Latar Belakang: Rumah Sakit (RS) harus menyelenggarakan perlindungan pasien dari risiko Healthcare-Associated Infections (HAIs). Program Pencegahan dan Pengendalian Infeksi harus diselenggarakan dengan baik untuk menurunkan risiko HAIs, termasuk kepatuhan hand hygiene pada seluruh staf RS. Rendahnya kepatuhan diantara petugas kesehatan menjadi masalah di fasilitas pelayanan kesehatan. World Health Organization (WHO) mengeluarkan Multimodal Hand Hygiene Improvement Strategy sebagai salah satu strategi untuk mengatasi permasalahan kepatuhan hand hygiene. Rumah Sakit Paru Dr. M. Goenawan Partowidigdo (RSPG) Cisarua Bogor telah memiliki regulasi hand hygiene yang mengacu pada kebijakan yang berlaku, namun kepatuhan hand hygiene tidak mencapai target selama tiga tahun. Analisis kepatuhan implementasi kebijakan, dalam hal ini regulasi, perlu dilakukan untuk memetakan faktor-faktor yang mempengaruhi implementasi. Oleh karena itu penelitian ini ingin menganalisis lebih lanjut bagaimana kepatuhan implementasi regulasi hand hygiene di RSPG Cisarua Bogor berdasarkan WHO Multimodal Hand Hygiene Improvement Strategy. Metode: Penelitian ini menggunakan pendekatan penelitian kualitatif deskriptif analitik dengan metode studi kasus. Peneliti melakukan analisis kepatuhan implementasi regulasi hand hygiene dengan mengembangkan teori George Edward III yang dikolaborasikan dengan WHO Multimodal Hand Hygiene Improvement Strategy. Penilaian WHO Multimodal Hand Hygiene Improvement Strategy dilakukan dengan skoring Hand Hygiene Self-Assessment Framework (HHSAF). Lokasi penelitian di Rumah Sakit Paru Dr. M. Goenawan Partowidigdo (RSPG) Cisarua Bogor yang merupakan Rumah Sakit Khusus Pusat Tipe III. Hasil: Berdasarkan analisis terhadap variabel komunikasi, masih perlu peningkatan konsistensi komunikasi. Persentase perolehan skor HHSAF pada variabel komunikasi 80,4%. Berdasarkan analisis terhadap variabel sumber daya, diperoleh persentase skor 73,9%. Pada SDM peneliti mendapatkan temuan selain kuantitas dan kualitas SDM, yaitu isu keaktifan dan perilaku. Berdasarkan analisis terhadap variabel disposisi didapatkan pada pengangkatan birokrasi masih kurangnya bentuk komitmen yang jelas dari kepala keperawatan. Bentuk apresiasi non materi dianggap akan lebih berdampak positif, dan masih kurangnya komitmen implementor. Persentase perolehan skor HHSAF pada variabel disposisi adalah 65%. Berdasarkan analisis terhadap variabel struktur birokrasi, diketahui perlu perbaikan pada SPO keperawatan mengenai momen cuci tangan sesuai SPO dan panduan PPI. Pada fragmentasi diketahui koordinasi penyebaran tanggung jawab untuk implementasi regulasi hand hygiene masih kurang baik, namun tidak terjadi bureaucratic fragmentation. Persentase perolehan skor HHSAF pada variabel struktur birokrasi adalah 23%. RSPG berada pada hand hygiene level Intermediate dengan skor total 312,5. Kesimpulan: Diantara keempat variabel, persentase perolehan skor HHSAF terendah adalah pada variabel struktur birokrasi, namun hal ini bukan menjadi variabel yang paling berpengaruh pada implementasi regulasi hand hygiene di RSPG. Variabel yang paling berpengaruh terhadap implementasi regulasi hand hygiene di RSPG adalah variabel sumber daya, yaitu sumber daya manusia, terkait isu keaktifan dan perilaku.

---

Background: Hospitals must organize patient safety from the risk of Healthcare-Associated Infections (HAIs). Infection Prevention and Control programs must be well organized to reduce the risk of HAIs, including hand hygiene compliance among all hospital staff. Low compliance among healthcare workers is a problem in healthcare facilities. WHO issued the Multimodal Hand Hygiene Improvement Strategy as one of the strategies to overcome the problem of hand hygiene compliance. Dr. M. Goenawan Partowidigdo Pulmonary Hospital (RSPG) Cisarua Bogor has hand hygiene regulations that refer to applicable policies, but hand hygiene compliance has not reached the target for three years. Compliance analysis of policy implementation, in this case regulation, needs to be done to map the factors that influence implementation. Therefore, this study aims to further analyze how the implementation compliance of hand hygiene regulation in RSPG Cisarua Bogor is based on WHO Multimodal Hand Hygiene Improvement Strategy. Methods: This study used a qualitative analytic descriptive research approach, with a case study method. Researcher analyzed the implementation compliance of hand hygiene regulations by developing the George Edward III theory collaborated with the WHO Multimodal Hand Hygiene Improvement Strategy. The WHO Multimodal Hand Hygiene Improvement Strategy assessment was carried out by scoring the Hand Hygiene Self-Assessment Framework (HHSAF). The research location was at the Dr. M. Goenawan Partowidigdo Pulmonary Hospital (RSPG) Cisarua Bogor which is a Type III Central Specialty Hospital. Results: Based on the analysis of communication variables, there is still a need to improve communication consistency. The percentage of HHSAF scores on communication variables is 80.4%. Based on the analysis of the resource variable, a percentage score of 73.9% was obtained. In human resources, researchers found findings other than the quantity and quality of human resources, namely the issue of activeness and behavior. Based on the analysis of the disposition variable, it was found that the bureaucratic appointment still lacked a clear form of commitment from the head of nursing. Non-material forms of appreciation are considered to have a more positive impact, and there is still a lack of implementor commitment. The percentage of the HHSAF score on the disposition variable is 65%. Based on the analysis of bureaucratic structure variables, it is known that improvements need to be made to the nursing SPO regarding hand washing moments according to SPO and PPI guidelines. In fragmentation, it is known that the coordination of the distribution of responsibilities for implementing hand hygiene regulations is still not good, but there is no bureaucratic fragmentation. The percentage of the HHSAF score on the bureaucratic structure variable was 23%. RSPG is at the Intermediate level of hand hygiene with a total score of 312.5. Conclusion: Among the four variables, the lowest percentage of the HHSAF score was on the bureaucratic structure variable, but this was not the most influential variable on the implementation of hand hygiene regulations in RSPG. The variable that has the most influence on the implementation of hand hygiene regulations in RSPG is the resource variable, namely human resources, related to the issue of activeness and behavior.