To Analyze and Evaluate the Rate of Compliance of Hand Hygiene Practices in a Tertiary Care Hospital: Initiation of Quality Improvement Program and Clinical Audit.

INTRODUCTION: Health care as a service organization is associated with hospital-acquired infection which is drawing attention. There are concerns raised by patients, attenders, stake holders, insurers, government agencies, and regulatory bodies. The study aims to evaluate the awareness and the rate of compliance with hand hygiene.

METHODS: The audit methodology implemented is a concurrent medical record audit. The period of the audit was conducted for 6 months. A random sampling method was incorporated. The sample size was determined as 20% of the staff had been involved.

RESULTS: The Total average level of awareness of hand hygiene and adherence to policy is 93.6%. The average of all the 3 categories of compliance at 5 levels of hand hygiene in percentage is 82.3%.

DISCUSSION: Hand hygiene practices if stringently implemented will minimize the cross-transmission of infection in health care facilities. By knowing the awareness level and compliance level are measured with standardized training modules.

APPLICATIONS: Create awareness on hand hygiene and provide training with respect to the effectiveness of implementation. Incorporate hand hygiene steps as well as in the audit process.

CONCLUSIONS: There is a requirement for training with respect to the effectiveness of the implementation of the techniques. The level of care and quality of services can be made better by incorporating quality improvement programs (QIPs). By regular audits, we can raise the service quality and benchmark it.