Hand Hygiene

Auditing and Evaluation

Auditing Hand Hygiene

The role of hand hygiene auditor is integral to reducing healthcare associated infections through auditing of their colleagues hand hygiene practices. Throughout the year, trained hand hygiene auditors collect data using direct observation of their colleagues hand cleaning when in clinical encounters. Based on the WHO '5 moments', hand hygiene compliance (HHC) rate is calculated as such:

Hand Hygiene Compliance % =

Total compliant moments x 100
Total moments observed

In NSW, there are over 220 facilities that regularly submit data as part of the National Hand Hygiene Initiative (NHHI).  All NSW Local Health Districts and Specialty Networks contribute data from facilities that include acute inpatient hospitals, residential aged care centres, community health networks, dental facilities and mental health units. National data can be found on theNational Hand Hygiene website.

There are three reporting cycles each year in which data must be submitted to the national database. Final dates for submission of hand hygiene compliance data are:

  • 31 March
  • 30 June
  • 31 October

NSW submits around 200,000 audited 'moments' each audit period - approximately 35 per cent of the national data.  Hand hygiene auditors can submit their data Hand Hygiene Compliance Application (HHCApp).

Using Data to Drive Change

Health facilities use data to compile reports that can identify areas of high compliance or low compliance with hand hygiene. These areas may include departments, professional groups or even compliance with specific 'moments'.

Frontline ownership of hand hygiene data is an important enabler of hand hygiene culture sustainability. It follows that clinical areas, and their management, are responsible for their own hand hygiene compliance results and staff should engage in strategies to improve and invigorate hand hygiene at a local level. For change to be implemented, results from hand hygiene auditing should be discussed in a relevant and timely fashion.

Public display of ward and facility hand hygiene compliance results can act as a visual cue for clinical practice improvement and reinforce consumer awareness that hand hygiene is everyone’s ‘core business’. The CEC Help Us Beat Infections poster is a resource for just this purpose. The CEC also provides progress reports in e-Chartbook.