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.