Mackenzie Health
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About Us - Our Performance - Hand Hygiene Compliance - Reporting


Question: How do we know how well we’re doing?

Answer: As the Auditor General of Ontario noted in his special report on Prevention and Control of Hospital-associated Infections, hospitals have been using different processes to measure hand hygiene compliance and, therefore, rates have not been comparable. As of April 30th, all Ontario hospitals will have a formalized baseline in place that we can use to measure and track hand hygiene compliance more reliably over time. If our rates fall below this baseline, we will be able to look at internal processes, identify areas for improvement, and implement strategies to further improve hand hygiene and, in turn, control and prevent hospital-associated infections.


Rates are not meant to be compared with that of other hospital rates. The rates can vary from hospital to hospital, month to month. Some hospitals will have fewer observation opportunities because they do not have as much direct provider-to-patient care opportunities. Due to the type of patient and the number of patients they care for (i.e. mental health), their rates may seem lower.


All hospitals should be able to collect the identified sample size of 200 observed opportunities for every 100 beds. If they don’t submit sufficient data the website will show that data was not provided.


Question: What do our rates tell us?

Answer: Patients should know that our hospital is safe, that the care they receive is top-notch, and that every effort is made to ensure the highest quality of care possible. Public reporting of hand hygiene compliance rates is another helpful measure to ensure the care we provide to our patients is even safer, and continues to improve over time.


Question: When do we start reporting?
Answer: We will begin reporting to the Ministry of Health and Long-Term Care (MOHLTC) on April 30, 2009. In addition to our website, the MOHLTC also reports the same information on its website at on an annual basis starting on the same date.


Question: What exactly is being publicly reported?

Answer: A provincial audit tool has been provided to us as part of the Just Clean Your Hands program. Specially-trained auditors observe hand hygiene practice. They use the tool to track four essential times when hand hygiene should be performed will be publicly reported.
Those times are:

  • Before Initial Patient/Patient Environment Contact
  • After Patient/Patient Environment Contact

We will submit the information on these four indicators for hand hygiene. We, like all Ontario hospitals, are required to post, by site, the percent compliance rates for before and after patient/patient environment contact for each period end date.


Question: How are hand hygiene compliance rates are calculated
Answer: Ontario hospitals are posting their hand hygiene compliance rates as percentages for time periods identified by the Ministry of Health and Long-Term Care, using the following formula: 


number of times hand hygiene performed
number of observed hand hygiene indications X 100



These percentages also reflect:

  1. hand hygiene before initial patient/patient environment contact by combined health care provider type (e.g., nurses, allied health professionals, physicians, etc.)
  2. hand hygiene after patient/patient environment contact by combined health care provider type (e.g., nurses, allied health professionals, physicians, etc.)

Hospitals are to collect at least 200 observations for every 100 in-patient beds.


To ensure statistically valid data for smaller hospitals, or hospitals with fewer in-patient beds a minimum of 50 observed opportunities for hand hygiene will need to be collected.


The goal of public reporting hand hygiene compliance is to achieve an overall assessment of whether compliance rates are improving. It is normal for rates to vary from hospital to hospital.


Mackenzie Health hand hygiene compliance rates

Number of times hand hygiene was performed before initial patient/patient environment contact Number of times hand hygiene was performed after initial patient/patient environment contact Percent compliance for before initial patient/patient environment contact Percent compliance for after patient/patient environment contact
April 1 2015 to 
March 31 2016
7985 7467 87.65% 89.49%
April 1 2014 to 
March 31 2015
7771 7895 87% 92%
April 1 2013 to 
March 31 2014
4994 5567 85% 91%
April 1 2012 to 
March 31 2013
10317 10871 79% 89%
April 1 2011 to 
March 31 2012
April 1 2010 to 
March 31 2011
April 1 2009 to 
March 31 2010
April 1 2008 to 
March 31 2009


Mackenzie Health / 10 Trench St. Richmond Hill, On. L4C 4Z3 / Richmond Hill Line: 905-883-1212 or Vaughan Line: 905-832-4554 / TTY Service: 905-883-2123