Hand hygiene

Hand hygiene relates to the removal of visible soil and the removal or killing of transient microorganisms from the hands and may be accomplished using soap and running water or an alcohol-based hand rub.

Baycrest will post hand hygiene compliance rates as percentages for time periods identified by the Ministry of Health and Long-Term Care, using the following formula:

Number of times hand hygiene performed divided by the number of observed hand hygiene indications x 100.

These percentages also reflect:

  • hand hygiene before initial patient/patient environment contact by combined health care provider type (e.g., nurses, allied health professionals, physicians, etc.)
  • hand hygiene after patient/patient environment contact by combined health care provider type (e.g., nurses, allied health professionals, physicians, etc.)

Baycrest will collect at least 200 observations for every 100 in patient beds.

To ensure statistically valid data for smaller hospitals, or hospitals with fewer in-patient beds a minimum of 50 observed opportunities for hand hygiene will need to be collected.

The goal of public reporting hand hygiene compliance is to achieve an overall assessment of whether compliance rates are improving. It is normal for rates to vary from hospital to hospital.

Rate of hand hygiene compliance in the hospital:

Percent compliance before patient contact Percent compliance after patient contact
2013/14 81.84 87.04
2012/13 84.29 86.74
2011/12 79.17 83.67

Hand Hygiene Frequently Asked Questions

What is hand hygiene?

Hand hygiene relates to the removal of visible soil and the removal or killing of transient microorganisms from the hands and may be accomplished using soap and running water or an alcohol-based hand rub.


Why is hand hygiene so important?

Hand hygiene is an important practice for health care providers and has a significant impact on reducing the spread of infections in hospitals. Hand hygiene is a different way of thinking about safety and patient care and involves everyone in the hospital, including patients and health care providers.

Effective hand hygiene practices in hospitals play a key role in improving patient and provider safety, and in preventing the spread of health care-associated infections.


Why is hand hygiene compliance one of the publicly reported indicators?

The single most common transmission of health care-associated infections (HAIs) in a health care setting is via transiently colonized hands of health care workers who acquire it from contact with colonized or infected patients, or after handling contaminated material or equipment. Monitoring hand hygiene practices and the provision of timely feedback are vital to improving compliance and, in turn, reducing HAIs.


What are health care-associated infections?

Sometimes when patients are admitted to the hospital, they can get infections. These are called health care-associated infections.


How will the public reporting of hand hygiene compliance affect compliance among health care professionals?

There are many factors that will improve hand hygiene compliance. Mandatory public reporting is one element. Certainly the increasing recent attention on the issue as well as the provincial government’s multifaceted hand hygiene program called Just Clean Your Hands are important to ensuring effective hand hygiene at the right times.


What can patients do to help improve their own safety?

Hand hygiene involves everyone in the hospital, including patients. Hand cleaning is one of the best ways you and your health care team can prevent the spread of many infections. Patients and their visitors should also practice good hand hygiene before and after entering patient rooms.

More patient-specific information is available at www.ontario.ca/patientsafety and www.oha.com/patientsafetytips.


What will the health care system do with the rate information?

Like the public reporting of other indicators, monitoring hand hygiene compliance rate is about overall performance improvement. The information gathered will assist hospitals with evaluating the effectiveness of their infection prevention and control interventions and make further improvements based on this information.


Public reporting and rates

What will be publicly reported for Hand Hygiene?

Beginning April 30th 2009, hospitals are required to post, by site, the percent compliance rates for each period end date on their corporate websites. Hospitals will post the compliance rate for:

  • hand hygiene before initial patient/patient environment contact by combined health care provider type
  • hand hygiene after patient/patient environment contact by combined health care provider type

How are compliance rates calculated?

Baycrest will post hand hygiene compliance rates as percentages for time periods identified by the Ministry of Health and Long-Term Care, using the following formula:

# of times hand hygiene performed
—————————————-
x 100
# of observed hand hygiene indications

These percentages also reflect:

  • hand hygiene before initial patient/patient environment contact by combined health care provider type (e.g., nurses, allied health professionals, physicians, etc.)
  • hand hygiene after patient/patient environment contact by combined health care provider type (e.g., nurses, allied health professionals, physicians, etc.)

Baycrest will collect at least 200 observations for every 100 in patient beds.

To ensure statistically valid data for smaller hospitals, or hospitals with fewer in-patient beds a minimum of 50 observed opportunities for hand hygiene will need to be collected.

The goal of public reporting hand hygiene compliance is to achieve an overall assessment of whether compliance rates are improving. It is normal for rates to vary from hospital to hospital.


Where can I access this information?

The Ministry will also report the above data, by hospital site, on its website www.ontario.ca/patientsafety.


Baycrest specific information

How frequently will Baycrest have to publicly report on hand hygiene?

Baycrest will have to enter their data in WERS for Hand Hygiene on an annual basis.


Why is reporting annually and not quarterly?

For the purpose of public reporting, data will be reported to the Ministry through WERS on an annual basis as noted in the schedule above. The decision was made to report annually so that hospitals were able to submit enough data and that the compliance rate was statistically valid.