Joint Commission is Preparing Monograph on Hand Hygiene Measurement Methods

In September 2006, the Joint Commission launched an initiative to collect comprehensive, innovative and cost-effective hand hygiene measurement methods from healthcare organizations as part of its Consensus Measurement in Hand Hygiene (CMHH) project. The goal is to address methods for measuring adherence to hand hygiene guidelines and identify real-world, proven measurement methods, according to Linda Kusek, RN, BSN, MPH, associate project director in the Division of Quality Measurement and Research at the Joint Commission.

The strategies identified through this initiative will be published in a free, educational monograph that will have examples of promising practices for measuring hand hygiene adherence. The monograph, planned for publication in early 2008, will be the culmination of an 18-month project by the Joint Commission in collaboration with the Association for Professionals in Infection Control and Epidemiology (APIC), the Centers for Disease Control and Prevention (CDC), the Society for Healthcare Epidemiology of America (SHEA), the World Health Organization (WHO) World Alliance for Patient Safety, the Institute for Healthcare Improvement (IHI), and the National Foundation for Infectious Diseases (NFID).

Measuring adherence to hand hygiene practices during the delivery of care has long been complicated because of the resources needed to monitor the practices of many different care providers in numerous locations for meaningful periods of time. The absence of standardized approaches to measuring hand hygiene performance makes it difficult to determine whether overall performance is improving, deteriorating or staying unchanged as new strategic interventions are introduced.

Examples of promising practices for measuring adherence to hand hygiene guidelines were sought from a variety of settings, including hospitals, ambulatory care, home care, long-term care, and behavioral health. Organizations submitting examples were asked to provide supporting documentation, such as published studies or summaries of results regarding the use of the method, as well as a sample of their data collection tool and a sample of the data as they display it.

Kusek reports that the field questionnaire submission process ended several months ago, and the Joint Commissions expert panel, under the direction of hand hygiene expert Elaine Larson, RN, PhD, FAAN, CIC, associate dean of Columbia Universitys School of Nursing, currently is evaluating the responses received. If the expert panel determines that a submitted example has potential value to other healthcare facilities, the organization will be contacted for additional information and permission to include it in the monograph. Kusek adds that they may conduct telephone interviews or site visits with selected participants to gather additional information.

The project is being funded by an educational grant from GOJO Industries.