Standards › Standard 1 › Policies
Policy · HH-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 1.2
At a glance
- Hand hygiene is required at the five moments of care, at every facility.
- A station must be available at every point of care.
- Compliance is observed at least monthly, not self-reported.
- Audit results are reported and every gap has an action.
- Stop and get help straight away if: a station is not available at the point of care, or an audit result is not acted on.
1. Purpose
To set out the organisation’s commitment to hand hygiene at the point of care, and the standard that applies at every facility [E-001].
2. Scope
| Applies to | All staff, students, volunteers and contractors |
| Locations | All clinical and clinical support areas |
3. Definitions
| Term | Meaning |
|---|---|
| Hand hygiene | Cleaning hands with handrub or soap and water |
| Five moments | The WHO points of care for hand hygiene |
4. Background
Basis,WHO Guidelines on Hand Hygiene in Health Care (2009) [E-001].
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Accountable executive | Approves the policy. Receives the audit report. | Leadership |
| Infection prevention lead | Maintains the procedure and the audit method. | Infection prevention |
| Ward or unit manager | Ensures stations are stocked and audits are done. | Unit leadership |
| All staff | Follow the procedure HH-SOP-001. | Induction and annual competency |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| HH-SOP-001 | Procedure that applies this policy |
7. Safety
- Supplies,The organisation supplies approved products at each point of care.
8. Before you start
- Before first work,Each member of staff completes induction on this policy.
9. Procedure
Step 1. Policy statement 1: Hand hygiene is required at the five moments of care.
- Apply HH-SOP-001 at every patient contact.
Key point: The five moments are the minimum.
Step 2. Policy statement 2: Stations are available at every point of care.
- Each bed space and treatment room has a station within arm’s reach.
Key point: Availability comes before compliance.
Step 3. Policy statement 3: Compliance is observed, not self-reported.
- Audits are done by observation at least monthly, using HH-FRM-001.
Key point: Self-report is not accepted as evidence.
Step 4. Policy statement 4: Results are reported and acted on.
- Audit results go to the accountable executive each quarter.
- Gaps have a named action and a date.
Key point: A result with no action is a failure of the policy.
10. Decision points
- Exceptions,None. Any exception must be approved in writing by the accountable executive.
11. Special situations
| Situation | Action |
|---|---|
| Emergencies | The five moments still apply. Hand hygiene is not delayed to save time. |
12. Escalation
- Shortage of product,Report to the accountable executive the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Annual review | The policy is reviewed each year, and after any serious infection event. |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Approved policy | Policy register | Current version and five years |
| Quarterly audit report | Governance file | Three years |
15. Training
- Induction, before first independent work
- Annual refresher
16. Related documents
| ID | Title | Use |
|---|---|---|
| HH-SOP-001 | Hand Hygiene at the Point of Care | Procedure that applies this policy |
| HH-FRM-001 | Hand Hygiene Observation Audit Tool | Audit record |
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)