National Hand Hygiene - Audit Requirements

NHHI

Hand hygiene compliance auditing is conducted to assess the effectiveness of hand hygiene programs in Australia, as part of the National Hand Hygiene Initiative (NHHI). Hand hygiene compliance is assessed across both public and private Australian hospitals, consistent with AHMAC endorsed benchmark. of 80 per cent.

Health service organisations 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. The health service organisation must also demonstrate that it uses the results of audits to improve hand hygiene compliance.

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 as a whole, and relevant areas within the health service organisations, that have the greatest staff/patient activity and interaction. This results in higher numbers of Moments being audited in shorter time periods.

As auditing in services 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), it is preferable to assess other aspects of a hand hygiene program, such as product placement and availability and participation in education. As such, 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.

Annual audit data submission dates

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 relevant state and territory regulator. Health service organisations should refer to current NSQHS Advisories regarding any changes to this requirement.

Annual audit periods for the NHHI 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.

Use of Audit data for quality improvement and improved patient safety

The health service organisation must also demonstrate that it uses the results of audits to improve hand hygiene compliance and patient safety.

Guidelines for submission of data for specific settings

Data validation

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.