Hand Hygiene Policy Version 2.0 - Ipswich Hospital

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If a particular soap or alcohol based product causes skin irritation, review methods as described above before consulting the Occupational Health team. 3.5 Replenishment of supplies Soap and paper hand towels will be replenished by domestic staff routinely, but supplies must be available for replenishment if required in their absence. Alcohol gel dispenser replenishment is the responsibility of the ward staff, including those located at the bug stops on entry to the ward. However, all staff have a duty to bring the ward staff’s attention containers that need replacing. All hand hygiene products used within the hospital must be approved by the Infection Control Team. Purchase through PASA will ensure that products have been subject to appropriate testing. 3.6 Signage Signs explaining the importance of hand hygiene must be visible on entry to all in-patient healthcare facilities. There must be clearly signposted hand hygiene facilities on entry and exit from in-patient wards. Visitors and patients need to be encouraged to comply with requests for hand hygiene through the use of easily visible and clear signage, information leaflets and where possible, automated speech systems explaining the importance of hand hygiene. 3.7 Equality Impact Assessment An Equality Impact Assessment has been undertaken and this policy complies with current legislation 3.8 Dignity and Respect Charter The hospital’s Dignity and Respect Charter will be adhered to in implementing this policy. SECTION 4 – TRAINING AND EDUCATION 4.1 The hospital places a high priority on IPC education and training which includes effective hand hygiene and use of gloves. It forms part of the hospital’s mandatory training programme to be completed by staff both on induction and at designated regular intervals throughout their course of employment. 4.2 Training Needs Analysis (TNA) The Head of Infection Control will undertake an annual training needs analysis of all IPC training, including hand hygiene, provided by the organisation to ensure compliance with minimum standards set by the NHS Litigation Authority and Health Act. This TNA identifies the level of training required by each staff group which acts as a baseline for identifying TNA for all individual members of staff. The Head of Infection Control will agree these mandatory training requirements with HICC. Following this, the Head of infection Control will forward the completed TNA to the Education and Training department which will be used to inform the hospital’s TNA Registered Document 472 Page 8 of 15 Hand Hygiene Policy v2.0 Implementation Date 25 February 2009
covering all areas of mandatory training. This TNA will be published on the hospital’s intranet. 4.3 Training Prospectus In addition the Head of Infection Control will compile information on the training to be held each year and forward details to the Education and Training Department for inclusion with the hospital’s training prospectus. This will also be placed on the hospital’s intranet. 4.4 Training It is the responsibility of all line managers to ensure that their staff receive mandatory training in line with the TNA. Each member of staff is also personally responsible for attending training courses and for carrying out their duties in accordance with the training given. Full information is given in the hospital’s Mandatory Training Policy including duties and responsibilities for managers and staff the arrangements for staff to receive training, the recording of training received on the hospital’s electronic staff record system and the availability of records the process for checking that all relevant staff groups, as identified by the TNA, complete mandatory training the process for following up those staff who fail to attend mandatory training linking mandatory training with annual staff appraisals. SECTION 5 – DEVELOPMENT AND IMPLEMENTATION, INCLUDING DISSEMINATION 5.1 This policy has been developed by the Infection Control Team, with input from members of the Hospital Infection Control Committee and infection control link nurses. The revised policy will be submitted to the Trust Management Team following approval by the Hospital Infection Control Committee. 5.2 This policy will be made available on the hospital’s intranet and brought to the attention of all staff by broadcast and through mandatory training and the work of Infection Control Link Nurses and via implementation of audits and the dissemination of results. SECTION 6 – MONITORING COMPLIANCE AND EFFECTIVENESS 6.1 Hand hygiene resources and individual practice will be audited at regular intervals and the results fed back to healthcare workers. 6.2 The application of the Standards Principles for Infection Control are intended to provide consistency of audit practice of hand hygiene compliance and do not preclude departments from continuing to audit hand hygiene facilities, competency and practice in respect of low and medium risk hand hygiene compliance. 6.3 An audit framework that includes the principle of "local audit for local action" which requires a clear escalation standard ensuring that an immediate response occurs at a local level and a rapid improvement cycle is embarked upon when compliance drops below the expected standards. The audit framework is as follows: 1. The target for Hand Hygiene is set at 100%, and monitored through weekly audits undertaken by peers. 2. If the standard is over 95% then the next audit is due the following week. If the standard is maintained for four weeks at 95% they may step down to two weekly, but no less than this. Registered Document 472 Page 9 of 15 Hand Hygiene Policy v2.0 Implementation Date 25 February 2009
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Hand Hygiene Policy Version 2.0 - Ipswich Hospital

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