INDICATOR NAME
Name
Hand hygiene compliance among health care providers
Alternate Name
Hand hygiene compliance among health care providers before and after patient or patient environment contact
INDICATOR DESCRIPTION
Description
This indicator measures the percentage of hand hygiene compliance by health care providers before and after initial patient or patient environment contact.
Indicator Status
Active
HQO Reporting tool/product
Public reporting
Dimension
Safe
Type
Process
DEFINITION AND SOURCE INFORMATION
Unit of Measurement
Percentage
Calculation Methods
Numerator divided by denominator times 100
Numerator including inclusion/exclusion
Number of times hand hygiene performed before initial patient or patient environment contact
Number of times hand hygiene performed after initial patient or patient environment contact
Inclusion:1. All publicly funded hospitals
2. Inpatient settings
Denominator including inclusion/exclusion
Number of observed hand hygiene indications before initial patient or patient environment contact
Number of observed hand hygiene indications after initial patient or patient environment contact
Inclusion:
1. All publicly funded hospitals
2. Inpatient settings
Adjustment (risk, age/sex standardization)- detailed
None
Data Source
Self-Reporting Initiative (SRI)
Data provided to HQO by
Ministry of Health and Long-Term Care (MOHLTC)
Reported Levels of comparability /stratifications (defined)
Institution, Province, Time
RESULT UPDATES
Indicator Results
OTHER RELEVANT INFORMATION
Caveats and Limitations
1. Data are self-reported by hospitals.
2. The number of observation sessions required will depend on the number of in patient beds. For example, to ensure statistically valid data, a hospital with 100 beds will observe at least 200 opportunities. The minimum number of observed opportunities is 50 for any hospital with 25 beds or less.
3. Data are collected through direct observation using a validated tool from the Just Clean Your Hands program run by PHO. Observers are trained to identify the indications for hand hygiene occurring during practice and point of care.
4. Since observers only record what they see, certain hand hygiene opportunities will not be captured. For example, if a privacy curtain is drawn closed, the audit cannot be performed.
Comments Detailed
The definition of a hand hygiene indication is the reason why health care providers must clean their hands at a given moment. For example, a health care provider needs to clean their hands before entering the patient environment to prevent transferring microorganisms onto the patient. Another hand hygiene indication is the need for a health care provider to clean their hands after patient contact so that they do not spread contamination from one patient to another.
Self-Reporting Initiative (SRI) (fiscal year 2012/13 to present) and Web Enabled Reporting System (WERS) (fiscal year 2009/10 to 2011/12), Ministry of Health and Long-Term Care
TAGS
Sector
Acute Care/Hospital
Type
Process
Topic
Patient Safety and Never Events
Dimension
Safe
Source
Self-Reporting Initiative (SRI)
PUBLISH
Publish Datetime
19/10/2017 12:13:00
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