“Sharing the Love” – Facilitating the implementation of a Hospital wide Hand Hygiene auditing program from an Infection Prevention and Control led model.

Mrs Kylie Fomiatti1, Mrs Tara McRaith1, Mrs Sharon Kenny1, Mrs Alison Wainwright1, Ms Heather Ilton1, Mrs Shelley Watt1

1Joondalup Health Campus, Joondalup, Australia



In 2015-2016 The Joondalup Health Campus (JHC) Hand Hygiene (HH) program audited following Hand Hygiene Australia (HHA) option A.

With less than 10 HHA trained auditors on site, the Infection Prevention and Control (IPC) team were responsible for collecting up to 65% of the required moments.

Following HHA onsite validation in September 2016, JHC moved to auditing option B – ensuring each clinical area (23 areas) is audited every audit period to meet key performance indicator (KPI) requirements.

The objective of this IPC team project was to increase the number of local Hand Hygiene Champion (HHC) Auditors in each clinical area including representatives from the Multidisciplinary Healthcare Team.


  • IPC Staff to undertake GSA training to facilitate site based “train the trainer” workshops
  • Managers tasked with identifying two HHC Auditors from each clinical area
  • Each clinical area to take ownership of their HH KPI i.e. allocate HHC to complete audits and develop action plans to improve compliance with JHC HH policy.


JHC now has more than 50 HHC Auditors representing members of the multidisciplinary Team, including Medical Practitioners, Nursing Executive, Critical Care Nurse Manager, Allied Health and Nursing staff.


The IPC team now complete less than 5% of HH audits significantly enhancing validation.

All clinical areas have taken ownership of their HH KPI with overall improvement in HH compliance rate demonstrated.

Hospital wide ownership of the program aligns with HH being everyone’s business not just IPC.


Kylie Fomiatti is an Infection Prevention and Control nurse at Joondalup Campus. She facilitates the JHC Hand Hygiene Program. She has completed her Gold Standard Auditor HH Training and Certificate IV in Training and Assessment and Infection Prevention and Control Graduate Certificate. She has been working in Infection Prevention and Control since 2013.

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