TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing...
Transcript of TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing...
![Page 1: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/1.jpg)
1
TABLE OF CONTENTS
EXECUTIVE SUMMARY
FINAL REPORT
BALCARRES INTEGRATED CARE CENTRE
DETOX CENTRE
FORT QU’APPELLE ALL NATIONS HEALING HOSPITAL
FORT QU’APPELLE ECHO LODGE
GOLDEN PRAIRIE NURSING HOME
GRENFELL PIONEER HOME
HOME CARE TREATMENT CENTRE
INDIAN HEAD UNION HOSPITAL
KIDNEY HEALTH CENTRE
MENTAL HEALTH SERVICES 3RD FLOOR
MENTAL HEALTH SERVICES CHILD AND YOUTH SERVICES
PASQUA HOSPITAL 2C CARDIO NEURO
PASQUA HOSPITAL 3A
PASQUA HOSPITAL 3B
PASQUA HOSPITAL 3C
PASQUA HOSPITAL 3D
PASQUA HOSPITAL 4A
PASQUA HOSPITAL 4B
PASQUA HOSPITAL 4C
PASQUA HOSPITAL AMBULATORY CARE
PASQUA HOSPITAL CSU
PASQUA HOSPITAL DAY SURGERY
![Page 2: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/2.jpg)
2
PASQUA HOSPITAL EMERGENCY
PASQUA HOSPITAL EYE CENTRE
PASQUA HOSPITAL FOOD AND NUTRITION SERVICES
PASQUA HOSPITAL ICU
PASQUA HOSPITAL INFUSIONS
PASQUA HOSPITAL OR
PASQUA HOSPITAL PACU
PASQUA HOSPITAL PHLEBOTOMY
PASQUA HOSPITAL RESPIRATORY THERAPY
PASQUA HOSPITAL SHORT STAY
POPULATION AND PUBLIC HEALTH SERVICES
REGINA CROSSING CENTRE FMU
REGINA LUTHERAN HOME
REGINA PIONEER VILLAGE 2 EAST
REGINA PIONEER VILLAGE 2 WEST
REGINA PIONEER VILLAGE 3 WEST
REGINA PIONEER VILLAGE 4 EAST
REGINA PIONEER VILLAGE 4 WEST
REGINA PIONEER VILLAGE HOSTEL
REGINA PIONEER VILLAGE MAIN WEST
RGH 0D/1D
RGH 3B
RGH 3F
RGH 4F
RGH 5A
RGH 6A
![Page 3: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/3.jpg)
3
RGH 6F
RGH AMBULATORY CARE
RGH CARDIAC CATH LAB
RGH CCU
RGH CSU
RGH DAY SURGERY
RGH ENDOSCOPY
RGH FAU
RGH FOOD AND NUTRITION SERVICES
RGH INTERVENTIONAL CARDIOLOGY EP LAB
RGH INTERVENTIONAL CARDIOLOGY PACER CLINIC
RGH LAB
RGH MBU
RGH MEDICAL IMAGING MDRU
RGH NICU
RGH PEDIATRIC OP
RGH PULMONARY FUNCTION
RGH RENAL - HEMODIALYSIS
RGH RESPIRATORY THERAPY
RGH SHORT STAY
RGH SICU
RGH SLEEP DISORDER CENTRE
RGH WOMEN’S HEALTH CENTRE
SANTA MARIA 2nd FLOOR
SANTA MARIA 3rd FLOOR
SANTA MARIA 4th FLOOR
![Page 4: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/4.jpg)
4
SANTA MARIA FOOD AND NUTRITION SERVICES
SANTA MARIA FOOD AND NUTRITION SERVICES
SANTA MARIA RECREATION THERAPY
SANTA MARIA SUPPORT SERVICES
SEICC/MOOSOMIN ACUTE
SEICC/MOOSOMIN LAB
SEICC/MOOSOMIN LTC
SILVER HEIGHTS SPECIAL CARE HOME
ST JOSEPH’S INTEGRATED CARE CENTRE
WHITEWOOD COMMUNITY HEALTH CENTRE
WILLIAM BOOTH SPECIAL CARE HOME
WOLSELEY MEMORIAL HOSPITAL
WRC 2-5
WRC 3-5
WRC 3-6
WRC ADULT OT
WRC CHILDREN’S PROGRAM
WRC FOOD AND NUTRITION SERVICES
WRC FRP
WRC MAIN 5
WRC MAIN 6
![Page 5: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/5.jpg)
5
EXECUTIVE SUMMARY
This report provides an analysis of the October 2014 hand hygiene audits for the Regina Qu'Appelle
Health Region. Methods of analyses included hand hygiene compliance and the frequency of missed
hand hygiene opportunities and the presence of jewellery and artificial nails/nail polish at the regional,
hospital, department, and healthcare worker levels.
Overall, the number of facilities/departments participating in the October audit increased from June.
However, hand hygiene audits were not received from a number of facilities/departments that have
direct patient care. Compared to previous hand hygiene audits, hand hygiene compliance at the
regional level has remained relatively stable since October 2013. Although the number of healthcare
workers wearing jewellery or having artificial nails/nail polish has decreased, approximately 24% of
staff failed to conduct hand hygiene. Furthermore, hand hygiene compliance among healthcare
workers was generally higher after patient contact compared to before patient contact.
Hand hygiene compliance in the Regina Qu’Appelle Health Region continues to fall below the
expected target of 100%. The introduction of a hand hygiene policy as well as increased promotion
and training among healthcare workers is expected to increase hand hygiene compliance. This
compliance will be assessed in February 2015.
This report is available on-line for healthcare workers and the public:
http://rhdintranet/InfectionControl/public/Stats/stats.htm
http://www.rqhrlean.com/hand-hygiene.html
http://www.rqhealth.ca/programs/infection_control/hand_hygiene.shtml
![Page 6: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/6.jpg)
6
FINAL REPORT
A total of 2528 hand hygiene observations were submitted for analysis. Of these, only 2499 (98.9%)
observations could be analyzed. Information regarding compliance at the facility and healthcare
worker levels is provided in this report.
For the analysis, the following definition of hand hygiene was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
![Page 7: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/7.jpg)
7
Table 1: Hand hygiene results for May 2013, October 2013, February 2014, June 2014, and October 2014.
Descriptive statistics
May
2013
(%)
October
2013
(%)
February
2014
(%)
June
2014
(%)
October
2014
(%)
Number of observations submitted 2847 2651 2626 2078 2528
Number of observations excluded from
analysis
1177
(41.3)
36
(1.4)
67
(2.6)
24
(1.2)
29
(1.1)
Compliance at the region level 572/1670
(34.3)
1513/2615
(57.9)
1516/2559
(59.2) Not reported
1461/2499
(58.5)
Noncompliance at the region level 1098/1670
(65.7)
1102/2615
(42.1)
1043/2559
(40.8) Not reported
1038/2499
(41.5)
Number of observations in which the
healthcare worker wore jewellery
331/1670
(19.8)
246/2615
(9.4)
259/2559
(10.1)
129/2054
(6.3)
156/2499
(6.2)
Number of observations in which the
healthcare worker had artificial nails/nail
polish
46/1670
(2.8)
71/2615
(2.7)
46/2559
(1.8)
68/2054
(3.3)
51/2499
(2.0)
Number of observations in which the
healthcare worker did not conduct hand
hygiene at all
Not reported Not reported Not reported 438/2054
(21.3)
602/2499
(24.1)
![Page 8: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/8.jpg)
8
Table 2: Facilities and units that participated in the October 2014 hand hygiene audit
Facility Unit
RGH
0D/1D
3B
3F
4F
5A
6A
6F
Ambulatory Care
Cardiac Cath Lab
CCU
CSU
Day Surgery
Endoscopy
FAU
Food and Nutrition Services
Interventional Cardiology/EP Lab
Interventional Cardiology/Pacer Clinic
Lab
MBU
Medical Imaging - MDRU
NICU
Pediatric OP
Pulmonary Function
Renal/Hemodialysis
Respiratory Therapy
Short Stay
SICU
Sleep Disorder Centre
Women's Health Centre
![Page 9: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/9.jpg)
9
PASQUA
2C Cardio Neuro
3A
3B
3C
3D
4A
4B
4C
Ambulatory Care
CSU
Day Surgery
Emergency
Eye Centre
Food and Nutrition Services
ICU
Infusions
OR
PACU
Phlebotomy
Respiratory Therapy
Short Stay
WRC
2-5
3-5
3-6
Main 5
Main 6
Adult OT
Children's Program
Food and Nutrition Services
FRP
RURAL ACUTE Fort Qu'Appelle All Nations Healing Hospital
![Page 10: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/10.jpg)
10
Indian Head Union Hospital
Southeast Integrated Care Centre - Moosomin
Wolseley Memorial Integrated Care Centre
RURAL LTC
Balcarres Integrated Care Centre
Fort Qu'Appelle Echo Lodge
Golden Prairie Home - Indian Head
Grenfell Pioneer Home
Silver Heights Special Care Home
Southeast Integrated Care Centre/Moosomin
St. Joseph's Integrated Care Centre - Lestock
Whitewood Community Health Centre
William Booth Specialty Care Home
Wolseley Memorial Integrated Care Centre
Regina Lutheran Home
Regina Pioneer Village
Santa Maria
COMMUNITY
Detox Centre
Home Care Treatment Centre1
Kidney Health Centre
Mental Health Services
Population & Public Health Services
Regina Crossing Centre - FMU
1 A hand hygiene audit was conducted by the Home Care Treatment Centre. However, the audit process is
different compared to the audit process for other patient care areas. Therefore, the Home Care Treatment
Centre numbers are not included in the overall analyses for this report.
![Page 11: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/11.jpg)
11
Table 3: Facilities and units that did not participate in the October 2014 hand hygiene audit
Facility Unit
RGH
3E
5E
5F
AU
ER
Labour and Birth
MICU
OR
PACU
Phlebotomy
Podiatry Clinic
Therapy Department
PASQUA
4D
Lab - Histology (submitted after deadline)
Medical Imaging (submitted after deadline)
Short Stay
WRC
2-6
3-2
3-3
RURAL ACUTE Broadview Union Hospital
RURAL LTC
Broadview Centennial Lodge (submitted after deadline)
Cupar & District Nursing Home
Elmview Extendicare
Long Lake Valley Integrated Care Centre
Lumsden & District Heritage Home
Montmarte Health Centre
Parkside Extendicare
Qu'Appelle House
Regina Pioneer Village – 3 East
![Page 12: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/12.jpg)
12
Sunset Extendicare
East Office Child Health Clinic
EMS
Four Directions Child Health
Grenfell Health Centre
North Office Child Health Clinic
Surgical Assessment Centre
![Page 13: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/13.jpg)
13
![Page 14: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/14.jpg)
14
![Page 15: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/15.jpg)
15
![Page 16: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/16.jpg)
16
![Page 17: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/17.jpg)
17
![Page 18: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/18.jpg)
18
![Page 19: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/19.jpg)
19
![Page 20: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/20.jpg)
20
BALCARRES INTEGRATED CARE CENTRE
![Page 21: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/21.jpg)
21
BALCARRES INTEGRATED CARE CENTRE
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the Balcarres Integrated Care Centre was 70%
For the Balcarres Integrated Care Centre audit:
o 1 staff member did not conduct hand hygiene at all
o 5 staff members were observed with jewellery
o 1 staff member was observed with artificial nails/nail polish
![Page 22: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/22.jpg)
22
DETOX CENTRE
![Page 23: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/23.jpg)
23
DETOX CENTRE
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the Detox Centre was 26%
Information regarding before/after patient contact was not recorded by the auditor
For the Detox Centre audit:
o 20 staff members did not conduct hand hygiene at all
o 1 staff member was observed with jewellery
o 1 staff member was observed with artificial nails/nail polish
![Page 24: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/24.jpg)
24
FORT QU’APPELLE ALL NATIONS HEALING HOSPITAL
![Page 25: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/25.jpg)
25
FORT QU’APPELLE ALL NATIONS HEALING HOSPITAL
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Fort Qu’Appelle All Nations Healing Hospital was 64%
o Hand hygiene compliance for the Lab/X-ray was 100%
For the Fort Qu’Appelle All Nations Healing Hospital audit:
o 23 staff members did not conduct hand hygiene at all
o 4 staff members were observed with jewellery
o 2 staff members were observed with artificial nails/nail polish
![Page 26: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/26.jpg)
26
FORT QU’APPELLE ECHO LODGE
![Page 27: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/27.jpg)
27
FORT QU’APPELLE ECHO LODGE
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Fort Qu’Appelle Echo Lodge was 48%
For the Fort Qu’Appelle Echo Lodge audit:
o 13 staff members did not conduct hand hygiene at all
o 1 staff members was observed with jewellery
o No staff members were observed with artificial nails/nail polish
![Page 28: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/28.jpg)
28
GOLDEN PRAIRIE NURSING HOME
![Page 29: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/29.jpg)
29
GOLDEN PRAIRIE NURSING HOME
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the Golden Prairie Nursing Home was 44%
For the Golden Prairie Nursing Home audit:
o 11 staff member did not conduct hand hygiene at all
o 3 staff members were observed with jewellery
o Artificial nails/nail polish was not observed
![Page 30: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/30.jpg)
30
GRENFELL PIONEER HOME
![Page 31: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/31.jpg)
31
GRENFELL PIONEER HOME
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the Grenfell Pioneer Home was 55%
For the Grenfell Pioneer Home audit:
o 7 staff members did not conduct hand hygiene at all
o 16 staff members were observed with jewellery
o No staff member was observed with artificial nails/nail polish
![Page 32: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/32.jpg)
32
HOME CARE TREATMENT CENTRE
![Page 33: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/33.jpg)
33
INDIAN HEAD UNION HOSPITAL
![Page 34: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/34.jpg)
34
INDIAN HEAD UNION HOSPITAL
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Indian Head Union Hospital was 11%
For the Indian Head Union Hospital audit:
o 10 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 35: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/35.jpg)
35
KIDNEY HEALTH CENTRE
![Page 36: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/36.jpg)
36
KIDNEY HEALTH CENTRE
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the Kidney Health Centre was 48%
For the Kidney Health Centre audit:
o 10 staff members did not conduct hand hygiene at all
o 7 staff members were observed with jewellery
o 3 staff members were observed with artificial nails/nail polish
![Page 37: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/37.jpg)
37
MENTAL HEALTH SERVICES 3RD FLOOR
![Page 38: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/38.jpg)
38
MENTAL HEALTH SERVICES 3RD FLOOR
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Mental Health Services 3rd Floor was 41%
For the Mental Health Services 3rd Floor audit:
o 11 staff members did not conduct hand hygiene at all
o 6 staff members were observed with jewellery
o 2 staff were observed with artificial nails/nail polish
![Page 39: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/39.jpg)
39
MENTAL HEALTH SERVICES CHILD & YOUTH SERVICES
![Page 40: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/40.jpg)
40
MENTAL HEALTH SERVICES CHILD & YOUTH SERVICES
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Mental Health Services Child & Youth Services was 23%
For the Mental Health Services Child & Youth Services audit:
o 14 staff members did not conduct hand hygiene at all
o 12 staff members were observed with jewellery
o 8 staff were observed with artificial nails/nail polish
![Page 41: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/41.jpg)
41
PASQUA HOSPITAL 2C CARDIO NEURO
![Page 42: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/42.jpg)
42
PASQUA HOSPITAL 2C CARDIO NEURO
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 2C Cardio Neuro was 100%
For the 2C Cardio Neuro audit:
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 43: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/43.jpg)
43
PASQUA HOSPITAL 3A
![Page 44: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/44.jpg)
44
PASQUA HOSPITAL 3A
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 3A was 81%
For the 3A audit:
o 3 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 45: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/45.jpg)
45
PASQUA HOSPITAL 3B
![Page 46: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/46.jpg)
46
PASQUA HOSPITAL 3B
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 3B was 67%
For the 3B audit:
o 4 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 47: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/47.jpg)
47
PASQUA HOSPITAL 3C
![Page 48: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/48.jpg)
48
PASQUA HOSPITAL 3C
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 3C was 63%
For the 3C audit:
o 5 staff members did not conduct hand hygiene at all
o 2 staff members were observed with jewellery
o Artificial nails/nail polish was not observed
![Page 49: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/49.jpg)
49
PASQUA HOSPITAL 3D
![Page 50: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/50.jpg)
50
PASQUA HOSPITAL 3D
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 3D was 70%
For the 3D audit:
o 4 staff members did not conduct hand hygiene at all
o 1 staff member was observed with jewellery
o 1 staff member was observed with artificial nails/nail polish
![Page 51: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/51.jpg)
51
PASQUA HOSPITAL 4A
![Page 52: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/52.jpg)
52
PASQUA HOSPITAL 4A
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 4A was 51%
For the 4A audit:
o 17 staff members did not conduct hand hygiene at all
o 4 staff members were observed with jewellery
o 1 staff member was observed with artificial nails/nail polish
![Page 53: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/53.jpg)
53
PASQUA HOSPITAL 4B
![Page 54: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/54.jpg)
54
PASQUA HOSPITAL 4B
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 4B was 48%
For the 4B audit:
o 23 staff members did not conduct hand hygiene at all
o 4 staff members were observed with jewellery
o No staff member was observed with artificial nails/nail polish
![Page 55: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/55.jpg)
55
PASQUA HOSPITAL 4C
![Page 56: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/56.jpg)
56
PASQUA HOSPITAL 4C
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 4C was 57%
For the 4C audit:
o 6 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 57: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/57.jpg)
57
PASQUA HOSPITAL AMBULATORY CARE
![Page 58: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/58.jpg)
58
PASQUA HOSPITAL AMBULATORY CARE
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Ambulatory Care was 81%
For the Ambulatory Care audit:
o 4 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 59: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/59.jpg)
59
PASQUA HOSPITAL CSU
![Page 60: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/60.jpg)
60
PASQUA HOSPITAL CSU
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for CSU was 88%
For the CSU audit:
o 2 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 61: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/61.jpg)
61
PASQUA HOSPITAL DAY SURGERY
![Page 62: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/62.jpg)
62
PASQUA HOSPITAL DAY SURGERY
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Day Surgery was 84%
For the Day Surgery audit:
o 3 staff members did not conduct hand hygiene at all
o 1 staff member was observed with jewellery
o 1 staff member was observed with artificial nails/nail polish
![Page 63: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/63.jpg)
63
PASQUA HOSPITAL EMERGENCY
![Page 64: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/64.jpg)
64
PASQUA HOSPITAL EMERGENCY
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Emergency was 21%
For the Emergency audit:
o 13 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 65: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/65.jpg)
65
PASQUA HOSPITAL EYE CENTRE
![Page 66: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/66.jpg)
66
PASQUA HOSPITAL EYE CENTRE
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the Eye Centre was 54%
For the Eye Centre audit:
o 11 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 67: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/67.jpg)
67
PASQUA HOSPITAL FOOD & NUTRITION SERVICES
![Page 68: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/68.jpg)
68
PASQUA HOSPITAL FOOD & NUTRITION SERVICES
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Food & Nutrition Services was 62%
For the Food & Nutrition Services audit:
o 4 staff members did not conduct hand hygiene at all
o 1 staff member was observed with jewellery
o Artificial nails/nail polish was not observed
![Page 69: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/69.jpg)
69
PASQUA HOSPITAL ICU
![Page 70: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/70.jpg)
70
PASQUA HOSPITAL ICU
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for ICU was 61%
For the ICU audit:
o 2 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 71: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/71.jpg)
71
PASQUA HOSPITAL INFUSIONS
![Page 72: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/72.jpg)
72
PASQUA HOSPITAL INFUSIONS
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the Lab was 92%
For the Lab audit:
o 2 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 73: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/73.jpg)
73
PASQUA HOSPITAL OR
![Page 74: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/74.jpg)
74
PASQUA HOSPITAL OR
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the OR was 59%
For the Lab audit:
o 2 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 75: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/75.jpg)
75
PASQUA HOSPITAL PACU
![Page 76: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/76.jpg)
76
PASQUA HOSPITAL PACU
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for PACU was 96%
For the PACU audit:
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 77: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/77.jpg)
77
PASQUA HOSPITAL PHLEBOTOMY
![Page 78: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/78.jpg)
78
PASQUA HOSPITAL PHLEBOTOMY
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Phlebotomy was 89%
For the Phlebotomy audit:
o 2 staff members were observed with jewellery
o Artificial nails/nail polish was not observed
![Page 79: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/79.jpg)
79
PASQUA HOSPITAL RESPIRATORY THERAPY
![Page 80: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/80.jpg)
80
PASQUA HOSPITAL RESPIRATORY THERAPY
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Respiratory Therapy was 100%
For the Respiratory Therapy audit:
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 81: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/81.jpg)
81
PASQUA HOSPITAL SHORT STAY
![Page 82: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/82.jpg)
82
PASQUA HOSPITAL SHORT STAY
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Short Stay was 73%
For the Respiratory Therapy audit:
o 4 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 83: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/83.jpg)
83
POPULATION AND PUBLIC HEALTH SERVICES
![Page 84: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/84.jpg)
84
POPULATION AND PUBLIC HEALTH SERVICES
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Population and Public Health Services was 73%
For the Population and Public Health Services audit:
o 3 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 85: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/85.jpg)
85
REGINA CROSSING CENTRE FMU
![Page 86: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/86.jpg)
86
REGINA CROSSING CENTRE FMU
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the Regina Crossing Centre was 26%
For the Regina Crossing Centre audit:
o 8 staff members did not conduct hand hygiene at all
o 1 staff member was observed with jewellery
o Artificial nails/nail polish was not observed
![Page 87: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/87.jpg)
87
REGINA LUTHERAN HOME
![Page 88: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/88.jpg)
88
REGINA LUTHERAN HOME
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Regina Lutheran Home was 44%
For the Regina Lutheran Home audit:
o 6 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o 1 staff member was observed with artificial nails/nail polish
![Page 89: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/89.jpg)
89
REGINA PIONEER VILLAGE 2 EAST
![Page 90: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/90.jpg)
90
REGINA PIONEER VILLAGE 2 EAST
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 2 East was 46%
For the 2 East audit:
o 6 staff members did not conduct hand hygiene at all
o 3 staff members were observed with jewellery
o 1 staff member was observed with artificial nails/nail polish
![Page 91: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/91.jpg)
91
REGINA PIONEER VILLAGE 2 WEST
![Page 92: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/92.jpg)
92
REGINA PIONEER VILLAGE 2 WEST
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 2 West was 70%
For the 2 West audit:
o 3 staff members did not conduct hand hygiene at all
o 1 staff member was observed with jewellery
o Artificial nails/nail polish was not observed
![Page 93: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/93.jpg)
93
REGINA PIONEER VILLAGE 3 WEST
![Page 94: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/94.jpg)
94
REGINA PIONEER VILLAGE 3 WEST
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 3 West was 60%
For the 3 West audit:
o 5 staff members did not conduct hand hygiene at all
o 1 staff member was observed with jewellery
o Artificial nails/nail polish was not observed
![Page 95: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/95.jpg)
95
REGINA PIONEER VILLAGE 4 EAST
![Page 96: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/96.jpg)
96
REGINA PIONEER VILLAGE 4 EAST
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 4 East was 19%
For the 4 East audit:
o 13 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 97: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/97.jpg)
97
REGINA PIONEER VILLAGE 4 WEST
![Page 98: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/98.jpg)
98
REGINA PIONEER VILLAGE 4 WEST
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 4 West was 30%
For the 4 West audit:
o 24 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 99: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/99.jpg)
99
REGINA PIONEER VILLAGE HOSTEL
![Page 100: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/100.jpg)
100
REGINA PIONEER VILLAGE HOSTEL
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Hostel was 32%
For the Hostel audit:
o 6 staff were observed with jewellery
o 8 staff were observed with artificial nails/nail polish
![Page 101: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/101.jpg)
101
REGINA PIONEER VILLAGE MAIN WEST
![Page 102: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/102.jpg)
102
REGINA PIONEER VILLAGE MAIN WEST
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Main West was 33%
For the Main West audit:
o 10 staff members did not conduct hand hygiene at all
o 1 staff member was observed with jewellery
o Artificial nails/nail polish was not observed
![Page 103: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/103.jpg)
103
RGH 0D/1D
![Page 104: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/104.jpg)
104
RGH 0D/1D
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 0D/1D was 62%
For the 0D/1D audit:
o 5 staff members did not conduct hand hygiene at all
o 1 staff member was observed with jewellery
o Artificial nails/nail polish was not observed
![Page 105: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/105.jpg)
105
RGH 3B
![Page 106: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/106.jpg)
106
RGH 3B
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 3B was 36%
For the 3B audit:
o 17 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 107: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/107.jpg)
107
RGH 3F
![Page 108: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/108.jpg)
108
RGH 3F
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 3F was 46%
For the 3F audit:
o 11 staff members did not conduct hand hygiene at all
o 2 staff members were observed with jewellery
o Artificial nails/nail polish was not observed
![Page 109: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/109.jpg)
109
RGH 4F
![Page 110: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/110.jpg)
110
RGH 4F
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 4F was 60%
For the 4F audit:
o 9 staff members did not conduct hand hygiene at all
o 2 staff members were observed with jewellery
o Artificial nails/nail polish was not observed
![Page 111: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/111.jpg)
111
RGH 5A
![Page 112: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/112.jpg)
112
RGH 5A
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 5A was 70%
For the 5A audit:
o 8 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 113: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/113.jpg)
113
RGH 6A
![Page 114: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/114.jpg)
114
RGH 6A
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 6A was 78%
For the 6A audit:
o 3 staff did not conduct hand hygiene at all
o Jewellery was not observed
o 1 staff member was observed with artificial nails/nail polish
![Page 115: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/115.jpg)
115
RGH 6F
![Page 116: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/116.jpg)
116
RGH 6F
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 6F was 59%
For the 6F audit:
o 2 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 117: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/117.jpg)
117
RGH AMBULATORY CARE
![Page 118: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/118.jpg)
118
RGH AMBULATORY CARE
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Ambulatory Care was 85%
For the Ambulatory Care audit:
o 3 staff members did not conduct hand hygiene at all
o 1 staff member was observed with jewellery
o Artificial nails/nail polish was not observed
![Page 119: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/119.jpg)
119
RGH CARDIAC CATH LAB
![Page 120: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/120.jpg)
120
RGH CARDIAC CATH LAB
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the Cardiac Cath Lab was 50%
For the Cardiac Cath Lab audit:
o 4 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 121: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/121.jpg)
121
RGH CCU
![Page 122: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/122.jpg)
122
RGH CCU
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for CCU was 89%
For the CCU audit:
o 2 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 123: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/123.jpg)
123
RGH CSU
![Page 124: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/124.jpg)
124
RGH CSU
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for CSU was 44%
For the CSU audit:
o 9 staff members did not conduct hand hygiene at all
o 1 staff member was observed with jewellery
o Artificial nails/nail polish was not observed
![Page 125: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/125.jpg)
125
RGH DAY SURGERY
![Page 126: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/126.jpg)
126
RGH DAY SURGERY
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Day Surgery was 85%
For the Day Surgery audit:
o 4 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 127: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/127.jpg)
127
RGH ENDOSCOPY
![Page 128: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/128.jpg)
128
RGH ENDOSCOPY
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Endoscopy was 56%
For the Endoscopy audit:
o 2 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 129: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/129.jpg)
129
RGH FAU
![Page 130: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/130.jpg)
130
RGH FAU
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for FAU was 83%
For the FAU audit:
o 1 staff member did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 131: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/131.jpg)
131
RGH FOOD AND NUTRITION SERVICES
![Page 132: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/132.jpg)
132
RGH FOOD AND NUTRITION SERVICES
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Food and Nutrition Services was 35%
For the Food and Nutrition Services audit:
o 9 staff members did not conduct hand hygiene at all
o 1 staff member wore jewellery
o Artificial nails/nail polish was not observed
![Page 133: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/133.jpg)
133
RGH INTERVENTIONAL CARDIOLOGY EP LAB
![Page 134: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/134.jpg)
134
RGH INTERVENTIONAL CARDIOLOGY EP LAB
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the EP Lab was 44%
For the EP Lab audit:
o 4 staff members did not conduct hand hygiene at all
o 2 staff members were observed with jewellery
o 2 staff members were observed with artificial nails/nail polish
![Page 135: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/135.jpg)
135
RGH INTERVENTIONAL CARDIOLOGY PACER CLINIC
![Page 136: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/136.jpg)
136
RGH INTERVENTIONAL CARDIOLOGY PACER CLINIC
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the Pacer Clinic was 33%
For the Pacer Clinic audit:
o 6 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 137: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/137.jpg)
137
RGH LAB
![Page 138: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/138.jpg)
138
RGH LAB
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the Lab was 96%
For the Lab audit:
o 1 staff member did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 139: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/139.jpg)
139
RGH MBU
![Page 140: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/140.jpg)
140
RGH MBU
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for MBU was 36%
For the MBU audit:
o 9 staff members did not conduct hand hygiene at all
o 1 staff members were observed with jewellery
o Artificial nails/nail polish was not observed
![Page 141: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/141.jpg)
141
RGH MEDICAL IMAGING MDRU
![Page 142: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/142.jpg)
142
RGH MEDICAL IMAGING MDRU
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for MDRU was 4%
For the MDRU audit:
o 7 staff members did not conduct hand hygiene at all
o 20 staff members were observed with jewellery
o Artificial nails/nail polish was not observed
![Page 143: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/143.jpg)
143
RGH NICU
![Page 144: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/144.jpg)
144
RGH NICU
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for NICU was 56%
For the NICU audit:
o 5 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 145: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/145.jpg)
145
RGH PEDIATRIC OP
![Page 146: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/146.jpg)
146
RGH PEDIATRIC OP
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Pediatric OP was 96%
For the Pediatric OP audit:
o 1 staff member did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 147: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/147.jpg)
147
RGH PULMONARY FUNCTION
![Page 148: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/148.jpg)
148
RGH PULMONARY FUNCTION
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Pulmonary Function was 60%
For the Pulmonary Function audit:
o 10 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 149: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/149.jpg)
149
RGH RENAL - HEMODIALYSIS
![Page 150: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/150.jpg)
150
RGH RENAL - HEMODIALYSIS
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Renal - Hemodialysis was 56%
For the Renal - Hemodialysis audit:
o 11 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o 1 staff member was observed with artificial nails/nail polish
![Page 151: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/151.jpg)
151
RGH RESPIRATORY THERAPY
![Page 152: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/152.jpg)
152
RGH RESPIRATORY THERAPY
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Respiratory Therapy was 81%
For the Respiratory Therapy audit:
o 5 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 153: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/153.jpg)
153
RGH SHORT STAY
![Page 154: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/154.jpg)
154
RGH SHORT STAY
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Short Stay was 59%
For the Short Stay audit:
o 6 staff members did not conduct hand hygiene at all
o 2 staff members were observed with jewellery
o Artificial nails/nail polish was not observed
![Page 155: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/155.jpg)
155
RGH SICU
![Page 156: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/156.jpg)
156
RGH SICU
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the SICU was 71%
For the SICU audit:
o 4 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 157: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/157.jpg)
157
RGH SLEEP DISORDER CENTRE
![Page 158: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/158.jpg)
158
RGH SLEEP DISORDER CENTRE
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the Sleep Disorder Centre was 53%
For the Sleep Disorder Centre audit:
o 14 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o 1 staff member was observed with artificial nails/nail polish
![Page 159: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/159.jpg)
159
RGH WOMEN’S HEALTH CENTRE
![Page 160: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/160.jpg)
160
RGH WOMEN’S HEALTH CENTRE
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the Women’s Health Center was 63%
For the Women’s Health Centre audit:
o 5 staff members did not conduct hand hygiene at all
o 1 staff members was observed with jewellery
o Artificial nails/nail polish was not observed
![Page 161: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/161.jpg)
161
SANTA MARIA 2nd FLOOR
![Page 162: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/162.jpg)
162
SANTA MARIA 2nd FLOOR
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the 2nd Floor was 83%
For the 2nd Floor audit:
o 1 staff member did not conduct hand hygiene at all
o 1 staff member was observed with jewellery
o 1 staff member was observed with artificial nails/nail polish
![Page 163: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/163.jpg)
163
SANTA MARIA 3rd FLOOR
![Page 164: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/164.jpg)
164
SANTA MARIA 3rd FLOOR
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the 3rd Floor was 67%
For the 3rd Floor audit:
o 3 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o 1 staff member was observed with artificial nails/nail polish
![Page 165: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/165.jpg)
165
SANTA MARIA 4th FLOOR
![Page 166: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/166.jpg)
166
SANTA MARIA 4th FLOOR
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
For the 4th Floor audit:
o 2 staff members were observed with jewellery
o 1 staff member was observed with artificial nails/nail polish
![Page 167: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/167.jpg)
167
SANTA MARIA FOOD AND NUTRITION SERVICES
![Page 168: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/168.jpg)
168
SANTA MARIA FOOD AND NUTRITION SERVICES
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the Food and Nutrition Services was 100%
For the Food and Nutrition Services audit:
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 169: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/169.jpg)
169
SANTA MARIA RECREATION THERAPY
![Page 170: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/170.jpg)
170
SANTA MARIA RECREATION THERAPY
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the Recreation Therapy was 89%
For the Food and Nutrition Services audit:
o 1 staff member did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 171: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/171.jpg)
171
SANTA MARIA SUPPORT SERVICES
![Page 172: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/172.jpg)
172
SANTA MARIA SUPPORT SERVICES
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
For the Support Services audit:
o 1 staff member did not conduct hand hygiene at all
o 3 staff members were observed with jewellery
o 3 staff members were observed with artificial nails/nail polish
![Page 173: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/173.jpg)
173
SILVER HEIGHTS SPECIAL CARE HOME
![Page 174: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/174.jpg)
174
SILVER HEIGHTS SPECIAL CARE HOME
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Silver Heights Special Care Home was 74%
For the Silver Heights Special Care Home audit:
o 3 staff members did not conduct hand hygiene at all
o 2 staff members were observed with jewellery
o 1 staff member was observed with artificial nails/nail polish
![Page 175: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/175.jpg)
175
SEICC/MOOSOMIN ACUTE
![Page 176: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/176.jpg)
176
SEICC/MOOSOMIN ACUTE
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for SEICC/Moosomin Acute was 90%
For the SEICC/Moosomin Acute audit:
o 2 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 177: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/177.jpg)
177
SEICC/MOOSOMIN LAB
![Page 178: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/178.jpg)
178
SEICC/MOOSOMIN LAB
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for SEICC/Moosomin Lab was 0%
For the SEICC/Moosomin Lab audit:
o 9 staff members did not conduct hand hygiene at all
o 7 staff members were observed with jewellery
o Artificial nails/nail polish was not observed
![Page 179: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/179.jpg)
179
SEICC/MOOSOMIN LTC
![Page 180: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/180.jpg)
180
SEICC/MOOSOMIN LTC
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for SEICC/Moosomin LTC was 56%
For the SEICC/Moosomin LTC audit:
o 8 staff members did not conduct hand hygiene at all
o 5 staff members were observed with jewellery
o Artificial nails/nail polish was not observed
![Page 181: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/181.jpg)
181
ST JOSEPH’S INTEGRATED CARE CENTRE
![Page 182: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/182.jpg)
182
ST JOSEPH’S INTEGRATED CARE CENTRE
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for St. Joseph’s Integrated Care Centre was 93%
For the St Joseph’s Integrated Care Centre audit:
o 2 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 183: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/183.jpg)
183
WHITEWOOD COMMUNITY HEALTH CENTRE
WHITEWOOD COMMUNITY HEALTH CENTRE
![Page 184: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/184.jpg)
184
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Whitewood Community Health Centre was 62%
For the Whitewood Community Health Centre audit:
o 6 staff members did not conduct hand hygiene at all
o 4 staff members were observed with jewellery
o 2 staff members were observed with artificial nails/nail polish
![Page 185: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/185.jpg)
185
WILLIAM BOOTH SPECIAL CARE HOME
![Page 186: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/186.jpg)
186
WILLIAM BOOTH SPECIAL CARE HOME
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for William Booth Special Care Home was 41%
For the William Booth Special Care Home audit:
o 12 staff members did not conduct hand hygiene at all
o 1 staff member was observed with jewellery
o Artificial nails/nail polish was not observed
![Page 187: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/187.jpg)
187
WOLSELEY MEMORIAL HOSPITAL
![Page 188: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/188.jpg)
188
WOLSELEY MEMORIAL HOSPITAL
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Wolseley Memorial Hospital was 7%
For the Wolseley Memorial Hospital audit:
o 11 staff members did not conduct hand hygiene at all
o 1 staff member was observed with jewellery
o 2 staff members were observed with artificial nails/nail polish
![Page 189: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/189.jpg)
189
WRC 2-5
![Page 190: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/190.jpg)
190
WRC 2-5
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 2-5 was 74%
For the 2-5 audit:
o 4 staff members did not conduct hand hygiene at all
o 1 staff member was observed with jewellery
o 2 staff members were observed with artificial nails/nail polish
![Page 191: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/191.jpg)
191
WRC 3-5
![Page 192: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/192.jpg)
192
WRC 3-5
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 3-5 was 77%
For the 3-5 audit:
o 2 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 193: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/193.jpg)
193
WRC 3-6
![Page 194: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/194.jpg)
194
WRC 3-6
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for 3-6 was 46%
For the 3-6 audit:
o 5 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 195: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/195.jpg)
195
WRC ADULT OT
![Page 196: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/196.jpg)
196
WRC ADULT OT
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Adult OT was 7%
For the Adult OT audit:
o 2 staff members did not conduct hand hygiene at all
o 3 staff members were observed with jewellery
o Artificial nails/nail polish was not observed
![Page 197: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/197.jpg)
197
WRC CHILDREN’S PROGRAM
![Page 198: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/198.jpg)
198
WRC CHILDREN’S PROGRAM
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for the Children’s Program was 57%
For the Children’s Program audit:
o 12 staff members did not conduct hand hygiene at all
o 3 staff members were observed with jewellery
o 1 staff member was observed with artificial nails/nail polish
![Page 199: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/199.jpg)
199
WRC FOOD AND NUTRITION SERVICES
![Page 200: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/200.jpg)
200
WRC FOOD AND NUTRITION SERVICES
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Food and Nutrition Services was 41%
For the Food and Nutrition Services audit:
o 12 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 201: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/201.jpg)
201
WRC FRP
![Page 202: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/202.jpg)
202
WRC FRP
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for FRP was 82%
For the FRP audit:
o 2 staff members did not conduct hand hygiene at all
o 3 staff members were observed with jewellery
o Artificial nails/nail polish was not observed
![Page 203: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/203.jpg)
203
WRC MAIN 5
![Page 204: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/204.jpg)
204
WRC MAIN 5
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Main 5 was 63%
For the Main 5 audit:
o 10 staff members did not conduct hand hygiene at all
o Jewellery was not observed
o Artificial nails/nail polish was not observed
![Page 205: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/205.jpg)
205
WRC MAIN 6
![Page 206: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT … · fort qu’appelle all nations healing hospital ... regina lutheran home regina pioneer village 2 east regina pioneer village](https://reader034.fdocuments.us/reader034/viewer/2022043011/5fa74fb7086d224ebc201e44/html5/thumbnails/206.jpg)
206
WRC MAIN 6
For this analysis, the following definition of hand hygiene compliance was used:
Compliant:
1) Hand gel or wash, AND
2) A required time component of ≥ 15 seconds
Noncompliant:
1) Gloves only,
2) Missed hand hygiene opportunity,
3) Hand gel or wash with a time component of < 15 seconds,
4) Jewellery, and/or
5) Artificial nails/nail polish
Overall, hand hygiene compliance for Main 6 was 52%
For the Main 6 audit:
o 8 staff members did not conduct hand hygiene at all
o 3 staff members were observed with jewellery
o 2 staff members were observed with artificial nails/nail polish