Hand Hygiene Compliance

At LHSC we measure staff performance for hand hygiene through directly observed audits. The audits are completed by trained staff using the Public Health Ontario hand hygiene audit tool with their “Just Clean Your Hands Program”. 

Hand Hygiene compliance rates are reported every year, and calculated based on when staff perform hand hygiene compared to the amount of times hand hygiene should be performed. 

The four moments of hand hygiene are: 

  1. Before initial patient/patient environment contact;
  2. Before aseptic procedure (such as inserting an IV or catheter);
  3. After body fluid exposure risk; and
  4. After patient/patient environment contact.

The Ministry of Health and Long-Term Care has mandated that moments one and four be reported, as these are the most important in preventing the spread of infections in hospitals.

Rates

Fiscal 2022-2023

University Hospital
  • Moment #1 - Before initial patient/patient environment contact
    • Number of times hand hygiene performed - 5844
    • Compliance rate - 89.77 per cent
  • Moment #4 - After patient/patient environment contact
    • Number of times hand hygiene performed - 5977
    • Compliance rate - 95.10 per cent
Victoria Hospital
  • Moment #1 - Before initial patient/patient environment contact
    • Number of times hand hygiene performed - 7710
    • Compliance rate - 95.10 per cent
  • Moment #4 - After patient/patient environment contact
    • Number of times hand hygiene performed - 7773
    • Compliance rate - 96.60 per cent

Fiscal 2021-2022

University Hospital
  • Moment #1 - Before initial patient/patient environment contact
    • Number of times hand hygiene performed - 7301
    • Compliance rate - 92.11 per cent
  • Moment #4 - After patient/patient environment contact
    • Number of times hand hygiene performed - 7604
    • Compliance rate - 95.83 per cent
Victoria Hospital
  • Moment #1 - Before initial patient/patient environment contact
    • Number of times hand hygiene performed - 9308
    • Compliance rate - 95.48 per cent
  • Moment #4 - After patient/patient environment contact
    • Number of times hand hygiene performed - 9232
    • Compliance rate - 96.73 per cent