Hand hygiene auditing

Hand hygiene is one of the most effective measures to reduce the occurrence of Hospital Acquired Infections (HAI).

The single most common way of transferring the organisms that cause HAIs is on the hands of health-care workers. At Eastern Health, employees take the lead in their clinical areas to reduce HAIs by ensuring hand hygiene is part of their day-to-day clinical practice.


Hand hygiene audits are completed in all areas of the organization through direct observation.

Audits are a mechanism to monitor adherence to hand hygiene practices, but also to provide a means of feedback to individual nursing units.

Information screens

Hand hygiene compliance rates are posted regularly on information screens across numerous nursing stations to allow individual units to see how they compare within their program area, facility and the organization as a whole.


Trained hospital staff, called hand hygiene auditors, observe health-care workers as they go into, and then leave a patient environment (room or bed space). Hand hygiene auditors observe whether the health-care provider cleaned his or her hands at the right times.

Four moments of hand hygiene

Eastern Health reports on the rates before initial patient/patient environment contact (moment 1) and after patient/patient environment contact (moment 4,) as described below:

  • Moment 1: before patient/patient environment contact
  • Moment 2: before aseptic procedure
  • Moment 3: after body fluid exposure risk
  • Moment 4: after patient/patient environment contact

hand hygiene graphic

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Last updated: 2021-06-11