Hand Hygiene Compliance (Cleaning Hands)

Clean hands keep you healthy!

What is hand hygiene?

Hand hygiene is all about keeping our hands clean. All of our staff are required to wash their hands upon entering and exiting a room, and before and after providing care to any patient outside of a room.

Why do we measure?

  • Hand hygiene is the best way to prevent all kinds of hospital infections

  • Clean hands protect everyone - patients, visitors and staff.

How do we measure?

  • The measurement we use is percentage of hand hygiene compliance.

  • Specially trained observers spend time on a daily basis watching all employees who enter or leave patients' rooms.

  • Observations are calculated by time of day, hospital department and type of employee.

How are we doing?

  • In November 2010, a hospital-wide campaign to remind employees of the importance of hand hygiene led to a significant increase in compliance.

  • We regularly reach nearly 100% compliance.

  • If the percentage of hand hygiene compliance falls below 90% in any department, corrective action is taken.

Never hesitate to ask a staff member or visitor to wash their hands.

hand hygiene compliance chart quality measures

How Do I Read This Chart?

We report our data using what is known as a control chart. There are four elements on the chart. 1) The blue diamonds: these are the actual data points for each month. They depict the event rate as defined on the vertical axis. 2) and 3): The dotted red lines: these are the upper and lower control limits. They are scientifically calculated to represent the statistical range within which normal random variation occurs in a stable system. 4) The solid red line. This is the average of the blue diamonds for that time frame. As long as the blue diamonds are within the dotted red lines, the system being measured is a stable one. There are certain patterns of blue diamond configuration (e.g. diamonds outside the control limits), that mean something in the system has changed. This is called special cause variation and will usually involve a deeper investigation as to why the new pattern of variation. Each control chart contains an arrow which indicates the desired change direction. For most harm events, the desired direction is down (i.e. less harm is better). For other measures (compliance rates, days between harm events) the desired direction is up.