Clean Hands = Best Care; Evaluation, redesign and relaunching of a regional healthcare facility hand hygiene program.

Ms Penelope Radalj1, Professor Patricia Dunning2, Professor Eugene Athan3

1Barwon Health, Geelong, Australia,

2Barwon Health, Geelong, Australia,

3Barwon Health, Geelong, Australia


Barwon Health (BH) has participated in the National Hand Hygiene Initiative since 2007. This hand hygiene project is based on The World Health Organisation 5 Moments for Hand Hygiene and included standardised education materials and a regular audit system of hand hygiene compliance (HHC). BH wanted to demonstrate multimodal interventions optimally delivered with support of executive and key stakeholders have the best chance of successfully improving adherence to hand hygiene practices. This project launched in 2012 evaluated the effect of the BH hand hygiene program, initiated in 2007. Aiming to improve HHC of existing staff and capture the attention of new staff towards the importance of hand hygiene.


A working party of executive and key stakeholders assessed the current state of the BH multimodal hand hygiene program in late 2012. These findings were translated into a diagnostic document and validated with appropriate staff. Then strategies were explored to address barriers to hand hygiene compliance. These strategies once finalised were implemented and utilised to improve HHC. Support from leadership, stakeholder engagement, readily accessible hand sanitiser at point of care, education for all staff, HHC monitoring with prompt HHC result feedback, local improvement programs to manage hand hygiene noncompliance and hand hygiene promotion.


BH HHC in October 2012 was 76% for Barwon Health. This hand hygiene project initiative has delivered sustained improvement and consistently delivers HHC of 80% and higher.


BH hand hygiene program has benefited from evaluating and redesigning their hand hygiene program.


Penny has managed the hand hygiene project at Barwon Health since 2008. She is a Gold Standard Auditor in hand hygiene compliance. Qualifications include a Graduate Diploma in Acute Care Nursing and Graduate Certificate in Infection Control.

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