Hand hygiene auditor training pathway

Healthcare facilities that promote and contribute to the National Hand Hygiene Initiative (NHHI) audit hand hygiene moments compliance based on the 5 moments of Hand Hygiene. All healthcare facilities aim to meet the National and State hand hygiene benchmark of greater than 80 %, to promote better patient outcomes by preventing or reducing  healthcare associated infections.  Consistent and standardised training as a validated auditor follows the principles of the NHHI and the 5 moments of Hand Hygiene which relies on a standardised approach to auditing to provide consistent and accurate compliance data.

Required auditors per facility

The number of auditors required for an organisation depends on the healthcare facility size. Please refer to Section 7.3 in the NHHI Hand Hygiene Manual, 2019.  Your hospital NHHI administrator or Infection Control Professional may request that you be trained as a general hand hygiene auditor that will submit data to the NHHI.  If your facility would like to monitor Hand Hygiene compliance but do not meet the guidelines for acute hospital data submission,  using the SA Health Hand Hygiene Observation Tool (PDF 196 KB) may be a more suitable option.

Prospective auditors

Key points for hospital administrators and ICP’s to consider that the prospective auditor will:

  • have time available to conduct audits and be able to collect a minimum of 100 moments annually to maintain validation and ongoing currency of auditor status
  • have a background as a clinical health professional
  • availability to attend NHHI auditor training
  • have a good understanding of auditing/feedback/education processes
  • acknowledge and understand safety and privacy concerns of patients and staff.

Other points to consider would be that the prospective auditor:

  • can provide immediate feedback to staff for good hand hygiene practices, and educate on correct hand hygiene practice
  • can promote widespread acceptance/ownership/participation in activities to improve hand hygiene within their area.

The resources required to train as NHHI Hand Hygiene General auditor (GA) can be achieved as an online self-learning package. The final validation will require a “shadowed” practical ward session, auditing with a Gold Standard auditor (GSA).  A GSA can attend from another site if this is not practical.

General hand hygiene auditor training

To become a Hand Hygiene General Auditor (GA), participants are required to complete mandatory pre-requisite online training module, self-learning package and a practical component.

Pre-requisite self-learning

Complete the following pre-requisite self-learning online education packages via the NHHI Learning Management System:

Note:  All new learners need to complete a registration as a new user the first time they access the system only.

The NHHI Learning Management System (LMS) is not compatible with Internet Explorer. The site works best using the following browsers: Google Chrome, Microsoft Edge, Safari and Firefox.

Provide the pre-workshop completion certificates to the Gold Standard Auditor (GSA) in your facility.

Self-learning package

Identified staff will need to complete the following seven-step components of the self-learning package:

  1. View the 5 Moments of hand hygiene presentation (PDF 1.5MB)
  2. View the Hand hygiene self-educational videos 1 to 34
  3. Complete the Hand hygiene written quiz (PDF 441KB)
  4. View the How to audit presentation:
    Note: the videos pertain into the below presentations cannot be viewed in the PowerPoint, please view the  Hand hygiene self-educational videos 35 to 40     
  5. View the Hand hygiene DVD No.1 quiz 
  6. Complete the DVD quiz No.1 worksheet (PDF 265KB) and provide to your facility's GSA for marking.

Any queries related to the self-learning package, please contact your facility’s GSA or Hand Hygiene Program Coordinator.

Practical component

Contact your GSA in your facility to complete a practical ward session to finalise the last stage of your hand hygiene training. Once all components of the training have been completed, the GSA can add the auditor to the NHHI database for access to enter hand hygiene audits.

Annual competency

Provide completion certificates for the annual Hand Hygiene Module for auditors to the GSA in your facility.

Gold standard auditor (GSA) pathway

The hand hygiene gold standard auditor pathway provides formally sequences of learning that enabling a general auditor to become a GSA within their facility.

Further information

For further information on hand hygiene auditor education and training, contact the SA Health Infection Control Service or (08) 7425 7161. 


NHHI resources have been used with the kind permission of Australian Commission on Safety and Quality in Healthcare (ACSQHC).