Hand Hygiene Audit

Joint Commission + WHO 5-moments hand hygiene audit. Direct observation of hand hygiene compliance at the 5 critical moments. Required by JC NPSG 07.01.01.

Observation Setup

• Observation location and unit identified
  Record the unit, department, or care area where the observation occurred.
• Observer trained in hand hygiene audit method
  Confirm the observer is trained to perform direct observation using the WHO 5 Moments method.
• Observation was unobtrusive and did not alert staff
  Confirm the audit was performed without coaching, prompting, or alerting staff before the moment of observation.
• Staff role observed
  Select the role of the staff member observed.
• Hand hygiene product available at point of care
  Alcohol-based hand rub or sink access is available within the care area where the observation occurred.
• PPE and supplies do not block access to hand hygiene
  Dispensers, sinks, and supplies are unobstructed and accessible at the point of care.

WHO 5 Moments Compliance

• Moment 1 - Before touching a patient
  Hand hygiene performed immediately before any direct contact with the patient.
• Moment 2 - Before clean/aseptic procedure
  Hand hygiene performed immediately before a clean or aseptic task, including device handling or invasive care.
• Moment 3 - After body fluid exposure risk
  Hand hygiene performed after exposure or potential exposure to blood, body fluids, secretions, or excretions.
• Moment 4 - After touching a patient
  Hand hygiene performed immediately after direct contact with the patient.
• Moment 5 - After touching patient surroundings
  Hand hygiene performed after contact with the patient's immediate environment, even if the patient was not touched.

Technique and Compliance Details

• Correct hand hygiene method used
  Select the method used for the observed hand hygiene event.
• Technique covered all hand surfaces
  If hand hygiene was performed, confirm all hand surfaces were adequately covered and rubbed or washed.
• Duration met minimum standard
  Record observed duration of hand hygiene in seconds.
• Gloves were removed when indicated before hand hygiene
  If gloves were worn, confirm they were removed at the appropriate time and hand hygiene was performed after removal when required.
• Hand hygiene performed after visible soil or contamination
  Soap and water was used when hands were visibly soiled or contamination required washing rather than alcohol-based hand rub.