Hand Hygiene Compliance

The single most common transmission of health care-associated infections (HAIs) in a health care setting is via transiently colonized hands of health care workers who acquire it from contact with colonized or infected patients, or after handling contaminated material or equipment. Monitoring hand hygiene practices and the provision of timely feedback are vital to improving compliance and, in turn, reducing HAIs.

Public reporting of hand hygiene compliance is about transparency and establishing a baseline for our facility. TBRHSC is participating in education provided by RICN and Public Health Units, as well as providing on-site education to front line staff. We are currently midway through our roll out of the “Just Clean Your Hands” Ministry of Health initiative. This is about a change in culture for our organization, including point of care hand hygiene and education, in addition to when and how to wash hands.

Hand hygiene compliance rates will be posted annually to ensure enough data is collected to be statistically valid. The reported rates provide a starting point to measure improvement resulting from our hand hygiene initiatives and education for the staff and users of the facility.

Calculation of Hand Hygiene Comploance Rates

The two hand hygiene compliance rates will be calculated as follows.

Number of time hand hygiene performed before initial patient or patient enviroment contact x 1000
Number observed hand hygiene performed before initial patient or patient enviroment contact
Number of time hand hygiene performed after initial patient or patient enviroment contact x 1000
Number observed hand hygiene performed after initial patient or patient enviroment contact

The Hand Hygiene Program at TBRHSC is aimed at reducing health care-acquired infections. In addition, there is a strong collaboration among Ontario hospitals, the provincial government and the OHA to continually improve system performance.

Elements of the TBRHSC Hand Hygiene Program:

  • Environmental changes and system supports
  • Education for health care providers about when and how to clean hands
  • Senior management support and commitment to make hand hygiene and organizational priority
  • Patient engagement
  • Opinion leaders and champions modeling the right behaviour
  • Ongoing monitoring and observation of hand hygiene practices with feedback to health care providers

Provincially, hospitals are participating in the Ministry infection prevention and control core competency education program, using PIDAC’s best practice guidance documents. They are implementing the provincial “Just Clean Your Hands” campaign, as well as attending educational sessions held by the OHA and the Regional Infection Control Networks on a variety of infection prevention and control topics.