Action 3.8

The health service organisation has a hand hygiene program that:

a. Is consistent with the current National Hand Hygiene Initiative, and jurisdictional requirements

b. Addresses noncompliance or inconsistency with the current National Hand Hygiene Initiative

Intent

Implement and support a hand hygiene program that is consistent with the current National Hand Hygiene Initiative.

Reflective questions

What processes are used to ensure that the health service organisation’s hand hygiene program is consistent with the current National Hand Hygiene Initiative and with state or territory requirements?

How does the health service organisation measure compliance with the current National Hand Hygiene Initiative? What action has been taken to improve compliance?

Key tasks

  • Implement systems and processes to meet the National Hand Hygiene Initiative and state or territory requirements.

  • Measure and report program outcomes, including hand hygiene compliance where appropriate according to the National Hand Hygiene Initiative and state or territory requirements

  • Identify how the organisation has responded to inconsistency or noncompliance with the current National Hand Hygiene Initiative.

Strategies for improvement

Hospitals

The current National Hand Hygiene Initiative is coordinated by Hand Hygiene Australia. Assess compliance of the organisation’s overall hand hygiene program using one or more measures applicable to the organisation’s scope, size and activities.

Ensure that a manager provides leadership, direction and support to the hand hygiene program by:

  • Supporting the program to meet the requirements of the National Hand Hygiene Initiative and the state or territory
  • Determining how the organisation’s hand hygiene program will be resourced and managed.

The hand hygiene program in the health service organisation should include:

  • Availability of alcohol-based hand sanitiser at the point of care
  • Education of the workforce about hand hygiene
  • Auditing of the hand hygiene program with performance feedback
  • Development or review of a plan to respond to identified gaps, barriers and enablers that may help show improvement
  • Identification of members of the workforce or work areas for which extra training and support are required (for example, medical officers, emergency department, anaesthetics department)
  • Provision of feedback to clinicians on the overall performance of the program and results of hand hygiene activities, including hand hygiene compliance and other process audits
  • Methods for evaluating the hand hygiene program when compliance auditing is not appropriate or not required – for example
    • review of the types of products used for hand hygiene
    • review of the availability of alcohol-based products at the point of care
    • evaluation of hand hygiene products used in the organisation
    • assessment of workforce knowledge of hand hygiene
    • completion of competency assessments for hand hygiene technique
    • completion of hand hygiene education and training
  • Review or development of a process, policy or protocol to deal with issues of noncompliance or inconsistency with the National Hand Hygiene Initiative, which can include
    • identifying reasons for noncompliance and solutions to these issues
    • engaging with clinicians to identify possible solutions
    • modifying procedures, protocols or work practices to deal with issues of noncompliance or inconsistent practices in clinical services (for example, anaesthetic and emergency departments, phlebotomy services)
    • reviewing availability and workforce acceptance of equipment, supplies and products required for appropriate hand hygiene.
Day Procedure Services

The current National Hand Hygiene Initiative is coordinated by Hand Hygiene Australia. Assess compliance of the service’s overall hand hygiene program using one or more measures applicable to the organisation’s scope, size and activities.

In some day procedure services, auditing of hand hygiene practice by direct observation may not be practical. These services should check with their local health network, state or territory health department, or nearby larger hospital for their requirements as part of the National Hand Hygiene Initiative.

Ensure that a manager provides leadership, direction and support to the hand hygiene program by:

  • Supporting the program to meet the requirements of the National Hand Hygiene Initiative and the state or territory
  • Determining how the organisation’s hand hygiene program will be resourced and managed.

The hand hygiene program in the health service organisation should include:

  • Availability of alcohol-based hand sanitiser at the point of care
  • Education of the workforce about hand hygiene
  • Auditing of the hand hygiene program with performance feedback
  • Development or review of a plan to respond to identified gaps, barriers and enablers that may help show improvement
  • Identification of members of the workforce or work areas for which extra training and support are required (for example, medical officers, emergency department, anaesthetics department)
  • Provision of feedback to clinicians on the overall performance of the program and results of hand hygiene activities, including hand hygiene compliance and other process audits
  • Methods for evaluating the hand hygiene program when compliance auditing is not appropriate or not required – for example
    • review of the types of products used for hand hygiene
    • review of the availability of alcohol-based products at the point of care
    • evaluation of hand hygiene products used in the organisation
    • assessment of workforce knowledge of hand hygiene
    • completion of competency assessments for hand hygiene technique
    • completion of hand hygiene education and training
  • Review or development of a process, policy or protocol to deal with issues of noncompliance or inconsistency with the National Hand Hygiene Initiative, which can include
    • identifying reasons for noncompliance and solutions to these issues
    • engaging with clinicians to identify possible solutions
    • modifying procedures, protocols or work practices to deal with issues of noncompliance or inconsistent practices in clinical services (for example, anaesthetics)
    • reviewing availability and workforce acceptance of equipment, supplies and products required for appropriate hand hygiene.

Examples of evidence

Select only examples currently in use:

  • Policy documents about a hand hygiene program that is consistent with the current National Hand Hygiene Initiative and state or territory requirements
  • Training documents about the hand hygiene program
  • Audit results of compliance with the hand hygiene program, including clinician compliance, using passive or active assessment
  • Strategies to reduce noncompliance or inconsistency with the current National Hand Hygiene Initiative in the health service organisation
  • Committee and meeting records in which inconsistency and noncompliance with the hand hygiene program were discussed
  • Communication with clinicians about the results of hand hygiene programs and compliance rates of the workforce
  • Audit results of evaluation of the hand hygiene program, including use and availability of equipment, supplies and products for hand hygiene.
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established hand hygiene program.

Small hospitals that are not part of a local health network or private hospital group should develop processes for monitoring compliance with the National Hand Hygiene Initiative.

The hand hygiene program should include:

  • Availability of alcohol-based hand sanitiser at the point of care
  • Education of the workforce about hand hygiene
  • Monitoring of hand hygiene program compliance, using indicators such as
    • types of products used for hand hygiene
    • availability of alcohol-based products at the point of care
    • evaluation of hand hygiene products used in the organisation
    • assessment of workforce knowledge of hand hygiene
    • completion of competency assessments for hand hygiene technique
    • completion of hand hygiene education and training
  • Development or review of strategies to improve compliance with hand hygiene
  • Identification of members of the workforce or work areas in which more training and support is needed
  • Provision of feedback to clinical areas on the overall performance of the program and results of hand hygiene activities, including hand hygiene compliance and other process audits.
Last updated 21st June, 2018 at 07:53pm
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