Hand Hygiene Checklist: 5 Suggestions for Process Improvement

Despite significant changes in infection prevention practices since the introduction of the CMS Conditions for Coverage requirements, hand hygiene practices continue to be inconsistent and fall short of infection prevention expectations, says Phenelle Segal, RN CIC, president of Infection Control Consulting Services based in Blue Bell, Pa.


During personalized on-site visits to several ASCs for the purpose of assessing best practices either before or after facilities surveys have been conducted, Ms. Segal says hand hygiene practices range from totally lacking to various inconsistencies resulting in the possibility of compromising patient safety. "The CMS surveyor's worksheet highlights the areas that the surveyors will concentrate on during a state visit," says Ms. Segal. "However, there is a lot more to hand hygiene that should be addressed by staff members." Note: You can download a sample version of the CMS surveyor's worksheet created by the ASC Quality Collaboration by clicking here (pdf).


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She says it is critical for staff members to assess systems in place to ensure adequate hand hygiene. This includes recognizing and identifying barriers. Ms. Segal has identified issues in three main areas of the facilities that she has visited — the preoperative or holding area, the anesthesia staff within the operating room suite and the post-procedure recovery area. She identified the following barriers:

  • Lack of availability of hand hygiene products (alcohol hand sanitizer dispensers or individual pump bottles) and handwashing facilities (sinks, running water and soap)
  • Misconception that staff members who scrub on a case are the only ones required to perform hand hygiene
  • Ignorance of guidelines or lack of ongoing education
  • Forgetfulness or "I just wasn't thinking"
  • Rapid turnover of procedures and high workload
  • Inadequate monitoring (covert or overt) and subsequent feedback to staff


Here is a checklist from Ms. Segal of five suggestions ASCs can follow to help ensure processes are in place (or strategies for improvement) to ensure patient safety from the time that patients enter the facility to the time they leave.

1. Provide ongoing education for all staff members including competencies. Education can be undertaken in many different ways including live in-services, webinars, audio-conferences or online training, Ms. Segal says. Facility determined competencies/ assessments for clinical staff should include a skills checklist addressing hand hygiene knowledge and practices. Education should include all clinical staff and those providing direct patient care.


2. Provide staff with The World Health Organization's "My 5 Moments of Hand Hygiene" which defines the key moments when healthcare workers should perform hand hygiene. This includes the following:

  • Before touching a patient
  • Before Clean/aseptic procedures (such as anesthesia services)
  • After body fluid exposure/risk
  • After touching a patient
  • After touching patient surroundings

Note: Learn more about the "My 5 Moments of Hand Hygiene" by clicking here.

3. Make hand hygiene easy by providing adequate opportunities for handwashing and use of alcohol based hand sanitizers. Sinks should be placed in strategic locations and supplies such as soap and paper towels should be provided at all times, Ms. Segal says. "Alcohol hand sanitizer products should be user friendly, available at all times and strategically placed throughout the facility, particularly in clinical areas and high demand locations," she says.


4. Introduce hand-hygiene monitoring programs. Tools for monitoring hand-hygiene compliance are available in various forms and include the use of "secret shoppers," i.e., a covert observation whereby no one but the person appointing the observer and the observer him/herself knows who is conducting the monitoring, or an overt observation whereby all staff members are aware of the person conducting the observation, Ms. Segal says. Note: You can learn more about hand hygiene monitoring tools by clicking here and clicking here.

5. Holding staff accountable by providing feedback from monitoring programs. "Staff should be informed of the findings from ongoing monitoring programs and should be provided the opportunity to improve practice by providing resources, educational opportunities and one-on-one consultation," Ms. Segal says.


Learn more about Infection Control Consulting Services.

More Articles Featuring Infection Control Consulting Services:

Safe Injection Practices Checklist: 12 Critical Rules to Follow

Storage and Access of Multi-Dose Medications Used for More Than One Patient

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