Hand Hygiene Compliance Audits

Hand hygiene is an important practice for health care providers and has a significant impact on reducing the spread of infections in hospitals. Hand hygiene is a different way of thinking about safety and patient care and involves everyone in the hospital, including patients and health care providers.

Effective hand hygiene practices in hospitals play a key role in improving patient and provider safety, and in preventing the spread of infections.

To be clear, health care providers are washing their hands, and it is a practice that continues to improve as we learn more about hand hygiene best practices.

Both hospitals and the government have done considerable amounts of work to improve the access and process challenges that once made hand washing in hospitals less expedient. For example, where sinks used to be located inconveniently throughout hospitals, there is now fast and easy access to alcohol-based hand rubs at patients’ bedsides. The MOHLTC’s provincial hand hygiene campaign, Just Clean Your Hands, which all Ontario hospitals have participated in, was designed in a way that helps hospitals and individuals overcome barriers to proper hand hygiene and to improve compliance with hand hygiene best practices.

Commencing April 30th, 2009, hospitals will be required to report hand hygiene compliance rates of Ministry of Health and Long-Term Care. A provincial audit tool has been provided to hospitals as part of the Just Clean Your Hands program. This audit tool captures data on the four essential indicators for when hand hygiene should be performed. Compliance rates will be publicly reported on:

• Before Initial Patient/Patient Environment Contact
• After Patient/Patient Environment Contact

Hospitals will be required to submit data on the four indications for hand hygiene; however the MOHLTC will not publicly report data on “before aseptic procedures” and “after body fluid exposure risk” as it is difficult for some hospitals to obtain a large enough sample size for these indications.

Hospitals are required to post, by site, the percent compliance rates for before after patient/patient environment contact for each period end date on their corporate websites.

Auditors trained using the provincial audit tool and training program have been conducting direct observations of hand hygiene practices in hospitals using the audit tool.

Hand Hygiene is a key issue for our hospital and our hospital has mobilized resources to enhance patient and health care provider safety through improved hand hygiene within our organization. To date the following initiatives have been put in place to improve our hand hygiene compliance:

• A multidiscipline team including managers and staff attended the Ministry of Health two day training session on their Just Clean Your Hands Campaign.
• The Provincial Infectious Disease Advisory Committee on Hand Hygiene has been implemented.
• Staff education has been done with over four hundred staff attending the formal sessions. Our facility has also implemented the Ministry of Health Core Competencies educational program on Hand Hygiene through e-learning.
• More alcohol hand rub has been placed in patient care areas to make it more accessible for staff to clean their hands.
• Ongoing auditing to ensure compliance and provide ongoing education is in place.
• A number of measures have also been put in place to educate the public and our patients on importance of clean hands.

There are many factors that will lead to improved hand hygiene compliance and mandatory public reporting is one element. Certainly, increasing recent attention on the issue, as well as the MOHLTC’s multifaceted hand hygiene program, Just Clean Your Hands, has reinforced the importance of improving hand hygiene among health care professionals.