National Hand Hygiene Audit Requirements 2021
Hand hygiene compliance auditing is conducted to assess the effectiveness of hand hygiene programs conducted in Australia, as part of the National Hand Hygiene Initiative (NHHI), and consistent with AHMAC endorsed benchmarks. Hand hygiene compliance is assessed in both public and private Australian hospitals.
Health service organisations which are being accredited to the National Safety and Quality Health Service Standards are required to collect hand hygiene compliance data for national hand hygiene audits, unless exempted by the state and territory health regulator.
Auditing with the 5 Moments for Hand Hygiene Tool (HHCApp)
The HHCApp is the Commission's 5 Moments for Hand Hygiene audit tool. It is ideally suited for facilities, and areas in health services organisations, that have the greatest staff/patient activity and interaction. This results in higher numbers of Moments being audited in shorter time periods.
Auditing facilities where there is a low level of staff/patient activity and interaction will result in a small number of Moments being observed (for example, non-acute, primary care, mental health settings). In these settings, it is preferable to assess other aspects of a hand hygiene program, such as product placement and availability and participation in education.
Routine hand hygiene compliance auditing with the 5 Moments for Hand Hygiene audit tool is not recommended in non-acute, primary care or mental health settings.
All facilities should be aware of their jurisdictional and organisational requirements when planning measurement of their hand hygiene program. A number of audit tools are available which can be used or modified as desired. Hand hygiene compliance audits should only be undertaken by trained and validated gold standard or general hand hygiene auditors.
Audit data submission dates – 2021
In accordance with Advisory 20/01, health service organisations which are being accredited to the National Safety and Quality Health Service Standards are required to collect hand hygiene compliance data for national hand hygiene audits, unless exempted by the state and territory regulator
Arrangements for audit periods for the NHHI in 2021 are:
Audit period 1: 1 November to 31 March
Audit period 2: 1 April to 30 June
Audit period 3: 1 July to 31 October
Submitting data to the National Audit
The HHCApp is used to enter data which must be submitted by the last day of each audit period.
The hand hygiene lead for each organisation is required to press the 'submit for approval' button in the HHCApp to demonstrate that data collection has been completed. Data submission can be completed at any time in the lead up to the last day of each audit period.
Please note: by pressing the 'submit for approval' button you are closing off the audit for your organisation, which does not allow for further data entry for that audit period. Please read the guidance on how to validate and submit a completed audit prior to submitting your organisation's audit data.
Guidelines for data submission
Guidelines that support submission of hand hygiene audit data by hospitals and some specific clinical settings are listed. These guidelines are intended to ensure all hand hygiene compliance data collected and submitted, as part of the NHHI, is an accurate and reliable representation of a participating organisation's hand hygiene compliance. All organisations submitting data as part of the NHHI are required to follow these guidelines.
Data validation must be completed by hand hygiene leads before final submission of data to the NHHI.
While an audit is active in HHCApp, changes can be made to data if errors are found. Once an audit has been submitted and the status in HHCApp is “pending approval”, then changes can only be made after discussion with your jurisdictional coordinator, or by contacting the NHHI Helpdesk.
Final submission of data by the hand hygiene lead provides confirmation that the data has been reviewed and accepted by the organisation.
Please review the NHHI Manual (Chapter 7.6 - Data Validation) for detailed guidance on how to conduct validation of your data. In summary, hand hygiene leads should review the following:
- Correct number of Moments reported for the organisation
- Correct number of Moments reported for each eligible department
- Data were collected by currently validated Gold Standard or General Auditors only
- Auditor hand hygiene compliance is appropriate for the area audited
- Observations were conducted in clinical settings
- Moments observed were appropriate for healthcare worker type
All outlier data should be investigated by the hand hygiene lead prior to submission.