Dear Colleagues,

I have included our complete hand hygiene audit in chart form below this message because I think it is important to recognize the significant improvement throughout the organization which, at the end of November, means that we have reached our 2010 goal on the Balanced Scorecard as an organization.  My thanks to everyone for their work on this goal and for protecting our patients and yourselves from hospital-acquired infections – I am very proud to lead this organization.

And now – we must maintain and improve our rates until the four points of hand hygiene become our normal practice throughout UHN.  The charts show out 3 month rates for all units, sites and UHN as a whole and then the results for the month of November.  What is key is that, throughout the organization there is dramatic improvement but, as I've said before, this organization is seldom satisfied with 70% on a test!  So, I'll continue to challenge everyone to do better and we'll set our target higher in 2011.

Keep up the great work.

Bob​

"Before" Hand Hygiene Compliance Rate ​​by Program - 
Rolling 3 Month Rates*

Unit

Q1 Apr-Jun 10

Q2 Jul-Sep 10

Aug-Oct 2010

Sep-Nov 2010

TGH

 

 

 

 

TGED

26%

54%

47%

61%

4CB

28%

62%

76%

85%

4CA

34%

42%

66%

70%

CVICU

42%

70%

69%

62%

6ES

39%

72%

81%

89%

5CB

29%

65%

70%

70%

CCU

31%

55%

61%

61%

6CB

49%

83%

88%

76%

9ES

38%

70%

65%

74%

10ES

35%

43%

49%

57%

6CA

37%

76%

89%

82%

TGMSICU

28%

50%

51%

59%

10WA

46%

75%

77%

77%

7A

46%

75%

72%

68%

7B

46%

75%

72%

74%

14ES

28%

56%

62%

61%

13ES

54%

51%

60%

58%

8ES

44%

55%

86%

92%

PMH

 

 

 

 

14A

50%

78%

77%

75%

15A

35%

67%

66%

64%

15B

60%

59%

71%

67%

14B

82%

93%

95%

92%

17A

37%

54%

63%

68%

17B

37%

54%

62%

69%

16P

62%

55%

67%

77%

18B

40%

75%

76%

76%

TWH

 

 

 

 

5A

32%

71%

69%

73%

5B

74%

58%

73%

80%

NCCU

33%

59%

71%

79%

9A

51%

69%

74%

77%

3AB

28%

77%

90%

94%

8A

48%

66%

78%

70%

8B

30%

86%

93%

92%

TWED

35%

59%

49%

43%

9B(prev 6A)

43%

47%

67%

70%

TWMSICU

28%

66%

71%

70%

6A(GIM Flex)

N/A

N/A

85%

76%

TGH

36%

60%

 

70%

PMH

49%

69%

74%

74%

TWH

38%

66%

74%

75%

UHN

39%

64%

71%

72%

UHN BSC Target

70%

70%

70%

70%

Green

meeting or exceeding target

 

Yellow

between baseline (48%) and target

 

Red

below baseline (48% in 09/10)

 

*Calculated by summing numerators and denominators of
previous 3 months, not by averaging rates

 

"Before" Hand Hygiene Compliance Rate by Program

 UHN Monthly Rates

 

 

 

Unit

July _10

Aug _10

Sep _10

Oct _10

Nov _10

TGH

 

 

 

 

 

TGED

78%

50%

43%

48%

80%

4CB

52%

26%

86%

90%

76%

4CA

23%

29%

76%

76%

59%

CVICU

67%

77%

65%

66%

58%

6ES

55%

65%

89%

83%

94%

5CB

28%

76%

84%

43%

73%

CCU

48%

53%

71%

62%

52%

6CB

84%

86%

81%

97%

50%

9ES

70%

64%

74%

57%

89%

10ES

60%

35%

35%

64%

63%

6CA

44%

93%

96%

81%

73%

TGMSICU

28%

61%

52%

35%

81%

10WA

75%

66%

80%

85%

61%

7A

75%

66%

80%

62%

45%

7B

75%

66%

80%

55%

71%

14ES

33%

67%

67%

57%

62%

13ES

50%

61%

44%

68%

55%

8ES

33%

44%

100%

98%

83%

PMH

 

 

 

 

 

14A

62%

80%

79%

64%

77%

15A

70%

64%

67%

67%

60%

15B

59%

80%

38%

84%

65%

14B

86%

92%

98%

96%

81%

17A

43%

58%

60%

83%

71%

17B

43%

58%

60%

71%

83%

16P

42%

43%

76%

77%

79%

18B

73%

76%

75%

76%

77%

TWH

 

 

 

 

 

5A

77%

61%

82%

68%

71%

5B

46%

56%

75%

86%

79%

NCCU

47%

47%

78%

80%

78%

9A

66%

53%

85%

78%

67%

3AB

55%

84%

85%

100%

95%

8A

57%

69%

69%

94%

50%

8B

71%

75%

100%

97%

81%

TWED

60%

62%

55%

38%

41%

9B (prev 6A)

17%

70%

61%

73%

79%

TWMSICU

62%

52%

89%

75%

59%

6A (GIM Flex)

N/A

N/A

N/A

85%

66%

TGH

52%

58%

73%

69%

68%

PMH

60%

73%

72%

77%

73%

TWH

53%

64%

78%

79%

70%

UHN

54%

64%

74%

73%

70%

UHN BSC Target

70%

70%

70%

70%

70%

Green

meeting or exceeding target

 

 

Yellow

between baseline (48%) and target

Red

below baseline (48% in 09/10)

*Calculated by summing numerators and denominators of 
previous 3 months, not by averaging rates​​

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