What Are We Measuring?

Practicing proper hand hygiene (cleaning) is an important action that health care workers can take to stop the spread of pathogens (germs that can cause disease) and reduce the risk of health care-associated infections.

Massachusetts General Hospital requires all physicians, nurses and other staff/volunteers to clean their hands with Cal Stat, an alcohol-based hand rub, both before and after contact with a patient or the patient’s environment. Nurse observers on patient care units measure how staff are performing.

How Are We Performing?

The chart below shows Mass General’s performance compared to the Joint Commission’s goal of 90%, both before and after patient contact.

Hand Hygiene Compliance

Higher scores are better

Mass General Source: Surveillance on units
Benchmark: The Joint Commission 90% Compliance Expectation

What Are We Doing to Improve?

We take hand hygiene very seriously and strive for 100% compliance both before and after patient contact. A multidisciplinary group called the STOP (Stop the Transmission of Pathogens) Task Force leads improvement efforts, which include:
  • Point-of-use product availability: Cal Stat dispensers are located both inside and outside most patient rooms, soap is located at all sinks, lotion dispensers are located in all clinical areas, and all dispensers are routinely monitored for product levels, expiration dates and working condition
  • Education: All staff and volunteers are trained on proper hand hygiene practices. Staff members are also encouraged to observe the habits of others and speak up with friendly reminders or tips for practice improvement as needed
  • Compliance monitoring: Hand hygiene compliance is measured by direct observation of practices throughout the hospital. Feedback is provided to staff through unit and role group leaders and Hand Hygiene Champions
  • Hand Hygiene Champions: Staff members throughout the hospital volunteer to serve as peer educators for local staff, share feedback from surveys, provide tips for improvement and promote compliance in their immediate work areas
  • Patients, families and visitor involvement: Everyone is encouraged to use hand hygiene when entering or leaving the patient’s room. Special hand wipes are made available to patients who are unable to reach a dispenser or sink. Patients and visitors are also encouraged to ask staff if they have used hand hygiene, or ask providers to use hand hygiene where it can be seen by the patient