Other Healthcare Associated Infections Measures

Improvement Stories

Hand Hygiene: Cleaner Hands, Safer Patients

Hand Hygiene

What are we measuring and why?

Practicing safe hand hygiene is the single most important action that healthcare workers can take to stop the spread of pathogens (germs that can cause disease) and reduce the risk of healthcare associated infections. MGH monitors adherence with national hand hygiene guidelines established by the Centers for Disease Control and Prevention (CDC). These standards were incorporated into MGH Infection Control policies in 2002. All physicians, nurses, and other MGH staff/volunteers are required to use Cal Stat, an alcohol-based hand rub, both before and after contact with a patient or the 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 practice?

The Joint Commission's target for hand hygiene compliance is 90% both before and after patient contact. MGH's hand hygiene rates often exceed this goal.

  • Current Scores
  • Scores Over Time
95% 86%

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

Jul - Sep 2018 data

97% 96% 95% 95% 97% 95% 95% 95% 88% 87% 86% 89% 87% 90% 88% 87%

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

What are we doing to improve?

The MGH Hand Hygiene Program launched in 2000 and continues to grow today through the efforts of the Infection Control Unit and multidisciplinary STOP* Task Force. It sets goals, provides education to spread awareness and foster culture change, conducts surveys and issues feedback, ensures product availability, and engages patients and visitors in improvement. This work is reinforced by strong leadership and local champion support. In 2007, a modest hospital-wide bonus was awarded when MGH first achieved the TJC targets. Our challenge now is to sustain those gains and pursue even higher levels 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 healthcare workers and other people, and know that good hand hygiene can reduce the risk of infection.
  • Know that all healthcare workers are expected to follow standard hand hygiene procedures before they touch you or your environment – and afterwards, too.
  • Ask your healthcare team if they have cleaned their hands as they approach you – or ask them to perform hand hygiene again where you can see it done. Don’t be shy… We all know that it’s an important question!
  • If your caregivers wear gloves, expect that a clean set will be used for each and every patient – and know that hand hygiene must still be performed 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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