|Hand Hygiene Compliance Rate|
Hand hygiene compliance results for April 1, 2012 - March 31, 2013
Learn more about Rouge Valley's hand hygiene program
Hand hygiene is an important practice for health care providers and has a significant impact on reducing the spread of infections in hospitals. Good hand hygiene helps to ensure patient safety, and involves everyone in the hospital. This includes the health care providers at Rouge Valley, as well as patients and their family and friends.
Hand hygiene relates to:
It is generally accomplished by either using soap and running water or by using an alcohol-based hand rub.
View easy handwashing guide (from the Ontario Ministry of Health and Long-Term Care)
Mandatory public reporting is one way that hospitals across the province are working together to improve hand hygiene compliance. Beginning April 30, 2009, each hospital is required to submit compliance data to the Ontario Ministry of Health and Long-Term Care (MOHLTC). For the purpose of public reporting, data will be reported on an annual basis so that hospitals are able to submit enough data and that the compliance rate is statistically valid.
The goal of publicly reporting hand hygiene compliance is to achieve an overall assessment of whether compliance rates are improving. It is normal for rates to vary from hospital to hospital.
Four moments of proper hand hygiene in hospitals
Hospitals must report on the following four indications (or moments) for hand hygiene:
While hospitals will be submitting data to the ministry on all four indications; the MOHLTC will not publicly report data on “before aseptic procedures” and “after body fluid exposure risk.” This is because it is difficult for some hospitals to obtain a large enough sample size for these indications. In keeping with the Ministry's public reporting, Rouge Valley also only publicly reports data for the first and fourth moments.
Calculating hand hygiene compliance
Hand hygiene compliance rates are calculated as the number of times that hand hygiene was performed for each of the four indications, divided by the number of observed hand hygiene indications for that specific indication. The results are multiplied by 100 as follows:
(# of times hand hygiene performed / # of observed hand hygiene indications) X 100
This calculation represents the percentage compliance rate for hand hygiene for the reporting facility.
For example, 60 times hand hygiene was performed before initial patient/patient environment contact by all health care providers divided by 100 observed hand hygiene indications for initial patient/patient environment contact for all health care providers = 60/100 = 0.60. Multiplying this by 100 = 0.60 x 100 = 60% compliance rate.
Important notes about data collection:
Improving patient safety over time
Rouge Valley is working to create a culture of patient safety involves everyone—health care administration, health care professionals, and, of course, patients and families.
We know that good hand hygiene is the single most effective way to reduce the risk of hospital-acquired infections. Hand washing has always been something that we do, but it’s also something that we want to continue to do better (i.e., at the right times and the right way).
Our target compliance rate is 90% for the first and fourth moments of hand hygiene practice. We have been able to achieve this target thanks to a dedicated hand hygiene program that has been implemented over the last few years.
Rouge Valley has a formal organization-wide audit system. Audits on compliance to hand hygiene protocols and practices are completed on all inpatient units and departments by local hand hygiene champions. These are staff members — including nurses, clinical practice leaders, unit clerks, etc. — who have been trained to conduct audits. The data from the audits are collated and results shared each month through the infection control department. The results are used to make improvements.
Every month, hand hygiene compliance data is distributed to clinical managers, program directors, the senior management team, and the Board of Directors. Managers in turn share the hand hygiene audit data with their staff and post results on each unit's performance boards.
Education and accountability
If low hand hygiene compliance rates are identified, we will review our infection prevention and control practices to ensure that they align with the Provincial Infectious Diseases Advisory Committee (PIDAC) best practices documents, as well as the Just Clean Your Hands program. In addition to PIDAC’s recommendations, hospitals also go through an extensive accreditation process that requires them to show their use of prevention best practices.
Here are some of the methods and activities that we use at Rouge Valley to ensure good hand hygiene and strengthen hand hygiene compliance:
Additionally, there have been many exciting initiatives that have also contributed to these great results—including universal hand hygiene audits. Through this new program being carried out on several units at each hospital campus, a nurse on each shift is assigned the duty of conducting random hand hygiene audits for the unit. This helps to create a more accurate picture of hand hygiene compliance at RVHS and engages all members of the team. This initiative will be rolled out to all units across Rouge Valley.
Cultivating a rich hand hygiene culture
Other initiatives that have assisted in promoting hand hygiene at RVHS include:
Using hand hygiene compliance rates as a measurement tool is a part of our broader performance management framework. This is just one of the indicators that helps us to assess quality of care and safety.