Action 3.10 states
The health service organisation has a hand hygiene program that is incorporated in its 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
Support implementation of a hand hygiene program that is consistent with the current National Hand Hygiene Initiative.
- What processes are used to ensure that the organisation's hand hygiene program is consistent with the current National Hand Hygiene Initiative and with state or territory requirements?
- How is compliance with the current National Hand Hygiene Initiative measured? What action has been taken to improve compliance?
- How and when does the organisation communicate hand hygiene compliance to the workforce, the governing body, consumers and other stakeholders?
- How does the organisation use hand hygiene compliance results to improve hand hygiene by its workforce and infection prevention and control practice?
Examples of evidence
- Hand hygiene program policy documents that are consistent with the current National Hand Hygiene Initiative and state or territory requirements
- Formative evaluation of the organisation's hand hygiene program, including use and availability of equipment, supplies and products for hand hygiene
- Training documents (for example, syllabus, attendance records or competency assessments) relating to the hand hygiene program
- Processes for auditing hand hygiene compliance within the organisation, including maintaining a registry of current valid auditors
- Evidence of workforce attendance and evaluation of hand hygiene training
- Observation and audit results of workforce compliance with the hand hygiene program
- Evidence of how audit and other data are used to inform strategies to reduce non-compliance or inconsistency with the current National Hand Hygiene Initiative and jurisdictional requirements
- Committee and meeting records in which hand hygiene data and strategies to improvement hand hygiene compliance were discussed
- Evidence of communication with consumers and the workforce about compliance rates and/or other data relevant to the organisation's hand hygiene program
- Memorandums, newsletters, posters or other communication material on hand hygiene provided to the workforce and consumers
- Availability of hand hygiene products or dedicated hand washing basins and promotional material in public areas
- Observation of hand hygiene consumer resources being provided to patients and/or carers as part of patient care discussions
- Feedback from consumers and the workforce on the hand hygiene program