One hand in your pocket enhancing hand hygiene auditing: A pocket book for auditors

Mr Brendon Heley1,

Mrs Ann Whitfield1

1Fiona Stanley Hospital, Murdoch, Australia.


The development and sustainability of a quality Hand Hygiene (HH) program has required leadership and engagement from all staff, including executives, to meet the Western Australian HH benchmark of 80% compliance. This said the ownership and accountability has largely been placed on the Infection Prevention and Management Team (IPMT) to undertake HH surveillance since 2015. Enhancing participation from general Hand Hygiene auditors in the clinical environment has proved challenging in obtaining mandatory data.


The idea and development of the HH auditor book was based on the experiences and challenges faced by general HH auditors in clinical areas. Challenges identified by staff included time constraints, difficulties in accessing the data collection sheets and juggling conflicting priorities. In 2016, the IPMT was the predominant data collector for the HH program, collecting 81% of moments.


The first audit period for 2017 saw 5001 moments being captured, with 52.7% being collected by ward auditors. This indicates that the HH auditor book had a significant and positive tool that aided moment collection. It allowed auditors to take ownership of data collection and note areas of poor compliance.


Sustainability of the HH program must focus on leaders and auditors’ engagement within clinical areas. The ability to make changes whilst ensuring patient safety starts with the clinicians caring for the patients.


Brendon Heley is a keen and passionate Clinical Nurse in Infection Prevention and Management at Fiona Stanley Hospital. He has a background in Intensive Care nursing which has given him firsthand experience in the impact of infection control. His vision is to see a reduction in healthcare associated infections.

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