Hand Hygiene Compliance

Patient safety is a top priority for North York General and the dedicated health professionals who work in this hospital are committed to providing the best possible care to our patients and their families.

Good hand hygiene is the single most effective way to reduce the risk of health care-associated infections. While hand washing is something we all do, it is also something we want to continue to do better - at the right times and in the right way

Definition

Hand hygiene refers to the proper removal of visible dirt and the removal or killing of transient microorganisms from the hands. This can be done by using soap and running water or an alcohol-based hand rub. Good hand hygiene helps eliminate the transmission of these microorganisms.

Four indications define proper hand hygiene compliance in a health care setting:

  1. Before the initial patient or patient environment contact 
  2. Before an aseptic procedure 
  3. After a risk to body fluid exposure 
  4. After the patient/patient environment contact.

Under this definition, a health professional may need to practice hand hygiene up to four separate times during a single contact with a patient or patient environment

Transmission

The most common transmission of health care-associated infections (HAIs) in health care is on the hands of health care workers who acquire the microorganisms from contact with other colonized or infected patients, or after handling contaminated material or equipment. Learn more about hand hygiene on the Canadian Patient Safety Institute website. 

What we are doing to improve patient safety

North York General Hospital has undertaken many initiatives to provide patients with safer care including:

  • Developing a comprehensive system for screening and surveillance of high-risk patients for infectious syndromes (e.g. diarrhea, meningitis, etc.) and antibiotic-resistant organisms (methicillin-resistant staphylococcus aureus or MRSA, vancomycin-resistant enterococci or VRE, C. difficile, etc.)
  • Enhancing our Infection Prevention and Control Program
  • Actively implementing an aggressive hand washing campaign across the entire hospital to dramatically increase hand washing compliance rates
  • Engaging North York General Hospital staff in developing plans to respond to pandemic influenza

Frequently asked questions

What is hand hygiene?
Hand hygiene relates to the removal of visible dirt 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.

What is the definition of hand hygiene compliance?
Four indications define proper hand hygiene compliance:

  1. Before initial patient/patient environment contact
  2. Before an aseptic procedure
  3. After body fluid exposure risk
  4. After patient/patient environment contact.

What can patients do to help reduce their chances of infection?
Frequent hand cleaning is a good way to prevent the spread of infection. Hand hygiene involves everyone in the hospital, including patients. 

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. Learn more on the Canadian Patient Safety Institute website. 

What is publicly reported for hand hygiene? 
Beginning April 30, 2009, each hospital was required to submit compliance data to the Ministry of Health and Long-Term Care on all four indications for hand hygiene. Hospitals are required to post, by site, the percent compliance rates for two of the indicators for each period end date on their corporate websites. Hospitals post the compliance rate for:
(i) hand hygiene before initial patient/patient environment contact by combined health care provider type

(ii) hand hygiene after patient/patient environment contact by combined health care provider type

What determines the compliance rate?
The number of times that hand hygiene was performed for each of the four indications is divided by the number of observed hand hygiene indications for that specific indication, and the results are multiplied by 100.

This calculation represents the percentage compliance rate for hand hygiene for the reporting facility. For example, if hand hygiene was performed 60 times before initial patient/patient environment contact by all health care providers ÷100 observed hand hygiene indications for initial patient/patient environment contact for all health care providers, we would arrive at the following compliance rate = 0.60 x 100 = 60% compliance rate.

How often will hand hygiene compliance rates be reported?
Hand hygiene compliance rates are posted annually. 

How are the hand hygiene compliance rates calculated?
Hospitals calculate the percent compliance for each of the four indications of hand hygiene as follows:

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

# of times hand hygiene performed after patient/patient environment contact x 100
# observed hand hygiene indications for after patient/patient environment contact