Why We Measure:
Hand Hygiene, or keeping our hands clean, is the best way to prevent all kinds of hospital infections. Hands can be cleaned either by using an alcohol-based hand sanitizer, such as Endure® or by washing with soap and water. We require all of our staff to clean their hands upon entering and leaving a patient’s room, even if they don’t touch anything. They should do the same any time they take care of a patient if they are not in their own hospital room. We also remind our patients and visitors to clean their hands often to help prevent the spread of infection. Clean hands protect everyone – patients, visitors, and staff.
What we measure:
The measure we use is "Percent of Hand Hygiene Compliance". To be marked as "compliant" hands must be cleaned both on entering and leaving the patient’s room. If both parts cannot be confirmed, or if the observer can’t be sure, it is not counted as an observation. We look for a goal of over 90% compliance, meaning that better than nine out of ten individuals seen going into a patient room cleaned their hands entering and leaving.
How we measure:
We have specially trained observers who spend time on a daily basis watching all employees who enter or leave patients’ rooms. This includes not just doctors and nurses but respiratory therapists, transportation personnel, and environmental services. Observations are counted up by the time of day, the unit within the hospital, the type of healthcare worker. The names of non-compliant individuals are recorded. They will need to have a discussion with either the Chief Medical Officer or the Chief Nursing Officer (or their delegate).
How are we doing?
We experienced a major improvement in November when we began a major hospital wide campaign to get everyone into the habit of washing their hands each and every time they enter or leave a room. The centerpiece of the campaign was a hospital wide, military style, Stand Down held twice on a single day for 15 minutes where non-essential patient care was suspended and entire units and departments concentrated on how to achieve near 100% hand hygiene compliance. Ideas were discussed and plans were made.
We continue to monitor all units and departments, so that if we fall below 90% we will know where we have problems in which group of employees so that we can take corrective action.