Hand Hygiene Audits - FOI Response Register

FoI Number
2023-704
Subject
Hand Hygiene Audits
Date Received
14/02/2024
Request and Response
  1. Do your wards / departments carry out regular hand hygiene audits?  If so, how frequently are these audits required?
  2. Are quality assurance hand hygiene audits carried out?  If so, who carries out these audits and how often?
  3. Does your health board have a hand hygiene audit target compliance rate (e.g. 90% or 95% compliance)?
  4. What are the consequences if any hand hygiene audit scores less than the target compliance rate?

In accordance with FOISA s 16(1), NHS Shetland confirms that it holds the information requested but that it is exempt from disclosure under FOISA s 25(1) as the information requested is accessible without submitting a request under FOISA s 1(1). The information you have requested is available here:

Board Meetings – NHS Shetland

  1. Are all wards / departments audited quarterly for hand hygiene?  If not, how is it decided which ward/department will be audited?

Yes all wards / departments are audited quarterly for hand hygiene. 

  1. Who performs these quarterly hand hygiene audits? (e.g. Infection Control Team? Senior Charge Nurse? Independent Auditor?)

The audits are carried out by various colleagues within the ward / department.  This is supported by the infection control link practitioner for that area, and the infection control team.   

  1. The board reports state:  "If however compliance levels for hand hygiene fall, monthly audits will be reinstituted immediately".  Can I ask is there a compliance target for hand hygiene audits?

Yes 100% compliance target

  1. At what % rate would monthly audits be reinstituted? (e.g. at 90%? 85%?)

If the % rate falls below 100% the infection control link practitioner for that area will look at any actions that are required, this will be supported by the infection control team