Standardization of an Ambulatory Hand Hygiene Observation Program

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      Hand hygiene (HH) is the single most important infection prevention practice to prevent the transmission of organisms to patients and employees in a healthcare setting. Hand hygiene compliance monitoring in our diverse pediatric ambulatory network has occurred since 2011 via staff observation or family feedback forms. A review of HH data collected in 2018 for 97 ambulatory locations raised concerns about data integrity and reliability.


      In partnership with ambulatory network leaders, sixteen (16) locations were selected for targeted observations of the data collection process due to data integrity concerns including: data saturation due to over submission of observation data, consistent high compliance of sites, consistent low compliance of sites, failure to submit data, and incorrect submission of HH moments. Our HH program manager visited each site to interview and observe staff responsible for onsite HH monitoring.


      Each of the 16 locations had variable data collection processes. Targeted observations identified errors in the data submission process, an incomplete understanding of the number of observations to be performed, and inconsistencies in defining HH breaches. Qualitative interviews with staff elicited lack of formal training on how to observe, collect, and enter data. Staff also expressed discomfort providing feedback when HH breaches/misses are observed.
      A standard operating procedure (SOP) was developed to address inconsistency in knowledge and practice. Issues with submission and compliance inconsistencies were addressed through mistake proofing the database where collected HH data are submitted.


      Comprehensive rounding of HH data collection across a diverse pediatric ambulatory network revealed need for standardized education and data collection methods and tools for ambulatory hand hygiene observers. Consistent communication and continued interfacing with staff and leadership has increased the capability of the collection of reliable HH data across a variety of ambulatory practice settings.
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