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Physician Hand Hygiene


Work to improve hand hygiene rates have resulted in a steady increase in compliance over the years from 26% compliance in 2006 to 90% in 2012. While the overall compliance rate of health care professionals has increased, a breakdown of the rates by health care provider (HCP) tells a different story. In many units, physician hand hygiene rates are well below that of other HCPs. Hence, it has become a priority of Joint Medical Advisory Committee (MAC) (Nov 9, 2011 meeting) that a strategy specifically targeting physicians be developed, a strategy developed by physicians for physicians.


Through a robust communication and education strategy combined with a change support structure and workplace audits, LHSC hopes to both increase compliance to meet 2013/2014 targets, and "sustain the gain" through the following mechanisms:

  • Physician hand hygiene rates posted publicly on every unit 
  • Bi-annual, online hand hygiene training module has become mandatory for all physicians 
  • In units with poor rates, workplace/environmental audits are conducted to identify any barriers to proper hand hygiene 
  • In units with poor rates, that chair/chiefs, or a delegate, provide information/education to physicians 
  • MAC endorse the change support structure roles, accountabilities and responsibilities 
  • The number of audits be increased 
  • MAC to monitor physician hand hygiene rates on a quarterly basis 



For more nformation about this project please contact: Dr. Andrea Lum, Chair, LHSC MAC.

Physician Hand Hygiene Reports: