Halfway to 90/90

The September results are official: The MGH has achieved a hospitalwide rate of 90 percent compliance with hand hygiene before patient contact and 93 percent after contact. This accomplishment meets the minimum standard of 90 percent compliance before and after contact with the patient or patient's environment set by the MGH Hand Hygiene Quality Incentive Program, which links this year's employee bonus directly to the hospital's hand hygiene standards. It's important to note, however, that MGHers will need to achieve a 90/90 compliance rate for October in order for eligible employees to receive the bonus amount through the program. Five individual patient care units — White 6, White 11, Ellison 6, Phillips 21 and Gray/ Bigelow 7 — have also met another hand hygiene milestone, achieving the 90/90 goal for the entire third quarter.

The Hand Hygiene Quality Incentive Program employs the same rigorous procedure to measure compliance that has been used at the hospital since 2002. Through this process, staff from the MGH Infection Control Unit perform surveillance directly on the patient care units involved in the program. Units are surveyed six times per month on a schedule that includes days, evenings and weekends to obtain a fair sampling. During each 15-minute observation period, the Infection Control staff member moves throughout the floor, monitoring how individual staff members practice hand hygiene.
No assumptions are made by observers. For example, many patient care floors have Cal Stat dispensers inside patient rooms in addition to hallway dispensers. Staff caring for patients in these types of rooms may use Cal Stat appropriately while still inside the room, but it can be difficult for an observer to see. If the observer cannot determine that a staff member used Cal Stat, his or her actions are marked as 'unknown" and do not affect the results. The observer must see a staff member fail to use to use Cal Stat after coming into contact with the patient or patient's environment before the action is marked as "nothing."

For more information about the bonus program, visit intranet.massgeneral.org/handhygiene. For more information about the hand hygiene surveillance process, call the Infection Control Unit at (617) 726-2036.