Advisory AS23/01: Advice on national hand hygiene audit period 2
To advise of changes to data submission requirements for national hand hygiene audit period 2.
|20 June 2023
|Compliance with this advisory
|It is mandatory for approved accrediting agencies to implement this advisory
|Information in this advisory applies to
|Preventing and Controlling Infections Standard, NSQHS Standards
Director, National Standards
Phone: 1800 304 056
|To be reviewed
To advise of changes to data submission requirements for national hand hygiene audit period 2
Health service organisations that are accredited to the NSQHS Standards were, until 1 April 2023 required to submit hand hygiene data to the national audits three times a year, unless exempted by the state or territory regulator, to meet Action 3.10 of the Preventing and Controlling Infections Standard. Action 3.10 Hand Hygiene requires health service organisations to have a hand hygiene program that is incorporated in their overarching infection prevention and control program as part of standard precautions and:
- Is consistent with the current National Hand Hygiene Initiative, and jurisdictional requirements
- Addresses noncompliance or inconsistency with benchmarks and the current National Hand Hygiene Initiative
- Provides timely reports on the results of hand hygiene compliance audits, and action in response to audits, to the workforce, the governing body, consumers and other relevant groups
- Uses the results of audits to improve hand hygiene compliance.
The current national hand hygiene audit periods 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.
In accordance with Action 3.10d, health service organisations should use the results of audits to inform quality improvement interventions to improve hand hygiene compliance. National audit period 2 will become a voluntary audit period from 1 April 2023. This will allow health service organisations some additional time to undertake quality improvement activities.
Audit 1 and Audit 3 will be retained as mandatory national audit periods.
The Commission will continue to support organisations that wish to voluntarily participate in national audit period 2. Data that is voluntarily submitted for national audit period 2 will be included in national reporting by the Commission, with an appropriate explanatory note.
To comply with action 3.10, health service organisations must submit hand hygiene audit data for period 1 and 3. Compliance with action 3.10d no longer requires the data of audit period 2 for this purpose. Evidence of submission of Audit 1 and Audit 3 data is required.
Individual organisations should refer to jurisdictional requirements (e.g. performance or service level agreements) when deciding whether to participate in national audit period 2.
To comply with action 3.10d health service organisations must, as a minimum, provide evidence the results of hand hygiene audits are used to inform quality improvement interventions.