In November 2023, inconsistent umbilical cleaning practices were identified across peri-operative areas, with cleanliness rates falling below 52%. Several attempts to improve outcomes — including switching from Betadine to gel sanitizers—did not achieve target goals. Peer-to-peer teaching and report reviews alone were not driving meaningful change.

After reviewing obstacles in each peri-operative area, a focused re-education initiative was launched in June 2024 in partnership with frontline teams and leaders. The program emphasized proper umbilical hygiene for ASU staff, patient care technicians, operating room nurses, and PACU nurses.

The ASU team reinforced pre-procedure teaching during pre-operative phone calls, ensuring patients had the necessary supplies to clean their umbilicus. This education was reiterated by pre-op nurses on the day of surgery, while patient care technicians and primary nurses performed the actual cleaning.

Operating room nurses assessed each abdominal surgery patient’s umbilical condition and documented cleanliness using Microsoft Forms. When standards were not met, PACU assistant managers were notified in real time and provided immediate staff re-education.

Within several months, compliance consistently exceeded 75% and has remained above the target rate. With the practice now sustained, ongoing surveys are no longer required.

This initiative highlights the importance of structured re-education, frontline engagement, and accountability in improving peri-operative practices. By focusing on consistent umbilical hygiene, the team not only achieved measurable improvements but also strengthened patient safety and reduced the risk of surgical site infections.