Patient Safety Improvement: A Hand Hygiene Quality Improvement Project.

Mrs Carolyn Ellis1, Ms  Kathy Dempsey1, Ms Susan Jain1, Mr Ronald Govers1

1Clinical Excellence Commission, Haymarket, Australia


The Healthcare Associated Infections (HAI) program of the Clinical Excellence Commission (CEC) aims to assist local health districts and specialty health networks in New South Wales to improve systems to manage and monitor the prevention and control of HAIs.

In November 2017, the CEC’s HAI program held the NSW Hand Hygiene Summit as a forum for stakeholders to share their knowledge and experience in working with the Australian National Hand Hygiene Initiative. The Summit was considered an opportunity for developing recommendations for the integration of hand hygiene improvements into a patient safety framework. The key recommendations from the Hand Hygiene Summit informed the direction and enabled opportunity for a Quality Improvement (QI) Initiative.


The CEC’s HAI program partnered with one NSW Local Health District to introduce stakeholders to an Improvement Science Framework ‘Plan, Do, Study, Act’ (PDSA) cycle for guiding the QI project.

The aims for the QI project are to improve:

  • Clinician’s engagement, knowledge, and shared accountability for Hand Hygiene
  • patient outcomes through safer clinical practices

The rationale:

  • Champion Standard Precautions through the ‘Before Moments’ of HH as a strategy in the prevention of HAIs and improvement of patient outcomes
  • Improve HH compliance with the HHA prescribed ‘Before Moments’.


The QI project will measure improvements in Standard Precautions compared to pre-existing data (Hand Hygiene audits, HAI data and, appropriate use of personal protective equipment).


The results will inform the conclusion of this presentation.


Carolyn Ellis is a Project Officer in the Healthcare Acquired Infection (HAI) Team at the Clinical Excellence Commission (CEC). Carolyn, has worked in HealthCare in a variety of environments as a Registered Nurse for 30 years. Most of that time has been spent in Operating Theatres as a clinician, Clinical Nurse Educator and Clinical Nurse Consultant with exposure in all surgical specialties and health populations.

Education: Diploma of Applied Science (Nursing); Post Basic Operating Theatre Nursing Certificate; Post Graduate Diploma Midwifery; Certificate IV Workplace Training and Assessment; Masters Higher Education (Teaching & Learning).

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