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FOI 3672 Hand Hygiene Audits

Please send me:

A summary of the annual results of any Hand Hygiene Audits conducted within your NHS Acute Trust in the time period: January 1st 2005 – present. Including, if available, for each year:

  • Number of opportunities
  • Number of opportunities taken
  • Number of opportunities not taken
  • Details of the audit process(es) used


Unfortunately, we are unable to provide the information requested although the infection prevention and control team are responsible for co-ordinating hand hygiene audits. We do not carry out annual hand hygiene audits rather individual clinical departments including community facilities within HEFT carry out a monthly hand hygiene audit and to gather this amount of information for all the departments within the Trust for the time span requested would exceed the 18 hours of staff time as laid down under section 12 of the Freedom of Information Act.

The hand hygiene audit was changed in 2013 (both the old and the current audit documents are attached) when we introduced the IPS hand hygiene audit based on the WHO five moments. The old audit took place over a twenty minute observational period with whichever members of staff were observed in that time being included. The new audit involves observing ten hand hygiene opportunities and can even be carried out over several days in order to obtain a cross section of HCPs.

Once completed the total numbers for each section of the audit are entered onto the electronic system and an overall % score is generated. It is unlikely that clinical departments will have retained their paper copies of the hand hygiene audit for as far back as 2005  so will not be able to provide the breakdown of information required. We have attached the overall Trust scores as an example.Old Hand Hygiene Audit Form Quality Improvement Tools HI – Performance Trends


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