An IP identifies roles and locations with decreased hand hygiene compliance and develops how to improve compliance. What is this called?

• A. Risk assessment
• B. Audit
• C. Action plan
• D. Policy development

Answer: (C)

Creating an action plan to address gaps in hand hygiene compliance. After identifying which roles and locations have lower compliance, the next step is to outline concrete corrective actions, assign responsibilities, set deadlines, and decide how progress will be measured. This moves from recognizing a problem to actively implementing improvements, which is what the scenario describes. An audit measures and reports current practices but doesn’t automatically specify the steps to fix them, a risk assessment identifies hazards and likelihoods without detailing corrective actions, and policy development creates guidelines without laying out the specific implementation steps and accountability needed to change behavior. For example, the plan might include targeted education, visible reminders, ensuring easy access to hand hygiene supplies at the point of care, and follow-up monitoring to see if compliance improves within a set timeframe.