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Hand Hygiene - Key Components of a Compliant Hand Hygiene Program

What is required to have a compliant hand hygiene program?

Any examples are for illustrative purposes only.

For all healthcare programs to be fully compliant with NPSG.07.01.01 and standard precautions, organizations must implement a hand hygiene program that follows categories IA, IB, and IC of either the current Centers for Disease Control and Prevention (CDC) and/ or the current World Health Organization (WHO) hand hygiene guidelines, set goals for improving compliance with hand hygiene guidelines and improve compliance with hand hygiene guidelines based on established goals.

When developing infection prevention and control activities, including the hand hygiene program, the organization must follow the hierarchical approach to infection control standards. This includes following local, state and federal regulations which includes following OSHA Bloodborne Pathogen Standards, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation or Conditions for Coverage if deemed, and ensure that the manufacturer's instructions for use of hand hygiene products or supplies are followed. You may also choose to evaluate current evidence-based guidance and new products for incorporation into your hand hygiene program

Goal Setting
Organizations must set goals for improving compliance with hand hygiene guidelines.

The healthcare organization determines how the goal for improving hand hygiene compliance will be described.  The goal may be a narrative description of activities or a numeric value, such as percent compliance.

The Joint Commission does not determine the goals or the scope of the goal. It should be based on the organization's risk assessment, organizational priorities, resources, etc.  There is no specific numerical target for this goal (e.g., 85%, 90%, 95% compliance) and no requirement for "organization-wide surveillance".

Goals for improving compliance with hand hygiene guidelines do not have to be confined solely to outcome metrics, but may include process measures for specific tasks or opportunities for hand hygiene, or may target metrics for specific areas or opportunities identified during your organization's risk assessment.

Hand hygiene goals must be documented.  The organization determines where the hand hygiene goal(s) will be documented. Some organizations choose to include hand hygiene goals in the organization's overall performance improvement plan and then include sub-goals at the department level while others choose to place the goal(s) in the Infection Control Plan.

Examples of goals for improving hand hygiene guideline compliance may include (these are examples only: organizations may choose their specific goals based on their needs):
  • Increase overall hand hygiene compliance in all inpatient units by at least 10% or maintain hand hygiene compliance rate of at least 80% by the end of the calendar year, whether through electronic and/or manual surveillance (NOTE: The Joint Commission does not require organization-wide hand hygiene surveillance and does not require capture of all hand hygiene opportunities).  
  • By the end of the fiscal year, improve compliance with hand hygiene prior to entering home care bag after touching the patient or their environment by 15%.
  • By the end of the calendar year, increase compliance with hand hygiene upon leaving the work bench in the laboratory by 5%.
  • Improve compliance with hand hygiene for entry/exit into the operating rooms 15% by the end of the year.
  • Improve compliance with correct use of alcohol based surgical scrub.
  • Improve compliance with organizational artificial nail policy in the operating room during FY21.
  • Increase availability of hand lotion in patient care areas by auditing to ensure product is available and not expired. 
Program development
Local, state or federal law and regulations may require your organization to follow a specific evidence based guideline, or may require specific elements of hand hygiene to be followed, so ensure you review all law and regulations when developing your hand hygiene program.
In addition to regulations, The Joint Commission expects organizations to use CDC and/or WHO evidence-based hand hygiene guidance, or other evidence based national guidelines or, in the absence of such guidelines, expert consensus to develop infection prevention and control activities.  
Program implementation
Organizations must ensure that the activities and interventions identified in the hand hygiene program have been implemented and are being performed by health care staff.  

When developing hand hygiene activities, keep in mind that monitoring is a general term that refers to active or passive observations of activities while surveillance is the method of collecting, consolidating, and analyzing data.  You should determine which activities require surveillance, so adequate data can be collected to support your goals and evaluate outcomes.

Implementation of the hand hygiene program is dependent on several important factors:
The organization provides supplies to support the infection prevention and control program.  Examples may include:
  • Alcohol based hand sanitizer available and accessible in all areas where patient care is performed as per standard precautions.
  • Ensure that placement of alcohol based hand sanitizer meets building code requirements. 
  • Soap and water or an OSHA approved alternative process are provided in a location where temporary healthcare services are provided and contact with blood or bodily fluids is anticipated.
Health care staff perform hand hygiene and observe other hand hygiene guidelines as per the organization's hand hygiene program. Examples may include:
  • Hand hygiene monitoring and feedback on non-compliant hand hygiene opportunities is provided in real time (note: there is no requirement for data collection for all opportunities).
  • All healthcare workers perform hand hygiene prior to touching a patient.
  • All healthcare workers follow manufacturer's instructions for use when using surgical scrub products.
  • Healthcare workers in the sterile compounding pharmacy perform hand hygiene as specified in USP 797.
Program evaluation
 IC.03.01.01 requires organizations to evaluate the effectiveness of their infection prevention and control plan's goals.  Though The Joint Commission does not prescribe how the organization should evaluate the hand hygiene goals that were set, your organization should be able to provide evidence that data related to the identified hand hygiene goal was collected and analyzed in order to identify if compliance with hand hygiene guidelines had improved over time.  Additionally, the evaluation of the infection prevention and control goals, including the hand hygiene goals, must be communicated to key stakeholders, and should be used when revising the infection control risk assessment or plan when required.  

Additional Resources
Centers for Disease Control and Prevention Guideline for Hand Hygiene in Healthcare Settings
World Health Organization WHO guidelines on hand hygiene in health care

See also Perspectives®, April 2019, Volume 39, Issue 4 p. 15 for additional information on infection control policy requirements
Manual: Assisted Living Community
Chapter: National Patient Safety Goals NPSG
First published date: July 28, 2021 This Standards FAQ was first published on this date.
This page was last updated on November 15, 2021

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