Advisory no: A12/01 | National Hand Hygiene InitiativePrograms

Advisory no: A12/01

TITLE / Hand Hygiene Programs
VERSION / 3.0
DATE OF PUBLICATION / 22 May 2017
REPLACES / Version 2.0 issued 8 September 2015
STATUS / ACTIVE
COMPLIANCE WITH THIS ADVISORY / Mandatory for accrediting agencies
APPROVED FOR DISTRIBUTION BY / Chief Operating Officer
REVIEW DUE DATE / 31 December 2018
INFORMATION IN THIS ADVISORY APPLIES TO / All health service organisations
KEY RELATIONSHIP / NSQHS Standard 3, Item 3.5
RESPONSIBLE OFFICER / Margaret Banks
Senior Program Director
CONTACT DETAILS / Phone:1800 304 056
Email:
TRIM NO. / D15-14607
LINKAGES TO OTHER ADVISORIES and/or DOCUMENTATION /
  • NSQHS Standards 3 Safety and Quality Improvement Guide
  • National Hand Hygiene Manual

ATTACHMENT / n/a
NOTES
(if applicable) / Note name change

Version 3.0|To be published1

Advisory no: A12/01 | National Hand Hygiene InitiativePrograms

Advisory no: A12/01

Hand Hygiene Programs

PURPOSE:

To clarify for accrediting agencies and their assessors the requirements for assessing the organisation’s hand hygiene program.

ISSUE:

To ensure assessment of hand hygiene programs covered in Actions 3.5.1, 3.5.2 and 3.5.3 is in clinical areas.

National Safety and Quality Health Service (NSQHS) Standard 3, Actions 3.5.1, 3.5.2 and 3.5.3 requires health service organisations to develop, implement and audit a hand hygiene program consistent with the current National Hand Hygiene Initiative.

The current manual on the National Hand Hygiene Initiative is available from the Hand Hygiene Australia website at: The 5 Moments for Hand Hygiene (

REQUIREMENT:

There is no requirement as part of the assessment of an organisation’s hand hygiene program for the assessment to include non-clinical areas. However, non-clinical workforce (such as food service or administrative team members) should use the 5 Moments for Hand Hygiene when they are working in clinical areas. Hand hygiene auditing should record observations of all members of the workforce in the clinical area during an audit.

Feedback of audit results should be shared with the non-clinical and clinical workforce working in clinical areas.

A health service organisation may decide to undertake hand hygiene auditing across all areas of the organisation. However, data submitted as part of the NHHI need only be collected from patient care areas, as identified in the Hand Hygiene Australia Manual.

Guidance on the number of audits to be undertaken and the location to be audited is available in the Hand Hygiene Australia Manual and is dependent on an organisation’s size, complexity, context and risk factors.

There is no requirement for hand hygiene to be standardised as long as the promotion of hand hygiene throughout the organisation is consistent with the 5 Moments for Hand Hygiene and the NHHI.

Version 3.0|To be published1