Hand Hygiene Campaign

According to the Centers for Disease Control and Prevention, an estimated two million patients contract a healthcare-acquired infection every year and 99,000 die from their infection.  Hand hygiene is critically important to reducing healthcare-acquired infection.  Unfortunately studies show that health care workers wash their hands less than 50% of the time.  

"The goal for everybody... is to deliver the highest quality of care, and to that end I think hand hygiene certainly has had a history of being recognized as being a simple, important mechanism to prevent infection, and yet it turns out doing it is not as simple as it seems."

Rekha Murthy, MD, Director, Hospital Epidemiology, Cendars-Sinai Medical Center, California

Clean Hands Saves Lives

To all invited Observers:

Thank you for agreeing to participate in Natividad’s new Clean Hands Save Lives hand hygiene program as an observer.  As many of us already know, evidence shows hand hygiene compliance is linked to the transmission of infection; and with our current hand hygiene compliance rate under 50, we have an opportunity to improve our compliance and reduce transmission of infection in our hospital. 

We will be following the Joint Commission Targeted Solution Tool (TST) Hand Hygiene performance improvement framework.  TST is online application created by the Joint Commission Center for Transforming Healthcare that guides health organizations through a step-by-step process to:

  • Accurately measure their organization’s actual performance
  • Identify barriers to excellent performance
  • Direct organizations to proven solutions that are customized to address their particular barriers. 

Your role as an Observer:

Our initial step in this program will be to gather baseline data on hand hygiene compliance through anonymous observations over a two week period.Your role will be to collect baseline data for your department.In order to ensure that our data collection is standardized through the organization, all observers must complete the TST Hand Hygiene Observer training by Wednesday, September 2nd, 2020.

Follow instructions for the training below (it’s a 2-step process):

  • Start with Step 1:  the Observer Training, by clicking  on the Joint Commission Hand Hygiene Observer Training tab; THEN
  • Complete Step 2:  the Evaluation 

After you completed the training and evaluation, Quality will be contacting you via email to give you instructions on starting your observations using TST Tools we provide. 

Please feel free to contact me or Drew Massengill should you have any additional questions on this process.


Maria Mata

Quality Department

Hand Hygiene Observer and Just-in-Time Coaching Education

​This training from The Joint Commission Center for Transforming Healthcare will help you understand how to observe hand hygiene compliance. 

Hand Hygiene Observer Training is a two (2) step process:

  1. Online training module from The Joint Commission which is a PDF document with inluded 8 video scenarios
  2. An online evaluation tool to measure your competence in what you learned from the training module

Step 1:  Click HERE to access Step 1:  The Training.

Step 2:  Click HERE to access Step 2:  The Evaluation.

For Step 2, you must get a score of 90% or better (15/16 questions) and you can take the evaluation up to three (3) times.

If you need help with any of these steps, please contact the Quality Department - Infection Preventionist at 755-4093.

Mobile Data Collection Tool

Joint Commission Center for Transforming Healthcare

You will need your assigned TST User Name and Password to access the mobile app.  The Quality Department will grant access to those who qualify and as the program rolls out through the hospital.

You can download the mobile app by clicking on the links below or search your App Store for "Targeted Solutions Tool." 


Once accessed...