Guidelines for Data Submission - Hospitals

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Hand hygiene auditing and performance feedback in considered a core element of the National Hand Hygiene Initiative (NHHI). Auditing hand hygiene compliance serves multiple functions, including quality of care assessment, incentive for performance improvement, outbreak investigation and infrastructure design.

To appropriately measure hand hygiene compliance, the Hand Hygiene Australia (HHA) 5 Moments approach allows a comparison of hand hygiene performance across a broad range of health care settings and within a facility across both high versus lower risk clinical environments. 

Data Collection Process
All hand hygiene compliance data submitted must:
  • be collected by a validated auditor (see Chapter 5 of the HHA Manual)
  • be collected from appropriate clinical areas as stated below
  • meet the minimum number of moments as outlined in Table 1 below
  • be submitted 3 times a year to HHA

Once submitted, HHA staff conduct data validation processes to ensure accuracy of data.

Clinical Area Selection

HHA recommend the initial selection of one department to start the pilot implementation of the program. It is important to choose a department where motivation and interest are high, and the health gain is likely to be substantial, thus impacting on the roll out to subsequent areas.

By piloting the program on one department, any initial problems with product placement or supply, staff motivation and education can be addressed prior to rolling out the program to the rest of the hospital.
Several factors need to be considered when determining which departments should be audited. As hand hygiene is the single most important element of strategies to prevent healthcare associated infection, departments known to have greater potential for high infection rates should be targeted. Improvements in hand hygiene compliance rates in these areas will have the greatest impact on the prevention of infection and provide a safer environment for patients. Generally, these departments also have the greatest staff/patient activity and interaction, which results in higher numbers of ‘Moments’ being audited in shorter time periods.
Auditing departments where there is little staff/patient activity and interaction (i.e. non-acute settings) will result in a small number of moments being observed and resources required to undertake auditing may be better utilised measuring other aspects of a hand hygiene program e.g. product placement, education etc. 
The selection of departments should be made in conjunction with the appropriate committee at the hospital (e.g. Infection Control Committee, Hand Hygiene Committee, Quality Improvement Committee) and with Executive approval.

Once a hand hygiene program has been established and hand hygiene compliance is audited regularly, HHA encourage hospitals to ensure that all wards/departments participate in the program throughout the year. Auditing and reporting results to each ward/department encourages ownership of the program by the whole hospital.

Numbers of Moments
Inevitably compliance data will be used for comparison, be it at a ward, hospital, jurisdictional or national level.
When data is used for comparison, it is important to remember that generally a higher number of Moments audited will generate a more reliable compliance rate, as demonstrated in Chart 1
HHA recommend 95% confidence intervals are included when reporting compliance rates.

 Please note:

The below guidelines for department selection for auditing within a hospital were updated as of 1st July 2017. The new single option process was approved by the National Hand Hygiene Initiative advisory committee in May 2017.

All hospitals currently submitting data to HHA should plan a transitioning process from the previous guidelines to the current guidelines below. The transition can begin at any time, but should be planned to begin by Audit 1 2018. 


Department Selection for Hand Hygiene Compliance Auditing

All eligible departments should be audited a minimum of once per year (ideally each National Audit Period).

At least 100-200 moments should be collected per each high risk area each year.

Eligible departments:

Eligible areas provide acute care. For the purposes of the National Hand Hygiene Initiative, they are further stratified into ‘high risk’ and ‘standard risk’:
High risk eligible departments
Critical care, neonatal care, oncology/haematology, transplantation, renal
High risk may also include departments with known or suspected high rates of healthcare infections, high prevalence of patients with multi-resistant organisms, crowded accommodation, and previous low hand hygiene compliance
Standard eligible departments
Surgical, medical, mixed, maternity, paediatrics, acute aged care, perioperative, emergency departments, radiology, sub-acute

Other departments that can be included:

The following departments within an acute organisation could be included in National audits (based on a risk assessment):
Ambulatory care, dental, mental health, palliative care, and long term care

Departments that should not be included:

CSSD, kitchen, laundry, other areas where there are no patients


TABLE 1 - Hospital stratification with number of wards


Number of acute inpatient beds
Minimum Total number hand hygiene moments per audit
> 400
301 to 400
201 to 300
151 to 200
101 to 150
51 to 100
25 to 50
<25 **

** Auditing in Hospitals < 25 beds is dependent on jurisdiction, see table 2 below.


TABLE 2 – Current Jurisdictional requirements for hospital < 25 beds

Auditing required in hospitals <25 beds?
Refer to Jurisdictional representative
Refer to Jurisdictional representative
Refer to Jurisdictional representative