Title Page

  • Inspection - Homecare Healthcare worker

  • Conducted on

  • Prepared by

  • Location

Infection Control - Hand Hygiene - 5 Moments Observations

  • Staff Interviewed Name, Title, Department:

Infection Control - Hand Hygiene - 5 Moments Observation

  • Is the patient on isolation precautions?

NON-ISOLATED HOME CARE/HOME SUPPORT PATIENT

  • What type of patient?

  • MOMENT 1: Did staff member perform hand hygiene when entering the patient room/before patient contact?

  • Coached?

  • Did staff member create or use a clean surface to place patient care items prior to use on the patient?

  • Coached?

  • MOMENT 2: Did staff member perform hand hygiene before performing a clean and/or aseptic procedure? (ex. medication pass, dressing change, etc).<br>See Sterile technique question at the bottom.

  • Coached?

  • If any items became contaminated did the staff member discard or clean the item as appropriate? (ex. items falls on floor or dirty surface)

  • Coached?

  • MOMENT 3: Did staff member clean their hands in between providing ‘dirty’ and ‘clean’ patient care - immediately after an exposure to bodily fluid and after removing gloves?

  • Coached?

  • Were observed glove changes done correctly? (hand hygiene before and between glove changes)

  • Coached?

  • Did staff member clean reusable equipment prior to storage or use on the next patient? (ex. glucometer, pulse oximetry, vital signs machine, etc.)

  • Coached?

  • MOMENT 4: Did staff member perform hand hygiene after any patient contact, such as assisting them with putting on their clothes or emptying catheter bag?

  • Coached?

  • MOMENT 5: Did staff member perform hand hygiene after touching unclean inanimate objects or themselves before approaching the patient?

  • Coached?

PERFORMANCE IMPROVEMENT PLAN (if applicable)

  • Does the staff member require additional training for improvement of skill?

Isolation Patient

  • Upon entering the patient’s room, did staff member perform hand hygiene and apply the appropriate PPE correctly for the level of isolation? (moment 1)

  • Coached?

  • Did staff member create or use a clean surface to place patient care items prior to use on the patient?

  • Coached?

  • Did staff member perform hand hygiene after touching unclean inanimate objects or themselves before approaching the patient? (moment 5)

  • Coached?

  • Did staff member perform hand hygiene before performing a clean and/or aseptic procedure? (ex. medication pass, dressing change, etc) (moment 2)<br>See Sterile technique question at the bottom.

  • Coached?

  • Did staff member clean their hands in between providing ‘dirty’ and ‘clean’ patient care? (moment 3)

  • Coached?

  • If any items became contaminated did the staff member discard or clean the item as appropriate? (ex. items falls on floor or dirty surface)

  • Coached?

  • Were observed glove changes done correctly? (hand hygiene before and between glove changes)

  • Coached?

  • Did staff member clean reusable equipment prior to storage or use on the next patient? (ex. glucometer, pulse oximetry, vital signs machine, etc.)

  • Coached?

  • Did staff member perform hand hygiene upon exiting the patient room? (moment 4)

  • Coached?

  • Ask the assigned nurse/caregiver if there is documentation in the chart that the patient/family received education on Isolation Practices and if the patient/family refused education.

  • Coached?

  • Sterile technique: Observe a staff member performing a sterile technique; did the staff member appropriately maintain sterile technique? (Ex. Did not touch non-sterile objects during procedure without removing gloves, glove changes with hand hygiene in between)

Completion

  • What sterile technique procedure did you observe?

  • Comments/Coaching/Equipment observed:

  • Observer Name & Signature:

SIGN OFF (NURSING SUPERVISOR)

  • NAME AND DESIGNATION

  • SIGNATURE

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