and 5th
floor ward (All areas to be
opened at 2nd phase)
4- Installation of Hand 158,000 PKR 42,000 PKR Hand sanitizer at first installation needs 2
Sanitizer- PICU, CICU, to 3 packs per unit as a backup before it
 MICU Executive Ward and will become a ward/ unit area cost
5th floor ward (All areas to
be opened at 2nd phase)
5- Hand Hygiene Campaign 100,000 PKR 50, 000 PKR Hand hygiene campaign may include
WHO International Hand external promotional talents (outside
Hygiene Day- May 5 MASH)
TOTAL 1,670,000 462,000 PKR
PKR

This project is concerned primarily on construction of hand hygiene facility both for hand
washing and alcohol hand rub. The project is also for adding hand hygiene as a very important
preventive measure practices in MASH through campaign, education and monitoring. Moreover, the
project will start the quality care culture in MASH and eventually will be a KPI in a year time. On the
other hand, since the hospital has not started the operations in all major units or departments, there
has not been a projection in estimated cost of financial benefit. However, it is globally known that cost
reduction due to prevention of additional hospital stay days and additional antibiotic treatment is about
50 to 80 percent. Therefore, there will be future estimated cost savings in the long run or after
development of whole hospital financial framework.

SCHEDULE ESIMATE

The total estimate of the project is 12 to 18 months given the time of opening of all areas/
departments in the whole hospital. Since only 70 percent will open in the first operational opening
phase in MASH the project cannot be hastened. Furthermore, the stage in which performance
monitoring that will make hand hygiene as a KPI will roughly start after 6 months post installation of
hand hygiene facilities.

RISKS

In this project, there are several risks identified. First, is the primary risk in which there is poor
compliance among nurses due to high turnover rate of the nurses in Multan area. There will be a big
possible chances of multiple training and evaluating of many batches of new joined nurses. This is due to
sudden resignation and rehiring. Therefore, hand hygiene compliance will always be affected due to fast
turnover. Second, the areas/ department in plan to be commissioned during the second phase of
opening such as CICU, PICU, MICU and other’s has a chance of some alteration. There are chances of
these area being repurposed from the original construction plan due to evolution of hospital goals such
as turning one unit into an office department. In this regard, the constructed hand hygiene facilities will
turn to be useless if the management will deviate from original plan.
EXHIBIT A: A RESEARCH STUDY OF HAND WASHING FACILITY TITLED: IMPACT OF SINK LOCATION ON
HAND HYGIENE COMPLIANCE AFTER CARE OF PATIENTS WITH CLOSTRIDIUM DIFFICILE INFECTION: A
CROSS-SECTIONAL STUDY

The diagram shows that there is an impact to which availability of hand hygiene facility affects hand
hygiene practices. In the study, the conclusion was an overall poor compliance to hand hygiene due to
inaccessibility of hand hygiene facility. It also states in the conclusion for urgent improvement strategies.