神秘客在推廣手部衛生扮演之角色

The Role of the Mystic Surveyor in the Hand Hygiene Program

手部衛生是預防及降低醫療照護相關感染（Healthcare-associated Infections, HAIs）推廣策略中最重要的因素之一。本研究目的是介紹某醫學中心，自2008年推行手部衛生運動起，神秘客於推廣手部衛生扮演之角色。推行手部衛生運動初期，手部衛生遵從率是偏低的，故開始進行改善。其中規劃並增設「神秘客」（手部衛生稽核員），來改善及提升手部衛生遵從率。神秘客是經由感染管制室護理師培訓且通過合格之手部衛生稽核員，每月至指定之醫療照護單位，透過稽核手部衛生遵從率，不但能真正落實手部衛生之稽核，也可避免霍桑效應（Hawthorne effect）之產生。經由神秘客的介入，手部衛生遵從率從2008年63.9%提升至2012年89.6%，並且本院逐年降低醫療照護相關感染率，由此可見，培訓合格之神秘客在手部衛生的推廣扮演重要的角色。

Hand hygiene is one of the most important factors for decreasing the healthcare-associated infections (HAIs). The aim of this study was to evaluate the role and efficacy of the mystic surveyor in the promotion of hand hygiene program in a medical center. In 2008, the rate of hand hygiene compliance (HHC) was low. The infection control committee of the hospital set up and trained the mystic surveyor team to perform surveillance and improve the rate of HHC every month. The mystic surveyor improved the surveillance of hand hygiene and prevented the Hawthorne effect in the hand hygiene surveillance. The HHC rates increased from 63.9% in 2008 to 89.6% in 2012, and the HAI rates decreased at the same time points. The role of the mystic surveyor is important in the hand hygiene program.