ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
Compliance to Hand Hygiene Practice
2
Indicator Name:Compliance to Hand Hygiene Practice JANFEBMARAPRMAYJUNJULAUGSEPOCTNOVDEC
3
Numerator:Total No of action performed Numerator
4
Denominator:Total no of hand hygiene opportunities auditedDenominator
5
RationaleHand Hygiene Compliance will help in the prevention and management of the risk of HCAIs which is an essential part of maintaining patient safety and fundamental in any healthcare setting (World Health Organization (WHO), 2011.
To increase the awareness about the importance of Hand Hygiene.
To reduce the risk of HAI and enhance patient safety		Rate#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!
6
Inclusion CriteriaAll healthcare workers providing direct patient care
All observed and documented opportunities 		Target- 85%85%85%85%85%85%85%85%85%85%85%85%85%
7
Exclusion CriteriaNon clinical staff with no direct or indirect patient contact. Situations outside patient care areas
8
Indicator Owner: Infection control nurse
9
Selection criteria:√ High Risk √ High Volume √ IPSG √ Problem Prone □High Cost
10
□ Contract Monitoring □ Regulatory Requirement
11
□ Others: Accreditation requirement
12
Type of Indicator:□ Structure √ Process □ Outcome □ Process & Outcome
13
Frequency:√Monthly □ Quarterly □ Bi-Annual □ Annual
14
Department/ Unit
15
Frequency: Monthly
16
Sample Size: Minimum 60 samples/ day
17
Data collection method / Source Staff are directly observed using Hand hygiene observation tool as per five moments of hand hygiene
18
Data methodology:□ Retrospective √ Concurrent
19
Unit of MeasurementPercentage
20
Target:85%
21
Benchmark (If Applicable)
22
Data Analysis:
23
Common variations
24
25
Action plan:
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100