Standards › Standard 1 › Forms
Form · HH-FRM-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 1.2
At a glance
- Observe for at least 30 minutes, without warning.
- Count the five moments and whether hand hygiene was done.
- Compliance is the number done divided by the total, times 100.
- Agree one action for any result below 70%.
- Stop and get help straight away if: the station is empty during the observation, or a result below 70% has no agreed action.
1. Purpose
To record direct observation of hand hygiene at the five moments, for the monthly unit audit [E-001].
2. Scope
| Area or unit | [write here] |
| Date and time of observation | [write here] |
| Observer name or role | [write here] |
| Total opportunities observed | [write here, 20 minimum] |
| Opportunities with hand hygiene | [write here] |
| Compliance (%) | [opportunities with hand hygiene divided by total, times 100] |
| Station empty at time of observation? | Yes / No |
| Action agreed | [write here] |
3. Definitions
| Term | Meaning |
|---|---|
| Compliance | Hand hygiene done at the moment, divided by opportunities observed |
| Opportunity | One of the five moments observed for one staff member, in one care episode |
4. Background
Use,Complete one form per area per month, using 20 observed opportunities.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Observer | Completes the form by direct observation, without telling staff in advance | Trained observer |
| Ward or unit manager | Receives the form and agrees actions | Unit leadership |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| This form | Printed or electronic |
7. Safety
- Confidentiality,Do not record staff names on the form.
8. Before you start
- Before observing,Read HH-SOP-001 for the five moments.
9. Procedure
Step 1. Choose the area and time.
- Observe for at least 30 minutes, at a time when care is being given.
Key point: Do not announce the audit.
Step 2. Count each opportunity.
- Tick each of the five moments you see.
- Record it as done or not done.
Key point: Count the moment, not the staff member.
Step 3. Calculate compliance.
- Divide opportunities with hand hygiene by total opportunities.
- Multiply by 100.
Key point: Target is 70% or above.
Step 4. Agree actions.
- Agree one action with the ward manager for any gap.
- Write who will do it and when.
Key point: A gap with no action is not closed.
10. Decision points
- Below 70%,Action required, reported to governance.
11. Special situations
| Situation | Action |
|---|---|
| Area with fewer than 20 opportunities | Continue the observation on a second day. |
12. Escalation
- Station empty,Report to the ward manager on the spot.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Monthly | Forms reviewed by the infection prevention lead each quarter. |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Completed form | Unit file | Three years |
15. Training
- Observer training before the first audit
- Recheck each year
16. Related documents
| ID | Title | Use |
|---|---|---|
| HH-SOP-001 | Hand Hygiene at the Point of Care | Procedure audited |
17. Evidence
| Reference | Note |
|---|---|
| E-001 | World Health Organization (2009). WHO Guidelines on Hand Hygiene in Health Care. Geneva: WHO. Approved, final. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | — | First approved version | Approved by the ASF Expert Committee |
E-learning for this document
References
- World Health Organization (2009). WHO Guidelines on Hand Hygiene in Health Care. Geneva: WHO. Open source (E-001)