Page 59 - Q BULLETIN, Ministry of Health Malaysia, VOLUME 1, NO. 31 (SUPPLEMENT 1), JAN-DEC 2022

Q Bulletin, Volume 1, No. 31 (Supplement 1), Jan - Dec 2022
11 National QA Convention, 4 – 6 October 2022
th
PP-21

Improving Hand Hygiene in Bagan Specialist Centre’s Clinical and Non-Clinical Services

Nur Syuhada K, Norsyaheera S, Nurul Syarina S, Tan TC
Bagan Specialist Centre, Pulau Pinang

SELECTION OF OPPORTUNITIES FOR IMPROVEMENT:
The hand hygiene compliance in Bagan Specialist Centre (BSC) was not good in 2019, with compliance below
75%. Poor compliance with hand hygiene practice poses a risk of hospital-associated infection and when
COVID-19 hits Malaysia, it strengthens the need for hand hygiene compliance among healthcare workers in
BSC.

KEY MEASURES FOR IMPROVEMENT:
Hand hygiene compliance at five key moments, as set out by the World Health Organisation (WHO), is the
metric employed. The goal was to achieve 80% compliance in all clinical and non-clinical services.

PROCESS OF GATHERING INFORMATION:
Data were acquired using the WHO method for direct observation of “Five Moments for Hand Hygiene”.
Observations have been done since January 2019 up to the current date.

ANALYSIS AND INTERPRETATION:
The compliance rate in 2019 was 69%, where the rate of non-compliance was higher among consultants
and inconsistent compliance rate among the nurses and allied health staff. The key factors identified were
sensitivity towards alcohol-based hand rubs, lack of hand hygiene facility and awareness.

STRATEGIES FOR CHANGE:
Multimodal interventions were executed, such as changing the alcohol sanitiser to suit those who are allergic,
improving access and readability of the hand hygiene facility, staff training and reward program. The Non-
Conformance Report was issued to those services that were unable to achieve a target above 80%, whilst the
unit with the lowest level of compliance due to negligence was penalised.

EFFECT OF CHANGE:
Data collected shows that the overall hand hygiene percentage improved from 69% (2019) to 78% (2020) and
88% (2021). Most of the services showed improvement except for the Central Sterile Service Department
and housekeeping. Some services manage to maintain >85% compliance. Several critical areas experienced
reductions.

THE NEXT STEP:
The next target is to attain the largest percentage of compliance in the critical area. Additional research will be
conducted to improve the respective services.

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