RBWH Hand Hygiene Program: “Leading the way to success”

Mrs Ivy Gabatan1, Michelle Doidge1, Trish Hurst1, Charles De Ruiter1

1Queensland Health-Royal Brisbane And Women’s Hospital, Herston, Australia



The RBWH Hand Hygiene (HH) Program was initially implemented in 2007.Core element of the program is the Lifesavers Program. It includes enhanced education focused on the when, why and how principles of hand hygiene, audit buddy, support, clinical staff engagement and HH accountability. Clinical leader’s engagement in the program determines the success of the strategies.          Methods:

Clinical leaders nominate participants for  the Lifesavers Program in which training is provided by Infection Monitoring and Prevention Service (IMPS) and actively promote the when, why and how principles of HH in their area. Part of the program is observation of HH audit with an IMPS staff in their clinical area when required; provide education and feedback to their unit when gaps are identified in the HH compliance.

Clinical leaders in Urology Ward undertook the Lifesaver Program and engaged with IMPS to improve their hand hygiene compliance. They created a closed Facebook page named: “7BS Uro-dynamics” which serves as their communication hub to update and information on their HH compliance and moments of HH they need to focus on.


Areas where Clinical leaders were involved in the Lifesaver program are taking accountability of their hand hygiene practice. Following their education of the when, why and how principles of hand hygiene, their work unit have shown increased compliance rates from 78% to 90% and maintained a sustained compliance rate of 85%.


Hand hygiene compliance can be improved and sustained when clinical leaders get involved and tailor actions to their clinical area needs.


I am  a Registered Nurse in three countries – Australia, New Zealand and the Philippines since 1992.

I am concurrently a Clinical Nurse in the Infection Monitoring and Prevention Service at the Royal Brisbane and Women’s Hospital managing Education portfolio. I have also worked

as Public Health Nurse at Communicable Diseases and Infection Management unit for the Department of Health Queensland and Metro North Public Health Unit of Queensland Health. I am a Metro North Hospital and Health Services credential nurse immunizer. I am currently undertaking a Graduate Certificate in Infection,Prevention and Control through the Griffith University.

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