Hand hygiene standards and reporting

Healthcare-associated infections can be a serious complication that prolongs a patient’s hospital stay.  Hand hygiene is the most effective way to limit the spread of infection. 

Embedding strong hand hygiene practices aligned with national standards is essential to creating a safer environment for patients, staff, and visitors. 

This helps health services to:

• reduce healthcare-associated infections
• prevent transmission of harmful pathogens
• minimise antibiotic resistance
• lower healthcare costs (by reducing the need for prolonged hospital stays and expensive treatments).

Health service standards

All public and private health services accredited under the National Safety and Quality Health Service (NSQHS) Standards must comply with hand hygiene requirements.

These requirements are defined in the NSQHS Preventing and Controlling Infection Standard.  The standard requires health service organisations to:

• have a hand hygiene program that is consistent with the National Hand Hygiene Initiative (NHHI)
• collect hand hygiene compliance data for national audits using standardised tools
• use audit results to improve hand hygiene compliance and infection prevention and control processes.

National Hand Hygiene Initiative

The Australian Commission on Safety and Quality in Health Care (ACQSHC) coordinates the National Hand Hygiene Initiative (NHHI).

Safer Care Victoria is the NHHI jurisdictional lead for Victoria.

The NHHI aims to improve hand hygiene compliance in healthcare settings by:

• promoting the use of alcohol-based hand rub at the point of care
• ensuring standardised hand hygiene and infection prevention and control education
• monitoring hand hygiene compliance and providing feedback as part of a quality improvement approach
• identifying targeted opportunities for improving hand hygiene compliance.

Implementation of the NHHI is led by states, territories, and health service organisations. 

Victoria’s public health hand hygiene target

Victoria’s public health service’s hand hygiene target is 85%. 

This is higher than the national benchmark of 80%. The target reflects Victoria’s commitment to best practice in infection prevention and patient safety. 

Reporting requirements

Health service organisations must collect, review and report their hand hygiene compliance rates to the NHHI. 

There are three national hand hygiene audits conducted each year. 

NHHI audits must be completed by qualified Hand Hygiene Auditors. These auditors must observe the hand hygiene practices of healthcare workers in their service. 

Data is submitted to the NHHI and used in national and state accreditation and reporting. 

For help implementing and managing hand hygiene programs and meeting the audit requirements, see the NHHI Implementation Guide. 

Audit periods

Voluntary audit period

Audit period 2 is voluntary. However, we encourage Victorian health services to conduct audits and submit data to the national data set during the voluntary audit period 2.

Victorian health services who are not participating in audit period 2 must submit an exemption request.

Recording hand hygiene compliance

Victorian health services must use the Hand Hygiene Compliance Application (HHCApp) to capture observational audit sessions and validate audit data.

To record, validate and submit audit data, health services must: 

1. Enter all data into the HCCApp before the audit period closes.
2. Validate and submit data in the HCCAapp before the data validation and submission deadline.

Visit the ACQSHC website for more information about:

• Audit requirements
• Audit tools
• NHHI HHCApp - frequently asked questions and instructions.

Key actions for health services

Before the audit period ends

• Enter all hand hygiene data into the HHCApp – no entries can be added after the audit period ends.
• Check you have met the minimum number of requirement moments outlined in the NHHI Implementation Guide.

Before the data validation and submission deadline

• Validate and submit data in HHCApp for national reporting.
• Check your inbox for emails from SCV’s Hand Hygiene team.
• Submit an exemption request if you are unable to participate in an audit period.

After the data validation and submission deadline

• Review your hand hygiene results.
• Collaborate with auditors to plan improvements.
• Expect a request for commentary if your health service or campus didn’t meet the 85% compliance target.

Exemption requests

Victorian health services must submit an exemption request if they: 

• are unable or fail to submit data for mandatory audits
• choose not to participate in the voluntary audit.

The Australian Commission on Safety and Quality in Health Care (ACQSHC) is the authorising body for National Hand Hygiene Initiative exemption requests.

Apply for an exemption

To apply for an exemption, hand hygiene administrators must complete the Hand Hygiene exemption request form.

Exemption requests must be approved by the health service Chief Executive Officer before submission. Health services must keep a record of this approval.

Exemption requests are reviewed and endorsed by the Department of Health. We advise health services to submit exemption requests as early as possible to allow time for the department to review the request and seek further information if required.

Health services requesting exemptions for mandatory NHHI audit periods will receive a letter from the Department of Health to present to the Commission.

More information