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Table 3 Expert panel’s evaluation of hand hygiene compliance as a process indicator

From: Development and application of an indicator assessment tool for measuring health services accreditation programs

Topic Infection control indicators
Indicator details
Description Audits of compliance with the “Five Moments” of hand hygiene
Type Process
Applicable accreditation standards
NSQHSS Standard 3—Preventing and controlling healthcare associated infections [15]
ACHS EQuIP Criteria 1.5.2 [16, 17]
  Scores Evaluation discussion summary
Assessment criteria
Research High This was given a high score due to the evidence linking hand hygiene outcomes with the multimodal approach used in Australian accreditation programs as per WHO guidelines [2124, 2630]
Accuracy Medium to low Hand hygiene audits were seen as an accurate method for measuring compliance with the sections of the accreditation standard dealing with preventing and controlling infections. However, a medium to low score was allocated due to the broad nature of the infection control standard that also includes anti-microbial stewardship and specialist cleaning policies
Proximity High Audits are performed three times a year, creating a close temporal link between hand hygiene audits and accreditation surveys. There is an organizational link between the accreditation criteria and the requirements for implementing hand hygiene programs
No adverse effects Medium The data are self-audited against a known national target providing incentives for hospitals to meet those targets, and some potential for gaming
Specificity Low There are a number of policies and initiatives aimed at improving hand hygiene rates making it difficult to isolate the effects of accreditation. For example, both the Clean Hands Save Lives project introduced by the NSW Clinical Excellence Commission and the National Hand Hygiene Initiative contained elements of the accreditation standards relating to hand hygiene and infection control
Associated programs Related programs initiated by state or federal governments or healthcare agencies Anti-microbial Stewardship Initiative [31] National Infection Control Guidelines [32] Clean Hands Save Lives project [33] National Hand Hygiene Initiative [24] NSW Infection Control Policy [34]