Background on Hand Hygiene | Public Reporting of Hand Hygiene Compliance | Rouge Valley's Hand Hygiene Compliance Results | Calcluating Hand Hygiene Compliance | Improving Patient Safety over Time | Return to Quality & Safety Indicators Main Page | Hand Hygiene for Visitors

Background on Hand Hygiene

Hand hygiene relates to:

1. The removal of visible soil; and
2. The removal or killing of microorganisms found on the upper layers of the skin of our hands.

It is generally accomplished by either using soap and running water or by using an alcohol-based hand rub.

The most common way that hospital-acquired infections (HAIs) are spread is from the hands. Health care workers may acquire it on their hands from contact with colonized or infected patients, from each other, or after handling contaminated material or equipment.

By complying to hand hygiene practices, we can help to reduce HAIs. One of the ways that we can improve compliance is by monitoring and reporting hand hygiene practices. Using this information, we can get a better understanding of where we need to make changes to increase compliance by staff throughout the hospital.

View these easy instructions on handwashing from the Ontario Ministry of Health and Long-Term Care (PDF 36k)

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Public Reporting of Hand Hygiene Compliance

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.

Hospitals must report on the following four indications (or moments) for hand hygiene: Before initial patient/patient environment contact; Before aseptic procedure; After body fluid exposure risk; and After patient/patient environment contact. 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.

Source: Illustration from www.justcleanyourhands.ca

• To view provincial hand hygiene compliance data, please visit the MOHLTC website.

• To learn more about Ontario's strategy for improving hand hygiene in hospitals and other health care settings, please visit www.just cleanyourhands.ca.

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Rouge Valley's Hand Hygiene Compliance Results

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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:



This calculation represents the percentage compliance rate for hand hygiene for the reporting facility.

Example calculation

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

• Hospitals are to collect at least 200 observations for every 100 in patient beds.
• To ensure statistically valid data for smaller hospitals (or hospitals with fewer inpatient beds), a minimum of 50 observed opportunities for hand hygiene will need to be collected.

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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).

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:

1. A dedicated and proactive Infection Prevention and Control department with knowledgeable Infection Control Practitioners;
2. Adherence to strict environmental cleaning policies and procedures in areas/rooms;
3. Regular education and support, including participating in a number of education opportunities provide by the ministry and OHA that are related to best practices for infection prevention and control; and
4. Incorporating expert advice into our organizational practices.

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.

Check out our other quality and safety indicators.

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