Mastering the Leapfrog Hand Hygiene Standard

Hand hygiene is a key component of patient safety. That’s why The Leapfrog Group added a new hand hygiene standard to the Leapfrog Hospital Survey in 2019.

Of course, COVID-19 hit in late 2019, and as the pandemic reached crisis levels, hospitals faced an increased demand for care at the same time COVID-19 sickened healthcare providers and interrupted global supply chains. In 2020 and 2021, Leapfrog adjusted the Leapfrog Hospital Survey to accommodate the impact of the COVID-19 pandemic. In 2022, in response to public comments and feedback from hospitals, Leapfrog announced an alternative path to achieving the Hand Hygiene Standard, giving hospitals the opportunity to monitor 100 hand hygiene opportunities (rather than 200) per unit per month.

Both paths are still available, so hospitals can choose which option is best for them. Here’s what you need to know to master the Leapfrog Hand Hygiene Standard:

You Must Collect Hand Hygiene Compliance Data on All Patient Care Units

Leapfrog requires hospitals to collect hand hygiene compliance data on all patient care units, including open bay areas such as the emergency department and post-anesthesia care units (PACUs).

Collecting Data on 100 (vs. 200) Hand Hygiene Opportunities (per unit per month) Creates Additional Obligations

At first glance, collecting hand hygiene compliance data on 100 hand hygiene opportunities per unit per month may seem like half as much work as collecting compliance data on 200 hand hygiene opportunities per unit per month. But that’s not entirely true.

The Leapfrog Hand Hygiene Standard includes five separate domains: Monitoring, Feedback, Training and Education, Infrastructure, and Culture. The 100 vs. 200 choice falls under the monitoring domain. Hospitals that opt to collect data on 100 hand hygiene opportunities per unit per month must also answer “yes” to all the questions in the remaining four hand hygiene domains. Hospitals that choose to monitor compliance data on 200 hand hygiene opportunities per unit per month only have to answer “yes” to all the questions in two of the four domains to meet the standard.

You should only choose the 100 hand hygiene opportunities per unit per month option if you are confident that your hospital can answer “yes” to each of the following questions:

Feedback:

• Are unit-level hand hygiene compliance data fed back to individuals who touch patients (or items touched by patients) at least monthly?
• Are unit-level hand hygiene compliance data used for creating unit-level action plans?
• Is hand hygiene compliance data, with demonstration of trends over time, given to senior administrative leadership, physician leadership, nursing leadership, the board, and medical executive committee at least every six months?
• Is senior administrative leadership, physician leadership, and nursing leadership held directly accountable for hand hygiene performance through performance reviews or compensation?

Training & Education:

• Do individuals who touch patients (or items touched by patients) receive hand hygiene training at the time of onboarding and annually thereafter?
• To pass the initial hand hygiene training, do individuals need to physically demonstrate proper hand hygiene?
• Are all six of the following topics included in your hospital’s hand hygiene training:
  • Evidence linking hand hygiene and infection prevention
  • When to perform hand hygiene
  • How to perform hand hygiene
  • When gloves should be used in addition to hand washing and how hand hygiene should be performed when gloves are used
  • Minimum amount of time that should be spent performing hand hygiene
  • How hand hygiene compliance is monitored

Infrastructure:

• Do all rooms and patient care areas have alcohol-based hand sanitizer dispensers located at the entrance of each patient room or bed space and have dispensers inside the room or bedspace that are equally accessible to the location of all patients in that space?
• Does your hospital have a process in place to ensure that hand hygiene supplies are refilled, and batteries are replaced as needed? Do you conduct quarterly audits to ensure the process is followed?
• Does your hospital conduct audits of the volume of alcohol-based hand sanitizer that’s delivered with each activation of a dispenser upon installation, when changing the brand or system, and whenever adjustments are made to the dispensers?
• Do all audited dispensers deliver the required amount of product?

Culture:

• Are patients and visitors invited to remind staff to perform hand hygiene?
• Do all patient rooms and bed spaces have a sink for handwashing that’s within 20 feet of the patient’s bed?

If you cannot answer yes to each of these questions, you should report hand hygiene compliance data on 200 hygiene opportunities per unit per month.

Some Direct Observation is Required

Because proper hand hygiene is so important to patient safety, The Leapfrog Group has expressed a strong preference for electronic hand hygiene monitoring due to “the limitations of human observers.” To ensure that electronic systems are properly tracking and reporting hand hygiene compliance, Leapfrog requires hospitals that use electronic compliance monitoring to perform direct observation on 10% of all required hand hygiene opportunities on a quarterly basis.

Hospitals that choose to report 200 hand hygiene opportunities per unit per month need to perform 20 direct observations in each patient care unit once a quarter; hospitals that report data on 100 hand hygiene opportunities per month need to perform 10 direct observations per unit per quarter.

Units with poor hand hygiene compliance (defined as two or more standard deviations below the hospital’s mean compliance rate) must perform additional direct observations to satisfy the Leapfrog Hand Hygiene Standard.

The SwipeSense team can help you explore your options and master the Leapfrog Hand Hygiene Standard.