Percentage-hand-hygiene-compliance - Health Quality Ontario (HQO)

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.

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 (short description i.e. not inclusions/exclusions)

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

Denominator (short description i.e. not inclusions/exclusions)

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

Adjustment (risk, age/sex standardization)- generalized

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

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 Summary

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