About compliance

Every number on the Compliance Analytics page is built from hand hygiene opportunities: patient room visits that Hand Hygiene expects to start and end with a wash. Hand Hygiene detects each visit from a staff member's Smart Badge, credits the dispenses around it as a wash-in or wash-out, and scores it. The Compliance Analytics page adds up those scores for the dates and filters you choose.

Knowing how that works helps infection prevention leads and nurse managers read a number correctly, explain it to others, and spot when a figure reflects a setup gap rather than staff practice. Hand hygiene data is meant for trend analysis and coaching, not for discipline.

Who has access to the Compliance Analytics page

The Administrator, User, Contact tracer, Viewer, Limited User, and Nurse Manager roles have access to Compliance. The Nurse role does not. Every role with access can also export the page's opportunities and generate a Compliance Report from it.

Everyone sees data only for the campuses they have access to in the Users app. Two people with different campus access can open the same page with the same filters and see different numbers. See About user access to Hand Hygiene.

What counts as an opportunity

An opportunity starts when a staff member's Smart Badge is detected entering a room where their visit requires hand hygiene. Which visits require hand hygiene is set by Room Types, Room Matching, and the Staff Types Rules for each Room Type. See About room types and room matching.

Hand Hygiene records the opportunity as soon as the visit starts, with both washes set to Pending. It then finishes the opportunity in one of these ways:

• Scored: the visit ends and the wash window closes, and Hand Hygiene records each wash as Done or Unfulfilled.
• Removed as a short visit: the visit was shorter than the Minimum Visit Duration. The opportunity is deleted, so it is not counted as a miss.
• Removed for low signal confidence: a dispense near the visit was detected with too little confidence to say whose badge it was, and fewer than two confident dispenses were found. The opportunity is deleted rather than scored as non-compliant.
• Removed as obsolete: the visit was still open 12 hours after it started, which usually means the exit was never detected. The opportunity is deleted.

A removed opportunity leaves every number on the page. A scored opportunity stays.

How washes are credited

A dispense counts toward an opportunity when it falls inside the opportunity's wash window. The window opens the Valid Wash-In Period before the badge enters the room and closes the Valid Wash-Out Period after it leaves. The time spent inside the room is part of the window, and any dispenser counts, wherever it is.

Hand Hygiene looks at the confident dispenses credited to the staff member's badge in that window:

Two things about this rule are easy to miss:

• A single wash is recorded as the wash-in, even when it happened after the staff member left the room. As a result, opportunities with a wash-out only are rare, and most single-wash opportunities show a wash-in only.
• The two washes are not checked against entry and exit. Two confident dispenses anywhere in the window make the opportunity fully compliant, including two dispenses in a row before entering.

One dispense can count for more than one opportunity. When a staff member leaves one room and enters the next, a wash between the two can fall inside both windows and count for both.

Which staff member a dispense is credited to is decided by the Dispenses Distribution Algorithm. See About the Dispenses Distribution Algorithm.

How long an opportunity takes to be scored

Hand Hygiene scores an opportunity after the visit ends and the Valid Wash-Out Period has passed, plus a five-minute allowance for late dispense data. It checks for opportunities ready to score every five minutes. With short wash windows, most opportunities are scored within about ten to fifteen minutes of the staff member leaving the room. An opportunity with two confident dispenses can be scored sooner.

Until then, the opportunity counts in Total Opportunities with a score of 0%. This is why today's numbers usually start low and rise as the day's opportunities are scored. See Troubleshooting: Compliance data looks incomplete or delayed.

How each number is calculated

The worked figures in this table use a sample of 10 opportunities: 6 with both washes, 2 with one wash, and 2 with none.

Overall Compliance is always between Full: and Any:. When Full and Any are far apart, many opportunities have only one wash, and the half credit for those is what lifts Overall Compliance above Full.

Total Activations is not a compliance measure. A dispense that falls outside every wash window still counts as an activation. Comparing it with Total Opportunities shows roughly how much dispenser use happens around patient visits.

Compliance Over Time

The Compliance Over Time chart draws one or two compliance rates as lines, with one point for each day or week. Select Series to choose which rates to compare. The list is headed Compare up to 2.

• Overall: the same calculation as Overall Compliance on the KPI tile.
• Any: the same calculation as Any: on the KPI tile, opportunities with at least one wash.
• Full: the same calculation as Full: on the KPI tile, opportunities with both washes.
• Single-wash: opportunities with exactly one wash, divided by all opportunities. It equals Any minus Full.

Overall and Any are shown when the page opens. At least one series is always shown, and no more than two: once two are selected, the others can't be selected until you clear one.

The chart also draws a target line at the value of the Good handle on the Compliance Thresholds slider in Settings. It is a target for full compliance. When Full is one of the series, the line is labeled Target, and you compare it with the Full line. Otherwise it is labeled Full target, as a reminder that Overall, Any, and Single-wash are not measured against it.

The chart shows one point per day when the date range is 35 days or shorter, and one point per week when it is longer. Weeks start on Monday, so the first and last weeks in a range can be partial weeks. A day or week with no opportunities has no point.

Rankings

Each ranking lists units in order of their Overall Compliance, using the same average-score calculation as the KPI tile. Units with the same score are listed alphabetically. Each row also shows the unit's number of opportunities and a trend indicator.

The rank color compares the unit's Overall Compliance with the Compliance Thresholds in Settings:

• Green: at or above the target.
• Yellow: below the target and at or above the warning level.
• Red: below the warning level.

The thresholds are defined as full-compliance targets, but the rankings color the Overall Compliance score, which includes half credit for single washes. A unit can show green in the rankings while its full compliance is still below target.

Which opportunities are included

Date range and time zone

An opportunity belongs to the date and time its visit started. A visit that starts at 11:50 PM and ends after midnight counts on the day it started.

The date range, the Day and Time filters, and the days and weeks on the chart all use the time zone set on your computer or browser. Two people in different time zones who choose the same dates can see different numbers. Every preset, such as Last 30 days, includes today, and the range always includes the whole of its last day.

Filters

Within one filter, selections combine with OR: choosing two departments includes both. Different filters combine with AND: a Department and a Role together include only that role's opportunities in that department.

Department is where the opportunity happened. Team is the staff member's own home department, wherever they worked. A nurse whose home department is ICU, covering a shift on a medical-surgical unit, is counted under the medical-surgical unit for Department and under ICU for Team. Staff with no home department set are left out when a Team filter is set and do not appear in Team Rankings.

Department names are grouped across campuses. If two campuses each have a department called "ICU", selecting "ICU" includes both unless you also select a campus in Location.

Some Time periods overlap. Evening (6pm-12am) falls mostly inside Night shift (7pm–7am), Afternoon falls inside Day shift (7am–7pm), and Morning (6am-12pm) falls mostly inside Day shift. When you select overlapping periods, each opportunity is still counted once.

How filters apply to Total Activations

Location, Department, Day, and Time filter activations by the dispenser's campus and department and the time of the dispense. Team and Role filter activations by the badge detected at the dispenser. With either of those set, dispenses where no badge was detected drop out of Total Activations, so the count can fall sharply.

Trend indicators and the comparison period

Each KPI tile and each ranking row shows a trend indicator: an up arrow, a down arrow, or a dash for no change. The comparison period is the stretch of time of the same length immediately before your date range. For Last 30 days, it is the 30 days before that.

The percentage beside the arrow is the relative change from the comparison period, not the difference in percentage points. If Overall Compliance goes from 50% to 60%, the indicator shows 20%, because 60 is 20% higher than 50. When the comparison period had no data, there is no indicator, because a change from zero can't be calculated. A ranking row shows no trend indicator when that unit had no opportunities in the comparison period.

On the Total Opportunities and Total Activations tiles, the indicator shows -- while data for your date range or the comparison period is still arriving or incomplete. Point at it to see Not enough data to calculate trend. Compare these counts once both periods are complete.

Each KPI tile also has a small bar chart. It shows the last seven days of the date range, one bar per day, with each bar scaled against the tallest of the seven. It shows the shape of the week, not exact values. These bars follow the Location, Department, and Team filters, but not Role, Day, or Time.

Rounding

Every percentage on the page is rounded to a whole number. Each rate is calculated from the underlying counts and rounded once, so Full:, Any:, and Overall Compliance are each exact to the nearest whole percent. Adding rounded figures together, such as Full and Single-wash on the chart, can be one point away from the rounded Any rate.

How Opportunity Configuration changes the numbers

The settings under Settings > Settings > Hand Hygiene Configuration decide what becomes an opportunity and which dispenses count:

• Minimum Visit Duration: a higher value removes more short visits, which lowers Total Opportunities and often increases compliance, because quick in-and-out visits are the ones most often missed.
• Valid Wash-In Period and Valid Wash-Out Period: longer windows let more dispenses count, which increases compliance. They also delay scoring, because Hand Hygiene waits for the wash-out window to close.
• Compliance Thresholds: these set the Target line and the ranking colors. They do not change any calculated number.

Changes apply to opportunities Hand Hygiene scores after the change. Opportunities already scored keep their scores, so a period that spans a change mixes old and new rules. See Opportunity configuration (system-wide).

When some locations have incomplete data

Hand Hygiene sometimes has not received all the data for a campus on some days. When any location that matches your date range and filters has missing or partial data, the Compliance Analytics page shows a notice that the calculated compliance, opportunities, or rankings might not reflect real data.

Select here in the notice to open Locations with incomplete data. It lists each affected campus with the day or days affected, each marked Missing (no data) or Partial (some data). Treat the numbers for those campuses and days with care, or choose a date range that leaves them out.

To hide the notice, select its close icon (Dismiss this note). It appears again when the affected campuses or days change.

When a number can mislead

• Small numbers of opportunities. A unit with 4 opportunities can top the rankings at 100% and drop to 50% after a single miss. Rankings have no minimum, so check the opportunity count on each row before drawing conclusions.
• Today and the current shift. Unscored opportunities count as 0% until they are scored. Judge compliance on completed days and weeks.
• Large trend percentages. The trend is a relative change, so small rates and small samples produce large swings. A move from 10% to 15% shows as 50%.
• Staff without a Smart Badge. Hand Hygiene can only see staff who wear a badge assigned to their staff profile. Staff without one create no opportunities, so their practice is missing from every number, not counted as a miss. See Provision a badge to staff.
• Rooms not matched to a Room Type. Visits to rooms without Room Matching, or with Staff Types Rules that don't require hand hygiene, create no opportunities. A department that looks very quiet may have unmatched rooms.
• Rooms or staff without a department. Opportunities in rooms with no department do not appear in Department Rankings or under a Department filter. Staff with no home department do not appear in Team Rankings or under a Team filter.
• Dispensers that are offline. A dispense that never reaches Hand Hygiene cannot be credited. Compliance drops in the area around that dispenser, and so does Total Activations. Check Dispensers Management when one area falls suddenly.
• Low-confidence dispenses. When a dispense near a visit cannot be confidently linked to a badge, the opportunity can be removed instead of scored. Crowded dispenser areas can lower Total Opportunities without changing practice.
• Test Mode walk-throughs. Test Mode shows the same live opportunities and dispenses as the rest of Hand Hygiene. Badges walked through rooms while testing a setup create real opportunities that count on the Compliance Analytics page. See About Test Mode.
• Different time zones. Colleagues comparing numbers from different time zones can see different days, shifts, and totals.
• Settings changes mid-period. A change to Opportunity Configuration or to the Dispenses Distribution Algorithm moves compliance without any change on the floor. Tell anyone who follows the numbers before the change takes effect.

How the Compliance Analytics page relates to other views

• All Opportunities (under Management) lists the individual opportunities behind these numbers, one row per visit, with the credited wash times. Use it when you need to see a specific staff member, room, or time. It filters by the same visit start time. See All Opportunities.
• Export CSV on the Compliance Analytics page downloads the same opportunities as All Opportunities, filtered by the Compliance Analytics page's date range and filters.
• Compliance Report shows Overall Compliance Rate with the same calculation as Overall Compliance. The report uses only the date range, location, and department chosen in the report window. It does not apply the Team, Role, Day, or Time filters, so it can differ from what the page shows. See About reports.
• Team Dashboard shows standings for the Department Race, which are calculated separately for that purpose. Its figures are not expected to match the Compliance Analytics page. See Team Dashboard.

For the steps to filter the page, read each chart, export, and generate a report, see View Compliance Analytics.