RVH Hand Hygiene Policy


This policy and procedure applies to all employees of the Royal Victoria Regional Health Centre (RVH) as well as professional staff with RVH privileges (i.e., medical, dental, midwifery, and extended class nursing staff), volunteers, students, and contractors. These individuals shall be referred to collectively as workers herein. The requirements apply whether working on RVH property or working on behalf of or representing RVH elsewhere.


This policy describes the process that is implemented to help workers overcome the barriers to proper hand hygiene and improve compliance with hand hygiene best practices.


This policy and procedure serves to provide clear expectations regarding appropriate methods and practices for hand hygiene for all RVH workers. This will:

  1. Decrease the risk of transfer of infectious organisms from one person to another, one area to another, and into the community.
  2. Decrease the risk of worker illness/injury.


Alcohol-based Hand Rub (ABHR): A liquid, gel or foam formulation of alcohol (e.g. ethanol, isopropanol) used to decrease the number of microorganisms on hands in clinical situations when the hands are not visibly soiled.

Hand Hygiene: Refers to any action of hand cleaning and relates to the removal or killing of transient microorganisms and removal of visible soil from the hands. Hand hygiene includes the use of soap and running water or ABHR. Hand hygiene includes surgical hand antisepsis.

Plain Soap: Detergents that contain very low or no concentrations of antimicrobial agents.

Point-of-Care: A concept that refers to a hand hygiene product which is easily accessible to staff, as close as possible to where patient contact is taking place. Three elements occur together: the patient, the health care provider and care or treatment involving patient contact. The products should be accessible without the provider leaving the patient environment.


  1. Health Care and Residential Facilities, Ontario Regulation 67/93
  2. Occupational Health and Safety Act, R.S.O. 1990, CHAPTER O.1


It is the policy of the RVH to:

  1. Provide an effective multidisciplinary Hand Hygiene program with ongoing initiatives, surveillance and public reporting of hand hygiene compliance rates.
  2. Provide education and visual reminders regarding indications for hand hygiene and proper hand hygiene techniques to all workers, patients and visitors through use of written and visual information and/or educational sessions.
  1. Provide adequate supplies for workers, patients, and visitors to perform proper hand hygiene that includes the placement of ABHR, sinks, and appropriate supplies.


  1. The RVH multifaceted hand hygiene program is composed of:
    1. The multifaceted, multidisciplinary Hand Hygiene Committee will meet quarterly to discuss strategies and review initiatives.
    2. Routine surveillance related to hand hygiene compliance will occur using a reliable, validated observer audit tool. On the spot feedback and monthly reports will be provided to the managers/worker related to the surveillance data.
    3. Compliance rates related to ‘Your 4 moments for hand hygiene’ will be posted on the units and departments and other various access points in the healthcare facility.
    4. Review results of hand hygiene compliance as part of the ongoing safety agenda of facility committees, such as Joint Health and Safety, Infection Prevention and Control, Medical Advisory Committee and Senior Leadership Team.
    5. Provide yearly surveillance data for submission to Ministry of Health and Long

Term Care for Public Reporting of hand hygiene compliance rates pre and post patient contact.

  1. Education and visual reminders regarding indications for hand hygiene and proper hand hygiene techniques for workers, patients and visitors through use of written and visual information and/or educational sessions.
    1. Orientation for all new workers will include hand hygiene education – “Your 4 Moments for Hand Hygiene”.
    2. Ongoing in-services, education, training and annual certification related to hand hygiene will occur.
    3. Visual workplace reminders will be in place in the form of posters and prompts.
    4. Hand hygiene pamphlets and other resources will be provided for patients and families for information purposes.


  1. Provide adequate, appropriate resources for workers, patients and visitors to perform proper hand hygiene that includes the placement of ABHR, hand washing sinks, and appropriate supplies.
    1. Hand washing sinks in the facility will be hands-free, free-standing and designated for hand washing.
    2. Electric eye-triggered devices have a contingency plan in place to deal with power failure (e.g. tie in to emergency power system).
    3. Hand soap must be dispensed from disposable single use containers only.
    4. Hand washing for routine care may be done with plain soap and water.
    5. ABHR will be accessible at all entrances to the facility (public and staff).
    6. ABHR dispensers will be at point-of-care and within reasonable distance from each patient room/area unless contraindicated by the risk assessment.
    7. Hospital supplied hand lotion will be available to maintain skin integrity. The lotion should not interfere with glove integrity.
    8. Occupational Health & Safety will maintain a hand care program for the staff.
    9. Prior to changing any hand hygiene product, review and trial of the product must include a representative from Infection Prevention & Control and proceed through the Product Evaluation and Standardization Committee (PESC).


RVH – Corporate Dress Code Policy

Infection Prevention and Control Manual Additional Tools:
3.2.1   Your 4 Moments for Hand Hygiene
3.2.2   When and How to Perform Hand Hygiene
3.2.3   Factors that Reduce Effectiveness of Hand Hygiene and Hand Care


Public Health Ontario.  Just clean your hands campaign. Retrieved March 3, 2014 from http://www.publichealthontario.ca/

Ministry of Health and Longterm Care. Best Practices For Hand Hygiene In All Health Care Settings Reviewed and Revised April 2014 –. Retrieved May 5, 2014 from:

World Health Organization. WHO guidelines on hand hygiene in health care. Retrieved March 3, 2014 from http://whqlibdoc.who.int/