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:

  1. Is consistent with the current National Hand Hygiene Initiative, and jurisdictional requirements
  2. Addresses noncompliance or inconsistency with benchmarks and the current National Hand Hygiene Initiative
  3. 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
  4. Uses the results of audits to improve hand hygiene compliance

 

Intent

Support implementation of a hand hygiene program that is consistent with the current National Hand Hygiene Initiative.

Reflective question

  • 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

See also: