HH_4_Percent Availability of Hand Hygiene Products by hedongchenchen

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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
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)
(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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