Amy Kile

DOCUMENT EXCERPT — PORTFOLIO SAMPLEPlatform Architecture Blueprint v1.0 Module 6 — Infection Prevention & Control Subdomain: Hand Hygiene Compliance JCI Standard Measurable Elements Owner Framework PCI.9 PCI.9 ME1–4 IPC Nurse / IPC Committee WHO 5 Moments for Hand Hygiene 1 PROCEDURE • IPC nurse or trained observer conducts direct observation on the ward using the WHO 5 Moments framework. • Record each hand hygiene opportunity observed and whether the action was performed. • Calculate compliance rate per ward, per staff category, and per moment. • Report monthly to the IPC Committee; trend against the organisation's target. • Wards below target for 2 consecutive months appear automatically on the IPC Committee agenda. 2 WHAT THE PLATFORM MUST BUILD • A hand hygiene observation form. Build the form with these exact fields: • — Ward / Unit (dropdown) | Date and time | Auditor name | Staff category (Doctor / Nurse / Allied Health / Support Staff) • — For each moment observed, one row per opportunity: Moment (dropdown: Before touching patient / Before clean or aseptic procedure / After body fluid exposure / After touching patient / After touching patient surroundings) | Action performed? (Yes / No / Not Observed) | Method if performed (Alcohol rub / Soap and water) • — Comments (optional free text) • A compliance dashboard by ward and staff category, updated in real time as audits are submitted. • A 12-month trend chart per ward with the organisation's target shown as a configurable reference line. 3 AUDIT PROTOCOL Audit Item Assessment Method JCI ME Hand hygiene compliance rate >=90% in ICU / high dependency? Observation — submitted audit forms PCI.9 ME2 Hand hygiene compliance rate >=80% on general wards? Observation — submitted audit forms PCI.9 ME2 Minimum 20 observations completed per ward per month? System — audit count report PCI.9 ME3 Are staff trained in the WHO 5 Moments? Training records current? Document Review — training records PCI.9 ME1 4 KPIs Indicator Target Frequency JCI Reference Hand hygiene compliance — ICU / High Dependency >=90% Monthly PCI.9 ME2 Hand hygiene compliance — General Wards >=80% Monthly PCI.9 ME2 Minimum observations per ward per month >=20 obs. Monthly PCI.9 ME3 5 EVIDENCE REQUIREMENTS Evidence Item Format Key Fields Retention Hand Hygiene Observation Record Digital form (auto-saved) Ward, date, auditor, moments observed, Y/N per moment, compliance rate auto-calculated 2 years Monthly HH Compliance Report System-generated Ward, staff category, compliance rate, trend vs. prior month 3 years Added Recommendations • Compliance rate = Yes ÷ (Yes + No) × 100. 'Not Observed' moments are excluded from the denominator. • A ward falling below target for 2 consecutive months auto-adds to the IPC Committee agenda. The benchmark line on the trend chart should show both the WHO global minimum (80%) and the organisation's own target as separate configurable lines.