Beyond the patient zone: Improving hand hygiene performance in a Sterilising Services Department

Abstract

Introduction The hand hygiene program, inclusive of audit methodology to measure compliance was reviewed at a Local Health District in NSW, Australia. The review resulted in a ‘whole-of-organisation’ approach being endorsed which incorporated non-patient areas; these included Sterilising Services Departments.Peer-reviewed articles consistently report the significance of effective hand hygiene performance within patient care settings. While the requirement for hand hygiene in non-patient areas has been recognised, relevant compliance measurement has not been advocated. Methods Sterilising Services Department managers elected to participate in the revised organisational approach. New signage was posted at identified hand hygiene performance points in the departments, with alcohol-based hand rub dispensers mounted below each sign. Consultation occurred with department staff about the proposed hand hygiene audit program and anticipated benefits for all staff to be involved. An audit tool was developed based on the department's core activities for which hand hygiene performance was considered essential. The tool was trialled and following amendments, implemented for ongoing use. All staff participated as auditors on a rotational basis. Results were shared at staff meetings. Results Initial compliance rates were lower than expected. The results raised staff awareness that improvement was required. Over an 18 month period, the total compliance rate increased from 43% to 88%. Conclusions The development of a tailored audit tool, involvement of all staff members as auditors, and the timely sharing of results, can be effective in developing a cultural shift to aid improvement in department-specific hand hygiene practices.