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Hand Hygiene - Monitoring

What are the changes regarding hand hygiene requirements beginning in 2018 ?

Any examples are for illustrative purposes only.

Effective January 1, 2018, for all accreditation programs: 
Any observation by surveyors of individual failure to perform hand hygiene in the process of direct patient care will be cited as a deficiency resulting in a Requirement for Improvement (RFI) under Infection Prevention and Control (IC) Standard IC.02.01.01, EP 2: "The [organization] uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection." Surveyors also will continue surveying an organization's hand hygiene program to National Patient Safety Goal NPSG.07.01.01. (see also the December 2017 issue of the Perspectives Newsletter).

It is a good idea to think of NPSG.07.01.01 EPs 2 and 3 as a basic outline for a required performance improvement project. EP 2 requires each accredited organization formulate a goal for hand hygiene, and EP 3 requires organizations to improve compliance based on the goal set in EP 2. Each organization should customize its goals and improvement efforts to meet its unique needs. Please note that there is no specific requirement as to how measurement must occur other than it must occur according to CDC or WHO guidelines.

Measurement: Organizations must perform an accurate baseline assessment of hand hygiene in order to identify opportunities for improvement. Please note that participants in the Center for Transforming Healthcare Hand Hygiene Project found that their actual hand hygiene rates were significantly lower than they had previously estimated. For more information, visit the Center for Transforming Healthcare Web site. In particular, please view page four of the storyboard presentation. The Joint Commission recognizes that hand hygiene measurement is a challenge. In an effort to provide assistance, we have co-authored a monograph on this topic along with several other infection prevention leadership organizations:  "Measuring Hand Hygiene Adherence: Overcoming the Challenges".

Goal Formation: After establishing an accurate baseline, each accredited organization must formulate a goal for improvement. The Joint Commission previously required that each organization have a hand hygiene goal of at least 90%; that requirement is no longer in place. Rather, each organization must formulate a goal to improve over past performance.

Improving compliance: After measurement and goal formation, interventions to achieve improvement must be implemented. Per EP 1, these interventions must be designed utilizing either CDC or WHO guidelines. If the goal is not met, interventions should be redesigned based on an analysis of causative factors. If the goal is met, it should be adjusted to foster higher levels of compliance.
Last updated on April 29, 2021
Manual: Hospital and Hospital Clinics
Chapter: National Patient Safety Goals NPSG

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