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HH_4_Percent Availability of Hand Hygiene Products

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					                                   HH 4 - Hand Hygiene Product Bundle Compliance - Overall
                     100%


                     90%


                     80%


                     70%


                     60%
Percent COMPLIANCE




                     50%


                     40%


                     30%


                     20%


                     10%


                      0%
                            Nov     Feb   May    Aug    Nov     Feb   May    Aug       Nov      Feb   May    Aug    Nov     Feb   May    Aug    Nov
                            2007   2008   2008   2008   2008   2009   2009   2009      2009    2010   2010   2010   2010   2011   2011   2011   2011

                                                                                      Month

                                                                             Actual           Goal
                                                       HH 4 - Individual Hand Hygiene Product Bundle Element Compliance
                                   100%

                                   90%

                                   80%
% Compliance by Individual Group




                                   70%

                                   60%

                                   50%

                                   40%

                                   30%

                                   20%

                                   10%

                                    0%
                                      Nov     Feb       May          Aug           Nov           Feb          May          Aug           Nov           Feb         May           Aug          Nov            Feb         May           Aug            Nov
                                      2007   2008       2008         2008          2008         2009          2009         2009          2009         2010         2010          2010         2010          2011         2011          2011           2011
                                                                                                                                      Month

                                                    Compliance Calculation for Bundle Element #1 - Alcohol-Based Hand Rub was: Easily visible, and accessible (optimal height and within easy reach of the point of interaction). (#4.4/#4.1 X 100)



                                                    Compliance Calculation for Bundle Element #2 - Alcohol-Based Rub was: Easy to mechanically activate with adequate volume of product in the dispenser. (#4.5/#4.1 X 100)
HH 4 - Percent Availability of Hand Hygiene Products at Bed Spaces or Patient Areas being Monitored - Bundle Compliance -
Measurement Worksheet
Intervention: Hand Hygiene (HH)
Definition       The percentage of bed spaces or patient areas being monitored at which the Alcohol-Based Hand Rub (ABHR) Dispenser (liquid or foam) is
                 (1) Easily visible, and accessible (optimal height, within easy reach of the point of interaction) AND; (2) Easy to mechanically activate with
                 adequate volume of product in the dispenser at the point of care. These numbered items represent the TWO elements of the Hand Hygiene
                 Product Bundle. In this measure compliance with the individual elements and overall bundle will be monitored through a regular audit
                 process. These bundle measures should be monitored on the same units where appropriate Hand Hygiene technique is also being
                 monitored. Direct observations should be made randomly throughout the month on different shifts.
Goal             95% of all patient areas will meet the two standards for Alcohol-Based Hand Hygiene Products Bundle.                                                                 Acute Specialist (ie., Cancer Centre, Pediatric)
Data Collection Details                                                                                                                                                               Acute Teaching
Hospital Name                                                                                                                           Team #                           Concurent
                                                                                                                                                                  Baseline            Large Acute (> 300)
                                                                                                                                        Hospital
Health Region
                                                                                                                                        Type                      Early               Medium Acute (50 – 300)
Patient Sample Describe the source of the patient population e.g., Intensive Care Unit, General Medicine Unit, Healthcare Facility etc.                           Full                Small Acute (< 50 beds)
                                                                                                                                                                                      None of the above

                                                                              2007                                      2008                                                                            2009
                                                                            Nov   Dec   Jan   Feb   Mar   Apr   May   Jun   Jul   Aug   Sep   Oct   Nov    Dec     Jan    Feb   Mar    Apr    May    Jun     Jul    Aug    Sep
       Implementation Stage

       Collection Method

Calculation of Denominator
  4.1 What is the total number of observations of Hand
      Hygiene Products within bed spaces, patient areas,
      or at points of care included in this monthly sample?
       e.g. recommended 10 -2 0 random obervations of a variety of
       points of care. A " Point of Care " is where the following 3
       elements are present at the same time: (1) Patient; (2) Healthcare
       Provider; (3) Care involving patient contact.

Implementation of Bundle Components
Calculation of Numerator
  4.2 What is the total number of observations of Hand
      Hygiene Products within bed spaces, patient areas,
      or at points of care in # 4.1 at which BOTH of the
      following elements were in place at the time of the
      audit? Hand Hygiene Products Bundle Elements:
      Alcohol-Based Rub (liquid or foam) Dispenser is
      (1) Easily visible, and accessible (optimal height,
      within easy reach of the point of interaction and
      additional supplies of product are readily available)
      AND,
      (2) Easy to mechanically activate with adequate
      volume of product in the dispenser.
Final Calculation
   4.3 Overall compliance with the Hand Hygiene Bundle
                                                                            #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### ####
       Elements. Divide # 4.2 by # 4.1. Multiply by 100.
       GOAL:                                                                95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%    95%    95%     95%   95%   95%     95%    95%     95%    95%    95%
Numerator for Individual Bundle Element Compliance
   4.4 What is the total number of observations of Hand
       Hygiene Products within bed spaces, patient areas,
       or at points of care # 4.1 that were in compliance with
       Bundle Element #1 - Alcohol-Based Hand Rub was:
       Easily visible, and accessible (optimal height, and
       within easy reach of the point of interaction)?
   4.5 What is the total number of observations of Hand
       Hygiene Products within bed spaces, patient areas,
       or at points of care # 4.1 that were in compliance with
       Bundle Element #2 - Alcohol-Based Hand Rub was:
       Easy to mechanically activate with adequate volume
       of product in the dispenser?
Individual Bundle Element Compliance Calculation
   4.6 Compliance Calculation for Bundle Element #1 -
       Alcohol-Based Hand Rub was: Easily visible, and
                                                                            #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### ####
       accessible (optimal height and within easy reach of
       the point of interaction). (#4.4/#4.1 X 100)
  4.7 Compliance Calculation for Bundle Element #2 -
      Alcohol-Based Rub was: Easy to mechanically
                                                                            #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### ####
      activate with adequate volume of product in the
      dispenser. (#4.5/#4.1 X 100)
      Comments
(ie., Cancer Centre, Pediatric)




 2009                                                                         2010                                                                    2011
                            Oct   Nov   Dec   Jan   Feb   Mar   Apr   May   Jun   Jul   Aug   Sep   Oct   Nov   Dec   Jan   Feb   Mar   Apr   May   Jun   Jul   Aug   Sep   Oct   Nov   Dec




                           #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### ####
                            95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%   95%




                           #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### ####




                           #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### #### ####
Data Year Data Month   Completed By   Email   Phone Number

 2007        Nov
             Dec

 2008        Jan
             Feb
             Mar
             Apr
             May
             Jun
             Jul
             Aug
            Sept
             Oct
             Nov
             Dec

 2009        Jan
             Feb
             Mar
             Apr
             May
             Jun
             Jul
             Aug
            Sept
             Oct
             Nov
             Dec

 2010        Jan
             Feb
             Mar
             Apr
             May
             Jun
             Jul
             Aug
       Sept
       Oct
       Nov
       Dec

2011   Jan
       Feb
       Mar
       Apr
       May
       Jun
       Jul
       Aug
       Sept
       Oct
       Nov
       Dec
Date of Submission (dd/mm/yyyy)

				
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posted:10/12/2011
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