Hand Hygiene Toolkit

The resources in this toolkit may only be used for internal improvement and education efforts. They may not be used for commercial purposes.

Hand hygiene reduces the risk of healthcare associated infections. Clean hands are the single most important factor in preventing the spread of pathogens and antibiotic resistance in healthcare settings.

The ASC Quality Collaboration has assembled a variety of resources and information that may be used to supplement your current processes to improve hand hygiene practices.

The BASIC Hand Hygiene Toolkit includes four essential resources:

The EXPANDED Hand Hygiene Toolkit contains both essential resources and a broader array of materials, including:

Assessment Tools
Implementation Aids
Training Materials
Monitoring Tools
Workplace Reminders
Guidelines from Leading Authorities

The materials presented here include publicly available resources from the following organizations:

Comments and other feedback may be directed to Ann Shimek, Executive Director, ASC Quality Collaboration, annshimek@ascquality.org.

Assessment Tools

Hand Hygiene: What CMS Surveyors Are Looking For
Perform a self-assessment using the same tool CMS surveyors use when evaluating hand hygiene practices in the ASC setting.
Hand Hygiene Knowledge Assessment Questionnaire (IHI)
This questionnaire may be used to survey clinical staff about their knowledge of key hand hygiene information. It is included in the Institute for Healthcare Improvement's "How-to Guide: Improving Hand Hygiene".
Checklist for the Availability of Alcohol-Based Hand Rub and Clean Gloves (IHI)
This checklist may be used to assess the availability of alcohol-based hand rub and clean gloves in patient care areas. It is included in Institute for Healthcare Improvement's "How-to Guide: Improving Hand Hygiene".

Implementation Aids

How-to-Guide: Improving Hand Hygiene (IHI)
This guide from the Institute for Healthcare Improvement provides a framework for projects aimed at improving hand hygiene and the use of gloves among health care workers. The guide also includes a hand hygiene knowledge assessment questionnaire.
Leadership Letter Template
This sample letter from clinical leaders in the ASC may be used to share plans for a hand hygiene improvement initiative with other staff in the center. The template should be adapted to fit the unique circumstances of each center.

Hand Hygiene Policy and Procedure Template
This sample hand hygiene policy and procedure is based on the Centers for Disease Control and Prevention (CDC) guidelines. It should be adapted as needed for use in each facility.
Selecting the Right Alcohol-Based Hand Rub for Your Healthcare Facility (HHRC)
This guide from the Hand Hygiene Resource Center (HHRC) lists and explains factors to be considered when selecting an alcohol-based hand rub for facility use.

Training Materials

Interactive Hand Hygiene Training Course (CDC)
This 10 to 15 minute interactive course from the Centers for Disease Control and Prevention (CDC) reviews key concepts of hand hygiene and other standard precautions to prevent healthcare-associated infections.
Hand Hygiene Technical Reference Manual (WHO)
This manual from the World Health Organization presents detailed hand hygiene information and is aimed at health-care workers, trainers and observers. It focuses on understanding, practicing and teaching hand hygiene concepts.
Hand Hygiene Why, How and When Brochure (WHO)
This brochure from the World Health Organization for health care workers summarizes why, how and when to perform hand hygiene.
Glove Use Information Leaflet (WHO)
This leaflet from the World Health Organization discusses the appropriate use of gloves with respect to hand hygiene.

Monitoring Tools

Hand Hygiene Observation Template
This template may be used to observe hand hygiene practices. It may be adapted as needed for use in the individual center.
Hand Hygiene and Glove Use Monitoring Form (IHI)
This form may be used to assess adherence to hand hygiene guidelines. It is included in Institute for Healthcare Improvement's "How-to Guide: Improving Hand Hygiene".
Measuring Hand Hygiene Adherence: Overcoming the Challenges (TJC)
This monograph from The Joint Commission provides practical techniques and examples for measuring adherence to hand hygiene guidelines.

Workplace Reminders

Hand Hygiene How-To Posters (WHO)
These posters from the World Health Organization designed for display in a healthcare facility demonstrate how to handwash and handrub and explain the Your 5 Moments for Hand Hygiene approach.

Hand Hygiene Posters (CDC)
These posters from the Centers for Disease Control and Prevention (CDC) promote recommended hand hygiene practices in healthcare facilities.

Clean Hands Count Fact Sheet for Healthcare Providers (CDC)
This fact sheet from the Centers for Disease Control and Prevention (CDC) is useful for dispelling common misconceptions regarding hand hygiene.

Guidelines from Leading Authorities

Guideline for Hand Hygiene in Health-Care Settings (CDC)
These hand hygiene guidelines were developed by the Centers for Disease Control and Prevention (CDC) in collaboration with the Society for Healthcare Epidemiology of America (SHEA), the Association of Professionals in Infection Control and Epidemiology (APIC) and the Infectious Disease Society of America (IDSA).