Hand Hygiene Governance

All NSW Health Local Health Districts and Specialty Networks are required to implement, monitor and report on hand hygiene using the National Hand Hygiene Initiative (NHHI) program. All NSW Local Health Districts and Specialty Networks have leads for Hand Hygiene (HH). These key leads work closely with the HAI team to identify and monitor opportunities for improvement with hand hygiene and the NHHI.

The NHHI is underpinned by:

  • ACSQHC National Standard for Prevention and Controlling Healthcare-Associated Infection
  • NSW Health Infection Control Policy

The NSW Health Infection Control policy outlines the specific hand hygiene practices required by any person working within NSW Health, to minimize the risk of patients, visitors and staff acquiring a HAI. It identifies when staff must perform hand hygiene and requires the use of alcohol based hand rubs for most instances of hand hygiene during patient care. Hand washing with liquid soap and water is recommended for situations when hands are visibly soiled, or when caring for a patient with Clostridioides difficile or norovirus.

Essential elements of a hand hygiene program are:

  • Strategic placement of alcohol based hand rubs (ABHR) for staff, patients and visitors
  • Provision of hand washing facilities for all staff, patients and visitors
  • Education and awareness of HH for all healthcare staff
  • Auditing and reporting of HH compliance to NHHI
  • Provision of compliance results to healthcare staff
  • Identification of improvement opportunities
  • Regular evaluation of the local HH program


The role of a hand hygiene auditor is integral to reducing healthcare associated infections through auditing of their colleagues hand hygiene practices. Hand hygiene auditing occurs regularly in patient areas with trained hand hygiene auditors observing direct and indirect patient care and or interactions, in line with the WHO My Five moments for Hand Hygiene.  NSW Health submits around 200,000 audited 'moments' each audit period. This represents approximately a third of the national data. Hand hygiene auditors submit their data through the Hand Hygiene Compliance Application (HHCApp). Hand hygiene compliance (audit) data is required to be submitted by all NSW Health Organisations (HOs) to the NHHI three times a year. NHHI HH audit periods are the same every year:

  • Audit period one: November 1 – March 31
  • Audit period two: April 1 – June 30
  • Audit period three: July 1 – October 31

At the end of each audit period, the HAI team review and validate the submitted NSW Health HH audits. Once approved, the validated HH audits are formally transferred to the NHHI. At the end of this process, the NSW Health results will be updated on the NHHI HH compliance dial.

The compliance dial is used by local HH leads for visual communication and display of the hand hygiene compliance results for individual wards, departments and facilities.

Education and Auditor Training

Hand hygiene auditors are an important and valuable resource for hand hygiene and the NHHI. There are two types of hand hygiene auditors:

  • gold standard auditors (GSA)
  • standard auditors

Both types of hand hygiene auditors are considered role models for hand hygiene and the NHHI and can provide hand hygiene feedback to colleagues in their workplace. The biggest difference, gold standard auditors;

  • train and support the development of standard auditors for local hand hygiene programs
  • support the local facility’s NHHI program
  • are a hand hygiene resource within their workplace

Gold standard auditor (GSA) training

A requirement of the NHHI, is for GSA training to be led and facilitated by jurisdictional leads in all states and territories in Australia. For NSW Health, the jurisdictional role sits with the HAI team at the CEC. The content, format and assessment process for GSA training is specified by the NHHI.

The CEC-HAI team are working closely with other NSW Health agencies to standardise enrollment of and access to hand hygiene auditor training resources.

Standard auditor training

Standard auditor training is led and facilitated by all NSW Local Health Districts and Specialty Networks. The content, format and assessment process for standard auditor training is specified by the NHHI program. The local infection prevention and control team is the first point of contact to seek further information for local hand hygiene auditor training.

Guide to Bare Below the Elbows

The efficacy of hand hygiene is enriched when: skin is intact, nails are natural, short and unvarnished; hands and forearms are free of jewellery including religious items, and sleeves are above the elbow.

Healthcare workers having direct contact with patients or a patient's zone should comply with the following:

  • Hand, wrist or forearm jewellery (e.g. piercings, rings, watches, bracelets, bands, movement trackers, embedded jewellery) must not be worn by healthcare professionals in the clinical environment and where providing direct patient care, unless required for patient care (e.g. watch) or medically essential (e.g. medical alert bracelet). These must be removable, able to be cleaned and not be able to cause injury to patients during direct clinical care.
  • Wearing of rings in clinical areas must be limited to a plain band on the finger and this should be moved about on the finger during hand hygiene.
  • To allow for adequate antiseptic scrubbing of hands and forearms prior to a high risk aseptic or surgical procedure all hand, wrist and forearm jewellery must be removed.
  • Long sleeve articles of clothing should not be worn in clinical environments. If worn sleeves must be rolled above the elbow during clinical/direct patient care.
  • The only forearm attire permitted within the clinical area is PPE (impervious gowns, sterile gowns, gloves).
  • Nails should be kept short and clean and nail polish should not be worn. Artificial nails (gel or acrylic) must not be worn by any Health Worker with direct patient contact.
  • Any breached skin (cuts, dermatitis or abrasion) should be covered with a waterproof film dressing. Staff with dermatitis should report for evaluation as per local protocols.

The ability to perform effective hand hygiene for the clinical care required must not be impeded by the wearing of long sleeved garments or forearm jewellery (for example religious bangles, medical bracelets or bandages).

Requirements for Clinical Glove Use

  • Wearing gloves does not eliminate the need for hand hygiene. Perform hand hygiene immediately before and after glove use.
  • Wear gloves when contact with body substance is anticipated.
  • Change gloves during patient care if moving from a contaminated body site to a clean body site.
  • Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient.
  • Change and discard gloves if they become torn, punctured or compromised in any way.
  • Gloves must not be sanitized, washed or reused.

More information is available via the National Hand Hygiene Initiative.