Standards reporting guide - Hand hygiene reporting standard [HHG]
To provide the HQCC with an indication of the degree to which your hospital is complying with this standard, we have developed reporting requirements. These are made up of a set of measures with related data items.
A brief description of the measures, including their rationale and interpretation notes is presented below. Each measure is derived from one or more data items. The data items are the questions or specific pieces of information that are required to be reported to the HQCC. The data items are described below the Measures section.
All data items relate to the reporting period, unless otherwise specified.
Measures
Proportion of hand hygiene compliance (HHG_M1)
| Rationale: |
Measure of process. |
| Interpretation: |
High proportion expected. This measure is defined by Hand Hygiene Australia. Awareness of observation may influence behaviour. Based on a sample audit. |
| Data items: |
HHG_D2, HHG_D1 |
Can you demonstrate that your hospital follows a process for hand hygiene that includes all the criteria of the HQCC Hand hygiene standard? (HHG_M2)
| Rationale: |
Demonstrates existence and alignment of process. |
| Interpretation: |
Yes expected. |
| Data items: |
HHG_D3 |
Can you demonstrate that your hospital has analysed data related to hand hygiene to identify risks to patient safety and opportunities for quality improvement? (HHG_M3)
| Rationale: |
Demonstrates analysis of relevant data to identify risks to patient safety and opportunities for quality improvement. |
| Interpretation: |
Yes expected. |
| Data items: |
HHG_D4 |
Can you demonstrate that your hospital has implemented quality improvement activities related to hand hygiene? (HHG_M4)
| Rationale: |
Demonstrates quality improvement. |
| Interpretation: |
Yes expected. |
| Data items: |
HHG_D5 |
Data items
The data items are the questions or specific pieces of information that are required to be reported to the HQCC. These are listed below with a brief technical description. The HQCC will calculate the measures (listed above) based on the data items provided. Underlined terms are defined in the
glossary.
Number of hand hygiene moments observed in the audit sample (HHG_D1)
Based on a sample audit of hand hygiene moments observed.
The Hand Hygiene Australia Manual describes the methodology to be followed. The manual and other useful information is available at the Hand Hygiene Australia website:
http://www.hha.org.au
Where possible, use the same data that is reported to Hand Hygiene Australia. Do not follow the HQCC sample audit guidelines.
Type: Number
Number of appropriately performed hand hygiene actions (HHG_D2)
Based on the sample audit of hand hygiene moments observed, see HHG_D1.
Count the number of hand hygiene actions for appropriate hand hygiene moments. Where relevant, use the same data that is reported to Hand Hygiene Australia. Report the hospital total, not the total for a single ward.
Type: Number
Can you demonstrate that your hospital follows a process for hand hygiene that includes all the criteria of the HQCC Hand hygiene standard? (HHG_D3)
Answer Yes or No only. The hospital’s process must include all criteria of the HQCC standard. The HQCC may request further information about alignment with the standard.
Type: Yes/no
Can you demonstrate that your hospital has analysed data related to hand hygiene to identify risks to patient safety and opportunities for quality improvement? (HHG_D4)
Answer Yes or No. The HQCC may request further information about the analysis.
The analysis may take the form of looking at performance trends across time, reviewing performance against benchmarks or peers, looking for subgroups within your hospital (such as wards or clinicians) with better or worse performance, looking for subgroups of patients with better or worse outcomes.
The analysis could look at:
- outcome data, such as rates of healthcare acquired infections
- process data, such as audits of hand hygiene behaviour, consumption of hand hygiene products, reviewing clinical incidents or complaints related to healthcare acquired infections
- evaluating the impact and effectiveness of related quality improvement initiatives.
Type: Yes/no
Can you demonstrate that your hospital has implemented quality improvement activities related to hand hygiene? (HHG_D5)
Answer Yes or No. The HQCC may request further information about the quality improvement activity.
Type: Yes/no
Potential data sources
- Infection control system
- CHRISP
- Pathology laboratory data
- Observational audits
- Hand Hygiene Australia reporting system