Hand Hygiene Policy Version 2.0 - Ipswich Hospital

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Version and document control: Version Date of issue Change Description Author number v 0.1 First draft Lesley Taylor v 1.0 15.1.08 Approved and ratified version including Lesley Taylor comments from HICC v 1.1 7.1.09 Updated to reflect new policy template Gill Fewkes v 1.2 9.1.09 Added para 2.6 on Education & Training and clarified Section 6 Gill Fewkes & Lesley Taylor This is a Controlled Document Printed copies of this document may not be up to date. Please check the hospital intranet for the latest version, destroy all previous versions. Hospital documents may be disclosed as required by the Freedom of Information Act 2000. Details about sharing this document with third parties are contained in Section 6 of this document. Sharing this document with third parties As part of the hospital’s networking arrangements and sharing best practice, the hospital supports the practice of sharing documents with other organisations. However, where the hospital holds copyright to a document, the document or part thereof so shared must not be used by any third party for its own commercial gain unless this hospital has given its express permission and is entitled to charge a fee. Release of any strategy, policy, procedure, guideline or other such material must be agreed with the Lead Director or Deputy/Associate Director (for hospital -wide issues) or Directorate/ Departmental Management Team (for Directorate or Departmental specific issues). Any requests to share this document must be directed in the first instance to the Head of Infection Prevention and Control. For further advice see the Development and Management of Strategies, Policies, Protocols, Procedures, Guidelines and other Guidance Material Policy Registered Document 472 Page 2 of 15 Hand Hygiene Policy v2.0 Implementation Date 25 February 2009
CONTENTS Page No SECTION 1 - INTRODUCTION ................................................................................................ 4 SECTION 2 – DUTIES AND RESPONSIBILITIES................................................................... 4 SECTION 3 – HAND HYGIENE ............................................................................................... 6 3.1 Hand Hygiene ............................................................................................................. 6 3.2 Hand washing facilities ............................................................................................... 6 3.3 Availability of handrub ................................................................................................. 7 3.4 Methods of effective hand hygiene .............................................................................. 7 3.5 Replenishment of supplies .......................................................................................... 8 3.6 Signage ...................................................................................................................... 8 3.7 Equality Impact Assessment ....................................................................................... 8 3.8 Dignity and Respect Charter ....................................................................................... 8 SECTION 4 – TRAINING AND EDUCATION .......................................................................... 8 4.2 Training Needs Analysis (TNA) ................................................................................... 8 4.3 Training Prospectus .................................................................................................... 9 4.4 Training ....................................................................................................................... 9 SECTION 5 – DEVELOPMENT AND IMPLEMENTATION, INCLUDING DISSEMINATION ... 9 SECTION 6 – MONITORING COMPLIANCE AND EFFECTIVENESS .................................... 9 SECTION 7 – CONTROL OF DOCUMENTS INCLUDING ARCHIVING ARRANGEMENTS 10 SECTION 8 – SUPPORTING COMPLIANCE AND REFERENCES ...................................... 11 APPENDIX 1 - HOW TO HANDWASH .................................................................................. 12 APPENDIX 2 - HOW TO HANDRUB ..................................................................................... 13 APPENDIX 3 - HAND HYGIENE OBSERVATION SHEET .................................................... 14 Registered Document 472 Page 3 of 15 Hand Hygiene Policy v2.0 Implementation Date 25 February 2009
Page 1: Hand Hygiene Policy Version 2.0 Pur
Page 5 and 6: managing the hospital’s Infection
Page 7 and 8: Hand wash basins must be cleaned re
Page 9 and 10: covering all areas of mandatory tra
Page 11 and 12: SECTION 8 - SUPPORTING COMPLIANCE A
Page 13 and 14: APPENDIX 2 - HOW TO HANDRUB Apply a
Page 15: Action following audit Nominated me

Hand Hygiene Policy Version 2.0 - Ipswich Hospital

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