Monitoring Compliance monitoring Observational studies Volume of products used CMS puts a strong emphasis on direct observation An important part of implementing any new process is monitoring for adherence. The CDC guideline suggests several possible performance indicators related to hand hygiene practices. One is direct observation of hand hygiene. Since this is difficult for the IP to do without looking “suspicious,” some facilities use light-duty staff or students to do the observation. Another method would be to monitor the volume of products used. This would be an indirect way to measure adherence since theoretically, more product would be used if hand hygiene practices increased in volume. Whatever method is chosen, compliance must be monitored in order to meet the CMS’s National Patient Safety Goal related to reducing healthcare-acquired infections Centers for Disease Control and Prevention: Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/APIC/IDSA Hand Hygiene Task Force. MMWR Morb Mortal Wkly Rep 51, 2002. 1

Monitoring Hand Hygiene Provide several tools in the handbook Important points to cover: Monitor only what you can see – do not assume HH necessary before and after direct contact with patient or contaminated items If soap and water used, must be according to policy to count as “yes” Alcohol gel counts as “yes” for all May indicate what discipline is being monitored Share the data May be difficult due to curtain, physical obstruction, if a HCW uses soap/water Coach the employee whenever encountering a missed opportunity slide 1 2