Hand hygiene compliance

As part of the Ministry of Health and Long-Term Care’s (MOHLTC) public reporting of patient safety indicators initiative, Holland Bloorview Kids Rehabilitation Hospital has been tracking hand hygiene compliance rates among our health care professionals.

Research shows that hand hygiene is the single most effective way to reduce the risk of healthcare-associated infections, and Holland Bloorview has demonstrated a strong commitment to ensuring the overall safety and wellbeing of patients.

Beginning in March 2008, hospitals across Ontario participated in a comprehensive training program called Just Clean Your Hands. Since that time, trained observers in hospital settings have been conducting hand hygiene audits (using a provincial audit tool) and recording what they see. With specific sample sizes based on hospital size, hospitals must then report their compliance rates to the MOHLTC.

The collection and public reporting of these rates will allow hospitals to establish a baseline from which to track their hand hygiene improvement over time. Hospitals will use this information to identify areas for improvement and strategies for reducing the incidence of healthcare-associated infections.

Surveillance at Holland Blooorview

Baseline hand hygiene rates 
% compliance Hand Hygiene before initial patient /patient environment contact
% compliance before aseptic procedure
% compliance for after body fluid exposure risk
% compliance after patient /patient environment contact 81.52%

The method of calculation of the hand hygiene compliance rate for the reporting period (on an annual basis) is:

# of times hand hygiene performed                     X 100
# of observed hand hygiene indications

Hand hygiene compliance rates will be reported annually. Hospitals are to collect at least 200 observations for every 100 inpatient beds.

To ensure statistically valid data for smaller hospitals, or hospitals with fewer inpatient beds like Holland Bloorview, a minimum of 50 observed opportunities for hand hygiene needed 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.

April 1, 2017 to March 31, 2018

April 1, 2016 to March 31, 2017

April 1, 2015 to March 31, 2016

April 1, 2014 to March 31, 2015

April 1, 2013 to March 31, 2014

April 1, 2012 to March 31, 2013

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