Skip to main content

The AHRQ National Quality Measures Clearinghouse (NQMC, qualitymeasures.ahrq.gov) Web site will not be available after July 16, 2018 because federal funding
through AHRQ will no longer be available to support the NQMC as of that date. For additional information, read our full announcement.
  • Measure Summary
  • NQMC:005014
  • Feb 2009

Hand washing: percentage of failures in compliance with standard norms on hand washing.

Ministry of Health. Safe practices indicators project: background, summary of methods and measurement strategies. Madrid: Ministry of Health; 2009 Feb 20. 97 p.

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in April 2016.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to determine the percentage of healthcare providers who comply with rules on hand washing, distinguishing between intensive care unit (ICU) staff and ward staff. Hand washing must be done before and after procedures and using the correct technique.

Rationale

Although hand washing has been shown to be highly effective in preventing the transmission of pathogens within a hospital, studies have repeatedly shown that hand washing compliance rates are generally less than 50 percent.

Main aim of indicator: to increase the percentage of healthcare providers who comply with standards norms on hand washing.

Evidence for Rationale

Ministry of Health. Safe practices indicators project: background, summary of methods and measurement strategies. Madrid: Ministry of Health; 2009 Feb 20. 97 p.

Primary Health Components

Failures in hand washing technique and timing in contacts with patient

Denominator Description

Total number of contacts observed x 7 possible failures in each (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of failures in hand washing technique and timing in contacts with patient x 100 (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Health personnel do not comply with standard norms on hand washing in 70% of occasions.

Evidence for Additional Information Supporting Need for the Measure

Ministerio de Sanidad y Consumo. Indicadores de buenas practicas sobre seguridad del paciente. Resultados de su medicion en una muestra de hospitales del sistema nacional de salud Español. Madrid: Ministerio de Sanidad y Consumo; 2008. 95 p.

Extent of Measure Testing

After pilot testing, the set of indicators has been measured in a random sample of 25 Spanish hospitals, stratified by hospital size. The main objective has been to field test the feasibility of measurement in the various settings representing real life situations in the context of the Spanish Health Care System.

Both the whole indicators validation report and the results of the baseline measurement in a sample of the Spanish National Health Service (NHS) hospitals may be accessed and downloaded from the Spanish Ministry of Health web page (in Spanish):

Evidence for Extent of Measure Testing

Ministerio de Sanidad y Consumo. Construccion y validacion de indicadores de buenas practicas sobre seguridad del paciente. Madrid: Ministerio de Sanidad y Consumo; 2008. 178 p.

Ministerio de Sanidad y Consumo. Indicadores de buenas practicas sobre seguridad del paciente. Resultados de su medicion en una muestra de hospitales del sistema nacional de salud Español. Madrid: Ministerio de Sanidad y Consumo; 2008. 95 p.

Ministry of Health. Safe practices indicators project: background, summary of methods and measurement strategies. Madrid: Ministry of Health; 2009 Feb 20. 97 p.

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Hospital Inpatient

Hospital Outpatient

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Allied Health Personnel

Nurses

Physician Assistants

Physicians

Respiratory Care Practitioners

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Unspecified

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Health and Well-being of Communities
Making Care Safer
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

End of Life Care

Getting Better

Living with Illness

Staying Healthy

IOM Domain

Effectiveness

Safety

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Institutionalization

Therapeutic Intervention

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Total number of contacts observed* x 7 possible failures in each

*Contacts to be observed:

  • Direct contact with patients
  • Insertion of vascular catheters
  • Insertion of urethral catheters
  • Dressing of wounds

Exclusions
Unspecified

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of failures in hand washing technique* and timing in contacts with patient x 100

*Items to be assessed include:

  1. Whether or not hands are washed before a contact with patient
  2. Whether or not hands are washed after a contact with patient
  3. The correct 5-step technique that must be used:
    1. Apply soap/solution from dispenser
    2. Rub palm against palm
    3. Rub palm to palm with fingers interlaced
    4. Rub with fingers closed over palms
    5. Dry with disposable towel

Exclusions
None

Numerator Search Strategy

Fixed time period or point in time

Data Source

Other

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a lower score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Percentage of failures in compliance with standard norms on hand washing.

Measure Collection Name

Safe Practices Indicators Project

Measure Set Name

Adopting Safe Practices in Specific Clinical Care Settings or for Specific Processes of Care

Measure Subset Name

Promotion of Hand Washing in Health Personnel

Submitter

Spanish Agency for Healthcare Quality of the Spanish Ministry of Health - National Government Agency [Non-U.S.]

Developer

Grupo de Investigación sobre Gestión de la Calidad en Servicios de Salud, University of Murcia, under contract to the Spanish Ministry of Health - National Government Agency [Non-U.S.]

Funding Source(s)

Agency for Quality, Spanish Ministry of Health

Composition of the Group that Developed the Measure

Saturno, Pedro J., MD, DrPH; Group Director and Project PI

Castillo, Carmen; López, M. José; Ramón, Teresa; Nurses

Carrillo, Andrés, MD; Intensive Care Specialist

Iranzo, M. Dolores; Hospital pharmacist

Soria, Victor, MD; Surgeon

Parra, Pedro, MD; Gomis, Rafael, MD; Gascón, Juan J., MD; Quality Management Specialists

Financial Disclosures/Other Potential Conflicts of Interest

Project entirely financed by the Spanish Ministry of Health.

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2009 Feb

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in April 2016.

Source(s)

Ministry of Health. Safe practices indicators project: background, summary of methods and measurement strategies. Madrid: Ministry of Health; 2009 Feb 20. 97 p.

Measure Availability

Source not available electronically.

For more information, contact:

  • Ministry of Health and Social Policy, at Paseo del Prado, 18-20, planta baja, esquina con Lope de Vega. 28014 Madrid; Phone: +34 901 400 100; Fax: +34 915 96 44 80; Web site: www.msc.es/en/home.htm External Web Site Policy.

    OR

  • Pedro J. Saturno, Facultad de Medicina, at Universidad de Murcia, 30100 Espinardo-Murcia (Spain); Phone: 868 883 948; Fax: +34 868 883947; E-mail: psaturno@um.es.

Companion Documents

The following are available:

  • Ministerio de Sanidad y Consumo. Construccion y validacion de indicadores de buenas practicas sobre seguridad del paciente. Madrid: Ministerio de Sanidad y Consumo; 2008. 178 p. This document is available in Portable Document Format (PDF) from the Ministry of Health and Social Policy Web site External Web Site Policy (in Spanish).
  • Ministerio de Sanidad y Consumo. Indicadores de buenas practicas sobre seguridad del paciente. Resultados de su medicion en una muestra de hospitales del sistema nacional de salud Español. Madrid: Ministerio de Sanidad y Consumo; 2008. 95 p. This document is available in PDF from the Ministry of Health and Social Policy Web site External Web Site Policy (in Spanish).

NQMC Status

This NQMC summary was completed by ECRI Institute on September 11, 2009. The information was verified by the measure developer on December 23, 2009.

This NQMC summary was retrofitted into the new template on July 27, 2011.

The information was reaffirmed by the measure developer on April 4, 2016.

Copyright Statement

No copyright restrictions apply.

NQMC Disclaimer

The National Quality Measures Clearinghouse™ (NQMC) does not develop, produce, approve, or endorse the measures represented on this site.

All measures summarized by NQMC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public and private organizations, other government agencies, health care organizations or plans, individuals, and similar entities.

Measures represented on the NQMC Web site are submitted by measure developers, and are screened solely to determine that they meet the NQMC Inclusion Criteria.

NQMC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or its reliability and/or validity of the quality measures and related materials represented on this site. Moreover, the views and opinions of developers or authors of measures represented on this site do not necessarily state or reflect those of NQMC, AHRQ, or its contractor, ECRI Institute, and inclusion or hosting of measures in NQMC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding measure content are directed to contact the measure developer.

About NQMC Measure Summaries

NQMC provides structured summaries containing information about measures and their development.

Measure Summary FAQs


Measure Summaries

New This Week

View more and sign up for our Newsletter

Get Adobe Reader