Hand Hygiene Policy Version 2.0 - Ipswich Hospital

3. If the standard is over 80% then the Head Matron must be informed and the audit
repeated daily until 95% is achieved for three consecutive days.
4. If the standard is below 80% the Head Matron will ensure hand hygiene training is
provided to the local area and it is re audited daily until it reaches 95% for three
consecutive days.
5. Should an area fail to achieve 60% or fall below 80% on three of four weeks, special
measures will be enacted (these can include daily visits from the Chief Executive/
Director of Nursing & Quality, targeted training or a calling to account to the Chief
Executive.
Compliance against a target of 100% will be audited and reported on across the hospital.
6.4 An audit tool must be used to observe a minimum specified number of individual healthcare
workers opportunities for and their subsequent compliance (or not) with hand hygiene
activity over a 20 minute period (see Appendix 3)
Audits of hand hygiene compliance, using the hand hygiene observation sheet, must take
place, as a minimum, in the context of clinical procedures and at the point of care using the
WHO ‘Your 5 moments for hand hygiene’ and results provided monthly to the
Commissioning Primary Care Trust for entry on to the Strategic Health Authority balanced
score card data. This will be undertaken by The Productive Ward
Clinical champions.
6.5 The hospital’s electronic staff record system will be used to monitor compliance with
training. The Assistant Director of Education and Training will produce monthly reports to
Business Units who will be required to follow up non-attendance of staff within their areas of
responsibility. Each Business Unit will be required to report on training levels to HICC as
part of their monthly performance reports together will action taken to improve training
levels where required. Action taken will be monitored by HICC.
6.6 Monthly ICT performance data is reported to HICC by DIPC and the Head of Infection
Control. Any remedial action is identified and action plans agreed by HICC. Responsibility
for implementation is agreed and progress monitored by HICC within agreed timescales.
Each Business Unit reviews IPC as part of its own governance arrangements and submits
highlight reports on compliance to HICC in accordance with an agreed reporting schedule.
Any identified risks with IPC compliance will be reported to and considered by the Risk
Management Committee who will monitor action taken to mitigate the risk.
Performance data is reported monthly to TMT, Trust Board, Senior Managers and
Clinicians and disseminated to staff – Lead DIPC.
SECTION 7 – CONTROL OF DOCUMENTS INCLUDING ARCHIVING
ARRANGEMENTS
7.1 Once ratified by the Trust Management Team, this policy will be forwarded to the
Information Governance Department for a document index number to be assigned and
recorded onto the hospital’s master index.
7.2 The DIPC is responsible for ensuring that this policy adheres to the Trust’s Record
Management Policy, including working with the Information Governance Department on
retention and archiving arrangements.
Registered Document 472 Page 10 of 15
Hand Hygiene Policy v2.0 Implementation Date 25 February 2009