Hand Hygiene Compliance

As part of the Ministry of Health and Long-Term Care’s (MOHLTC) public reporting of patient safety indicators initiative, Holland Bloorview Kids Rehabilitation Hospital has been tracking hand hygiene compliance rates among our health care professionals.

Research shows that hand hygiene is the single most effective way to reduce the risk of healthcare-associated infections, and Holland Bloorview has demonstrated a strong commitment to ensuring the overall safety and wellbeing of patients.

Beginning in March 2008, hospitals across Ontario participated in a comprehensive training program called Just Clean Your Hands. Since that time, trained observers in hospital settings have been conducting hand hygiene audits (using a provincial audit tool) and recording what they see. With specific sample sizes based on hospital size, hospitals must then report their compliance rates to the MOHLTC.

The collection and public reporting of these rates will allow hospitals to establish a baseline from which to track their hand hygiene improvement over time. Hospitals will use this information to identify areas for improvement and strategies for reducing the incidence of healthcare-associated infections

Surveillance at Holland Blooorview

Hand Hygiene rates for April 1 2010-March 31, 2011

• The percentage compliant for before initial patient/environment contact (moment #1) is 87.47%. This meets our target of 80%.
• The percentage compliant for after patient/environment contact (moment #4) is 86%

For comparison purposes, rates for April 1, 2009- March 31, 2010 are as follows:

• The percentage compliant for before initial patient/environment contact (moment #1) =58.51%
• The percentage compliant for after patient/environment contact (moment #4) = 76.13%

2009-10:

% compliance Hand Hygiene before initial patient/patient environment contact	58.51%
% compliance after patient/patient environment contact	76.13%

Baseline Hand Hygiene Rates

The method of calculation of the hand hygiene compliance rate for the reporting period (on an annual basis) is:

# of times hand hygiene performed                     X 100
# of observed hand hygiene indications

Hand Hygiene compliance rates will be reported annually.  Hospitals are to collect at least 200 observations for every 100 inpatient beds.

To ensure statistically valid data for smaller hospitals, or hospitals with fewer inpatient beds like Holland Bloorview, a minimum of 50 observed opportunities for hand hygiene needed to be collected.

The goal of public 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.

FAQs for clients and families:

Public Reporting on Hand Hygiene Compliance

To view hand hygiene compliance rates for all Ontario hospitals please visit: www.ontario.ca/patientsafety

 

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