Impact of a Plan-Do-Check-Act Hand Hygiene Bundle on Compliance, Infection Rates, and Nursing Quality: A Controlled Before-and-After Study

Summary

This controlled before-and-after study demonstrates that a Plan-Do-Check-Act (PDCA)-based governance bundle significantly improves hand hygiene compliance. Furthermore, the intervention effectively reduces hospital-acquired infection rates and elevates nursing management quality in inpatient wards, providing a sustainable, data-driven framework for institutional infection control.

Abstract

Hand hygiene remains one of the most important measures for preventing hospital-acquired infections, yet sustained compliance in routine inpatient care remains difficult to achieve through reminders or training alone. This study evaluated the effect of a Plan–Do–Check–Act (PDCA)-based hand hygiene governance bundle on hand hygiene compliance, hospital-acquired infection rates, and nursing management quality. A controlled before-and-after study was conducted in 16 inpatient wards of a general hospital. Eight wards received a PDCA-based hand hygiene governance bundle, while eight control wards continued routine hand hygiene management. The study covered a 12-month period, including a 6-month pre-intervention period and a 6-month post-intervention period. The ward-month was used as the main analytical unit. The primary outcome was monthly hand hygiene compliance. Secondary outcomes included hospital-acquired infection rate per 1,000 patient-days and nursing management quality score. Difference-in-differences models were used to estimate intervention-associated changes. Hand hygiene compliance increased from 66.2% to 83.2% in the intervention group and from 63.1% to 66.8% in the control group. The adjusted difference-in-differences odds ratio (OR) for hand hygiene compliance was 2.38 (95% CI: 2.19–2.59, P < 0.001). Hospital-acquired infection rates decreased from 7.07 to 4.37 per 1,000 patient-days in intervention wards, with an adjusted incidence rate ratio of 0.60 (95% CI: 0.52–0.69, P < 0.001). Nursing management quality scores increased more substantially in intervention wards than in control wards. The PDCA-based hand hygiene governance bundle was associated with improved hand hygiene compliance, lower hospital-acquired infection rates, and higher nursing management quality. Embedding hand hygiene into repeated ward-level governance cycles may provide a practical strategy for strengthening infection-control management.

Introduction

Hospital-acquired infections remain a major challenge for patient safety because they increase morbidity, prolong hospitalization, raise healthcare costs, and place additional pressure on clinical staff and hospital management. The WHO Guidelines on Hand Hygiene in Health Care¹ position hand hygiene as a core infection-prevention practice because transmission of microorganisms through the hands of healthcare workers is one of the most preventable pathways in healthcare settings. Although the principle is simple, reliable implementation remains difficult in real clinical environments where workload, role differences, supply access, habits, and s....

Protocol

The study protocol was reviewed and approved by the Ethics Committee of Guangzhou Panyu Shiqiao Hospital (Approval Number: ASJIO729). Because the study strictly used routinely collected, de-identified ward-level quality-improvement and infection-control indicators, the ethics committee explicitly waived the requirement for individual informed consent. No patient names, staff names, medical record numbers, or other directly identifiable information were included in the analytical dataset, and data access was restricted to authorized members of the study team.

Study design
This controlled before-and-after study evaluate....

Results

Baseline ward characteristics
A total of 16 inpatient wards were included in the study, with 8 wards in the intervention group and 8 wards in the control group.

The two groups showed no marked imbalance in ward workload or observation volume at baseline. Baseline hand hygiene compliance was 66.2% in the intervention group and 63.1% in the control group. The baseline hospital-acquired infection rate was 7.07 per 1,000 patient-days in the intervention group and 6.20 per 1,00.......

Discussion

This controlled before-and-after study demonstrates that a PDCA-based hand hygiene governance bundle significantly improves compliance, reduces hospital-acquired infection (HAI) rates, and enhances nursing management quality. Unlike interventions relying solely on generalized education, our approach translates multimodal strategies into a repeatable, ward-level governance cycle. Our findings align with international literature demonstrating the broad efficacy of multimodal programs in reducing healthcare-associated infec.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Alcohol-based hand rub (ABHR)	3M Company, St. Paul, MN, USA	N/A	Used by healthcare workers for hand hygiene actions during the study period.
Alcohol-based hand rub consumption records	Ward supply records / Hospital logistics system	N/A	Used to calculate alcohol-based hand rub consumption standardized by patient-days.
GraphPad Prism	GraphPad Software, San Diego, CA, USA	Version 9.0	Used to prepare figures and check graphical outputs against final statistical results.
Hand hygiene knowledge test	Study team / Infection-control nurses	N/A	Structured 0–100 test; Used to assess healthcare workers’ knowledge of hand hygiene indications, procedures, glove use, and infection-control risk points.
Hospital infection-control surveillance records	Hospital infection-control department	N/A	Used to identify monthly hospital-acquired infection cases and verify infection events using clinical, microbiological, medication, temperature, imaging, and ward log data.
IBM SPSS Statistics	IBM Corp., Armonk, NY, USA	Version 27.0	Used for descriptive statistics and baseline comparison tables.
Nursing management quality assessment form	Hospital nursing management department	N/A	Structured 0–100 scoring form; Used for monthly assessment of hand hygiene governance, infection-control documentation, supplies, staff training, audit feedback, environmental management, and corrective action implementation.
PDCA corrective action form	Study team / Infection-control department	N/A	Ward-month observation form; Used to record ward code, month, professional role, hand hygiene moment, hand hygiene opportunities, and performed hand hygiene actions.
R packages: stats, MASS, sandwich, lmtest	R Foundation / CRAN	Versions consistent with R 4.3.2	Used for regression modeling, count models, robust standard errors, and statistical inference.
R software	R Foundation for Statistical Computing, Vienna, Austria	Version 4.3.2	Used for difference-in-differences models, Poisson/negative binomial models, clustered standard errors, subgroup analyses, and sensitivity analyses.
Standardized hand hygiene observation form	Study team / Infection-control department	N/A	Ward-month observation form; Used to record ward code, month, professional role, hand hygiene moment, hand hygiene opportunities, and performed hand hygiene actions.
Ward administrative records	Hospital administrative system	N/A	Used to obtain admissions, patient-days, and ward workload indicators for denominator calculation and baseline comparison.