ࡱ> uwv@ bjbjFF )2,,+++8V+j+lb8&+++++,,,7777777$9R;8w-,,w-w-8++8---w-8++7-w-7---++ !"+-(-. 280b8-<-:<-<-$,,-, ,,,,88(+-+Hand Hygiene/Glove Use Observation Tool (Developed for VA-3M Six Sigma Project) INSTRUCTIONS: Observe practice. Include a variety of disciplines. NOTE: Hand Hygiene refers to use of alcohol foam hand rub or washing hands with soap and water for at least 15 seconds Date(s): ________________________________ Unit: Completed by:_______________________________________ Staff TitleYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNo HAND HYGIENEBefore clean and aseptic procedures, including medication prep and prior to prep, gown & glove for sterile procedures.After contact with blood, body fluids, secretions or excretions, mucous membranes, non-intact skin.After handling objects and devices such as soiled linen, trash, equipment.After removing gloves or other PPE used for contact with body substances.Before patient contact. *After patient contact upon exiting patients room. *Upon entering patients room before equipment contact. **After equipment contact upon exiting patients room. **  GLOVE USEWhenever potential for hand contact with blood/body substance.Gloves removed immediately after use to avoid contaminating the environment. Staff Titles: MD attending (MDA); MD resident/fellow (MR/F); Med Student (MS); RN; NA; Respiratory Therapy (RT); X ray (XR); IV team (IVT); Dietitian (DT); Chaplain (Chap); Social Worker (SW); other-identify. Make a single hash mark for each hand-hygiene opportunity. * Use of hand-hygiene between patients (as on rounds) is acceptable if no other activity intervenes(e.g. use of a telephone.) **Hand-hygiene is recommended before entering and upon exiting a patients room even if the only contact is with equipment in the room (CDC Level II). It is NOT necessary to repeat hand-hygiene when moving between the patient and equipment WITHIN the same patients room (e.g. patient to computer to ventilator to monitor to patient). 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