hand hygiene
By Paul Alper, BA
Self-Assessment in COVID-19:
Know Your Baseline, Measure Your Progress
his month, we provide a facility-based
Tself-assessment tool, informed by the latest
guidance from CMS and the CDC. This is
designed for infection prevention and clinical
leaders to get a solid baseline of where they
stand today and then conduct routine self-assessment
updates to measure improvement.
Accordingly, a scoring guide is provided.
A Hand Hygiene Self-Assessment Tool
Note that point values for each response
are included as part of the questions, but these
should be removed when using the tool with
the units.
Select the response that best describes
your facility and its routine practices related to
hand hygiene:
1.Our facility has a comprehensive
hand hygiene program that creates accountability
for the following program
elements 1.1 - 1.7:
1.1 Hand hygiene products and
appropriate dispensers are available
at all points of care with appropriate
measures in place to ensure prompt
replenishment when they are empty
a) Strongly Agree (10)
b) Agree (7)
c) Neither Agree nor Disagree (0)
d) Disagree (0)
e) Strongly Disagree (0)
1.2 Individual (personal carry)
size hand sanitizers are provided for
all staff and volunteers for use when
hand hygiene is indicated but access
to dispensers is not convenient
a) Strongly Agree (10)
b) Agree (7)
c) Neither Agree nor Disagree (0)
d) Disagree (0)
e) Strongly Disagree (0)
1.3 New and on-going staff are
trained and educated routinely on
performance expectations including
the indications for hand hygiene along
with proper technique and when to use
soap vs. sanitizer
a) Strongly Agree (10)
b) Agree (7)
c) Neither Agree nor Disagree (0)
d) Disagree (0)
e) Strongly Disagree (0)
1.4 Staff are required demonstrate
that they can do a proper 20
second hand wash + hand sanitization
at training times
a) Strongly Agree (10)
b) Agree (7)
c) Neither Agree nor Disagree (0)
d) Disagree (0)
e) Strongly Disagree (0)
1.5 Patients, family members and
visitors are educated on hand hygiene
behavior expectations
a) Strongly Agree (10)
b) Agree (7)
c) Neither Agree nor Disagree (0)
d) Disagree (0)
e) Strongly Disagree (0)
1.6 Tools for such training are
reviewed and updated at least annually
a) Strongly Agree (10)
b) Agree (7)
c) Neither Agree nor Disagree (0)
d) Disagree (0)
e) Strongly Disagree (0)
1.7 We use and update facility
wide reminders of hand hygiene
behavior expectations
a) Strongly Agree (10)
b) Agree (7)
c) Neither Agree nor Disagree (0)
d) Disagree (0)
e) Strongly Disagree (0)
2. Our units/departments are individually
responsible for hand hygiene
improvement and they are held accountable
for meeting monthly/quarterly
compliance growth targets.
a) Strongly Agree (10)
b) Agree (7)
c) Neither Agree nor Disagree (0)
d) Disagree (0)
e) Strongly Disagree (0)
3. Our units/departments leaders’
annual performance appraisal/bonus is
tied in some way to meeting our hand
hygiene improvement goals.
a) Strongly Agree (10)
b) Agree (7)
c) Neither Agree nor Disagree (0)
d) Disagree (0)
e) Strongly Disagree (0)
4. Our units/departments routinely
identify obstacles and barriers to hand
hygiene performance and then put
in place action plans with the goal of
eliminating them.
a) Strongly Agree (10)
b) Agree (7)
c) Neither Agree nor Disagree (0)
d) Disagree (0)
e) Strongly Disagree (0)
5. Our units/departments identify the
obstacles and barriers to hand hygiene
compliance using:
Direct Observation (10)
Group Discussion (7)
Other (1)
6. We measure hand hygiene compliance
and give feedback on performance.
Daily or Weekly (10)
Monthly (7)
Quarterly (5)
Twice a year (1)
Once a year (0)
7. We celebrate when goals are
achieved and identify what we will do
differently when they are not.
Strongly Agree (10)
Agree (7)
Neither Agree nor Disagree (0)
Disagree (0)
Strongly Disagree (0)
8. When our goals are met, we then
set a new, higher goal.
Strongly Agree (10)
Agree (7)
Neither Agree nor Disagree (0)
Disagree (0)
Strongly Disagree (0)
9. Psychological safety is the way we
work in our facility – anyone can speak
up when there is risk of doing harm
without fear of retribution or other
negative consequences.
Strongly Agree (10)
Agree (7)
Neither Agree nor Disagree (0)
Disagree (0)
Strongly Disagree (0)
10. Our organization’s senior leaders
are responsible for modeling proper
hand hygiene behavior and they are
authentically engaged in our hand
hygiene improvement efforts.
Strongly Agree (10)
Agree (7)
Neither Agree nor Disagree (0)
Disagree (0)
Strongly Disagree (0)
Add 10 points if you stop a healthcare
worker as a matter of standard practice
when conducting direct observation
and they fail to perform hand hygiene,
reminding them that they need to do so
before providing care.
Scoring: Max Score including 10 Point
Bonus = 170 Points
● 150-170: Outstanding. Stay diligent and
focused
● 130-150: Excellent, but still room for
improvement
● 100-130: Good, but should make getting
over 110 a high priority for the next period
● Below 100: Poor, and in need of coaching
and feedback. It’s an opportunity to take your
safety culture and HH practices up a notch
We are still a long way from getting hand
hygiene right; this is just one framework that
requires no investment other than time and
that might make sense to consider in some
adapted form. Feel free to modify and adapt
in any way that aligns well with your culture
and organization.
Paul Alper, BA, led the launch of PURELL®,
invented the first electronic hand hygiene
monitoring system proven to reduce infections
while improving behavior and eliminating costs
and is now the VP Patient Safety Innovation for
Medline Industries, Inc. through an exclusive
engagement with his consulting practice, Next
Level Strategies, LLC.
36 august 2020 • www.healthcarehygienemagazine.com