Hand Hygiene Compliance Reporting

The dedicated health professionals who work at Runnymede Healthcare Centre are committed to providing the best possible care for our patients and the community. Our hospital supports any initiative that will enhance patient safety, improve performance and strengthen the public’s confidence in Ontario’s hospitals.

Patients can be assured that Runnymede Healthcare Centre is a safe environment that delivers leading specialized complex continuing care.

What is hand hygiene?

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

What is the definition of hand hygiene compliance?

Four indications define proper hand hygiene compliance:

1.  Before initial patient/patient environment contact
2.  Before aseptic procedure, that is to say a procedure free of microbiological organisms
3.  After body fluid exposure risk
4.  After patient/patient environment contact

What are the elements of Runnymede Healthcare Centre’s hand hygiene program?

Runnymede Healthcare Centre has a long-standing and effective hand hygiene program. The program takes a multi-faceted approach and includes:

• Environmental changes and system supports – like alcohol-based hand rub easily accessible at points of care. This makes it easy for health care providers to clean their hands
• Education for health care providers about when and how to clean their hands
• Runnymede Healthcare Centre’s senior management are committed to patient safety and in so doing make programs like the Hospital’s Hand Hygiene Program a priority for the organization
• Patient engagement
• Opinion leaders and champions continually model right behaviours
• On-going monitoring and observation of hand hygiene practices, with feedback to health care providers

What is the difference between “moment, indication and opportunity”?

“Moment” and “indication” may be used interchangeably and refer to the four times when hand hygiene is essential (i.e. before patient/patient environment contact, after aseptic procedure, after body fluid exposure risk, and after patient/patient environment contact).

A “moment’ is often used for teaching or for use on public materials such as posters and brochures.

An “indication” is always used when discussing audits; it is the reason why hand hygiene is necessary at a given moment.

An “opportunity” is the need for hand hygiene; there may be single or multiple indications. Hand hygiene must correspond to each opportunity. Multiple indications may come together to create a single opportunity. For audit purposes, the opportunity block is used to record single or multiple indications that provide a single opportunity for hand hygiene.

Why would the public be interested in reporting on hand hygiene compliance?

The single most common transmission of health care-associated infections (HAIs) in a health care setting like a hospital is via transiently hands of health care workers. Monitoring hand hygiene practices and the provision of timely feedback are vital to improving compliance and in turn reducing HAIs. Runnymede Healthcare Centre is committed to ensuring the very safest environment for our patients, visitors and staff.

What will Runnymede Healthcare Centre publicly report regarding hand hygiene?

Beginning April 30, 2009 every hospital in Ontario is required to submit compliance data to the Ministry of Health and Long-Term Care (MoHLTC) on all four indications for hand hygiene which the Ministry posts regularly on its website at www.ontario.ca/patientsafety. In addition to the Ministry reports and publications, Runnymede Healthcare Centre will post information that includes the percent compliance rates for each period end date for:

1.  hand hygiene before initial patient/patient environment contact by combined health care provider type
2.  hand hygiene after patient/patient environment contact by combined health care provider type

How are hand hygiene compliance rates calculated?

Reporting methods for hand hygiene compliance rates have been standardized. Along with all hospitals in the Province of Ontario, Runnymede Healthcare Centre will calculate the percent compliance for each of the four indications of hand hygiene as follows:

(Number of times hand hygiene performed before initial patient/patient environment contact) / (Number of observed hand hygiene indications for before initial patient/patient environment contact) x 100

(Number of times hand hygiene performed before aseptic procedure) / (Number of observed hand hygiene indications for before aseptic procedure) x 100

(Number of times hand hygiene performed after body fluid exposure risk) / (Number of observed hand hygiene indications for after body fluid exposure risk) x100

(Number of times hand hygiene performed after patient/patient environment contact) / (Numbers of observed hand hygiene indications for after patient/patient environment contact) x 100

Runnymede Healthcare Centre Hand Hygiene Compliance Percentage (Apr 2010 – Mar 2011)

• Percent Compliance for before initial patient/patient environment contact: 68.34% 
• Percent Compliance for after patient/patient environment contact: 80.41%