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Measure Summary
Title
Hand washing: does the hospital have appropriate infrastructure for hand washing in all units of the hospital in which patient care is administered?
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 Domain

Primary Measure Domain
Clinical Quality Measures: Structure
Secondary Measure Domain
Does not apply to this measure

Brief Abstract

Description

This measure is used to determine whether or not the hospital has appropriate infrastructure for hand washing (washbasins, supplies of soap/alcohol gel hand cleaners) in all units of the hospital in which patient care is administered.

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.

The existence of adequate infrastructure (washbasins provided with soap and antiseptic solution/alcohol gel hand cleaners) indicates that the hospital complies with this fundamental structural quality criterion that facilitates 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

Infrastructure for hand washing (washbasins, supplies of soap/alcohol gel hand cleaners)

Denominator Description

This measure applies to hospitals (one hospital at a time).

Numerator Description

The hospital has appropriate infrastructure for hand washing (washbasins, supplies of soap/alcohol gel hand cleaners) in all units of the hospital in which patient care is administered (see the related "Numerator Inclusions/Exclusions" field).

Evidence Supporting the Measure

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

48% of hospitals have some room for improvement in relation to infrastructure for hand washing in the units of the hospital in which patient care is administered.

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 of the Measure

State of Use
Current routine use
Current Use
Internal quality improvement

Application of the Measure in its Current Use

Measurement Setting
Hospital Inpatient
Hospital Outpatient
Intensive Care Units
Professionals Involved in Delivery of Health Services
Does not apply to this measure (e.g., measure is not provider specific)
Least Aggregated Level of Services Delivery Addressed
Single Health Care Delivery or Public Health Organizations
Statement of Acceptable Minimum Sample Size
Does not apply to this measure
Target Population Age

Does not apply to this measure

Target Population Gender
Does not apply to this measure

National Strategy for Quality Improvement in Health Care

National Quality Strategy Aim
Better Care

Institute of Medicine (IOM) National Health Care Quality Report Categories

IOM Care Need
Not within an IOM Care Need
IOM Domain
Not within an IOM Domain

Data Collection for the Measure

Case Finding Period

Does not apply to this measure

Denominator Sampling Frame
Health care or public health organization
Denominator (Index) Event or Characteristic
Does not apply to this measure
Denominator Time Window
Does not apply to this measure
Denominator Inclusions/Exclusions

Inclusions
This measure applies to hospitals (one hospital at a time).

Exclusions
None

Exclusions/Exceptions
Does not apply to this measure
Numerator Inclusions/Exclusions

Inclusions
The hospital has appropriate infrastructure* for hand washing (washbasins, supplies of soap/alcohol gel hand cleaners) in all units of the hospital in which patient care is administered.

*The following are considered appropriate infrastructure:

  • One washbasin with soap and antiseptic solution per intensive care unit (ICU) patient
  • One washroom area per operating room
  • At least one washbasin per nursing area in conventional wards
  • Disposable towels

Availability of alcohol-based hand rub may be assessed also.

Different areas of hospital to be assessed:

  • ICU
  • A ward at random
  • An operating room at random

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

None

Computation of the Measure

Measure Specifies Disaggregation
Does not apply to this measure
Scoring
Dichotomous
Interpretation of Score
Desired value is presence of a characteristic
Allowance for Patient or Population Factors
Does not apply to this measure
Standard of Comparison
Internal time comparison

Identifying Information

Original Title

Existence of washbasins provided with soap and antiseptic solution/alcohol gel hand cleaners (dispensing units or single-use handrubs) easily accessible to healthcare workers.

Measure Collection Name
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 May 2014.

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

The individual measure, "Existence of Washbasins Provided with Soap and Antiseptic Solution/Alcohol Gel Hand Cleaners (Dispensing Units or Single-use Handrubs) Easily Accessible to Healthcare Workers," is published in "Safe Practices Indicators Project: Background, Summary of Methods and Measurement Strategies."

For more information, contact:

  • Ministry of Health and Social Policy, 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, Universidad de Murcia, 30100 Espinardo-Murcia (Spain); Phone: 868 883 948; Fax: +34 868 883947; E-mail: psaturno@um.es; Web site: http://www.calidadsalud.com External Web Site Policy.
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 May 13, 2014.

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