Other Healthcare Associated Infections Measures

Related Measures

Improvement Stories

Hand Hygiene: Cleaner Hands, Safer Patients

Hand Hygiene

What are we measuring and why?

MGH monitors compliance by healthcare workers with the current hand hygiene guidelines, which were established by the Centers for Disease Control in 2002 and incorporated into MGH Infection Control policies.

Hand hygiene is the single most important action that a health care worker can take to stop the spread of pathogens (germs that can cause disease) and reduce the risk of healthcare associated infections. Improved hand hygiene compliance has been shown to reduce infections. All MGH physicians, nurses, other staff and volunteers are expected to use Cal Stat, an alcohol-based handrub, both before and after contact with a patient or a patient’s environment. Handwashing with soap and water, followed by the use of Cal Stat, is also indicated in some circumstances.

How are we doing and how do we compare to best practices?

Starting in 2009, MGH hand hygiene compliance rates had been more than 90 percent both before and after patient contact for ten consecutive quarters. We continued to pursue this goal throughout 2015. The Joint Commission benchmark for hand hygiene performance is 90 percent both before and after patient contact.

  • Current Scores
  • Scores Over Time
94% 92%

MGH Source: Surveillance on units.
Comparison Group Source: Joint Commission compliance expectation.

Oct-Dec 15 data.

93% 94% 94% 94% 96% 94% 94% 94% 95% 94% 96% 91% 93% 96% 96% 96% 96% 94% 94% 96% 95% 94% 95% 95% 93% 97% 94% 94% 85% 88% 89% 90% 91% 92% 92% 89% 88% 92% 91% 88% 90% 93% 92% 93% 92% 91% 91% 93% 92% 93% 90% 94% 89% 93% 91% 93%

MGH Source: Surveillance on units.
Comparison Group Source: Joint Commission compliance expectation.

What are we doing to improve?

The MGH Hand Hygiene Program was first organized in 2000 and it continues to grow through the efforts of the Infection Control Unit and the multidisciplinary STOP* Task Force. It provides education, ensures product availability, conducts surveys, provides feedback, enlists local Champions, promotes awareness through posters and publicity, sets goals, features rewards and special incentives, encourages patient and visitor involvement, receives strong leadership support, seeks to expand, and fosters cultural change. In 2007, a modest hospital-wide bonus was awarded when the hospital had achieved TJC targets. Our challenge now is to sustain those gains and push on to achieve an even higher level of compliance.

* STOP = Stop the Transmission of Pathogens

Learn more about our hand hygiene improvement initiative.

What can you do?

Patients and their families should:

  • Be aware that germs can be spread on the hands of health care workers and other people, and know that good hand hygiene can reduce your risk of infection.
  • Know that all health care workers are expected to use hand hygiene before they touch you or your environment – and afterwards, too.
  • Ask your health care workers if they cleaned their hands as they approach you – or ask them to use hand hygiene again where you can see it done. (Don’t be shy… We all know that it’s an important question!)
  • If your health care workers wear gloves, expect that a clean set will be used for each and every patient – and know that hand hygiene must still be used regardless of glove use.
  • Ask your visitors to use hand hygiene “before” and “after” contact, too.
  • Learn about good handwashing techniques for use at home or anywhere.
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To learn more about hand hygiene expectations in health care settings, visit the CDC Hand Hygiene website: http://www.cdc.gov/handhygiene/


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