Hand Hygiene Policy Directive
PDF 299 KB
Hand hygiene is one of the most effective measures to prevent the spread of infection. The most common way that harmful organisms are spread between patients in health care settings is on the hands of health care workers. Studies show that effective hand decontamination can significantly reduce the rate of healthcare associated infection.
As part of the World Health Organisation's First Global Patient Safety Challenge, the Australian Commission on Safety and Quality in Health Care (ACSQHC) established the National Hand Hygiene Initiative (NHHI) and for the past 10 years have engaged Hand Hygiene Australia (HHA) to implement a culture-change program into all health services throughout Australia. Since the 1st November 2019, the ACSQHC has managed the NHHI program, including education packages, resources and the national database of hand hygiene compliance audit results. Compliance with hand hygiene according to the WHO '5 moments' is recorded by specially trained and validated auditors, and hospitals are required to submit data three times per year according to the NHHI schedule. The number of 'moments' required to be audited is proportional to the size of the hospital
South Australia is supporting this initiative by including hand hygiene compliance as a key performance indicator of patient safety and quality of health care delivery. SA Health has provided several resources to assist healthcare facilities to implement the NHHI program. Healthcare facilities can contribute hand hygiene data to national and local audits. For more information refer to the ACSQHC NHHI Website.
SA Health supports World Hand Hygiene Day campaign annually.
Sampling matrix fact sheets developed by SA Health have been retired as of the 1st January 2020. Refer to the NHHI Manual, section 7.3 - Requirements for national hand hygiene data submission for acute hospitals, day hospitals, standalone/satellite/oncology centres and dental sites.
Facilities not meeting the requirements for national data submission may choose to utilise the SA Health observational audit tool (PDF 133KB), to estimate overall hand hygiene compliance and is in keeping with the 5 Moments for hand hygiene.
The SA Health Hand Hygiene Policy directive (PDF 299KB) establishes a uniform approach to hand hygiene across the public health sector.
The associated SA Health Hand Hygiene Guideline (PDF 223KB) summarises best practice for healthcare workers in the clinical setting.
NHHI audit tools are available via the National Hand Hygiene Initiative audit tool page, including:
A SA Health hand hygiene competency tool (PDF 87KB) has been developed to assess staff competency in carrying out an effective hand hygiene rub or wash.
Health-care facilities can track their progress in hand hygiene resources, promotion, activities, plan their actions and aim for improvement and sustainability through the use of the following resources:
The following fact sheets have general information on the use and selection of alcohol-based hand rub products and the appropriate use of gloves in health care.
Click on the below images to download the relevant poster.
World Hand Hygiene Day, 5 May, is part of a major global effort led by the World Health Organization (WHO). This day aims to support health-care workers to improve hand hygiene in health care and accordingly support the prevention of often life threatening healthcare associated infection (HAI).
Information on the latest campaign can be found on the WHO hand hygiene campaign website.
Infection prevention courses are available to all SA Health employees to support the National Safety and Quality Health Service Standards. There are currently three infection prevention related courses available to staff:
For further information, visit the Infection control education and training page.
Annually SA Health checks the compliance rates of hand hygiene across SA Health.
Here is how we all measured up: