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 |
