‘Doctors auditing Doctors’ – Cleaning Up Doctors’ Compliance with Hand Hygiene

Dr Simone Visagie1, Dr  Liam Clifford1, Dr Michael David2, Dr Rukaiya Malik1, Dr Amanda Dawson1, Dr Sean Kelly1

1Central Coast Local Health District, Central Coast, Australia

2Newcastle University, Newcastle, Australia


Gosford and Wyong hospitals, part of the Central Coast Local Health District (CCLHD) have failed to meet NSW Ministry of Health Hand Hygiene (HH) targets with overall 59% compliance in June 2017. Medical Officers (MOs) were identified as the worst performers with 55% average compliance.

The quality improvement project is aimed at addressing key issues relating to HH as identified by Junior Medical Officers (JMOs) including; a need for cultural change, improved accessibility to HH facilities and a shift in cognitive focus from 5 to 2 moments (moment 1: before touching patients and moment 4: after touching patients). A ‘Doctors auditing Doctors’ program was implemented whereby JMOs regularly assessed their own team’s HH during ward rounds with feedback to respective teams. The improvement aim is that MOs achieve greater than 80% HH compliance for these 2 moments in the National HH audit by December 2018.

National HH data showed 52% compliance for moment 1 and 75% for moment 4 from November 2017 to March 2018. Preliminary results from ‘Doctors auditing Doctor’s surveys showed an initial rise in compliance upon initiation of the project at Gosford and consultant notification. Compliance decreased with inclusion of Wyong data but stabilised to 60% for both moments in April 2018, coinciding with ongoing departmental updates and further JMO involvement.

‘Doctors auditing Doctors’ has increased dialogue among MOs about HH and has generated senior clinician engagement. Achieving 80% compliance for 2 of the 5 moments could generate further momentum for improving all 5 moments of HH.


Resident Medical Officer at Central Coast Local Health District

Current Chair of Junior Medical Officer Quality and Safety Committee with interest in education on quality improvement and active involvement of JMOs in QI projects.

Graduated from University of Sydney in 2016 and  interested in pursuing a career in critical care

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