Hand Hygiene Compliance Audit

This WHO 5 Moments for Hand Hygiene compliant audit checklist enables systematic observation and measurement of hand hygiene compliance rates in healthcare settings. Aligned with CDC hand hygiene guidelines, Joint Commission NPSG.07.01.01 National Patient Safety Goal, and international infection prevention standards. Use this observation audit methodology to monitor alcohol-based hand rub (ABHR) and handwashing compliance, reduce healthcare-associated infections (HAIs), and meet regulatory requi

  • Industry: Healthcare
  • Frequency: Weekly/Monthly audits
  • Estimated Time: 15-30 minutes per observation period
  • Role: Infection Preventionist / Quality Nurse
  • Total Items: 28
  • Compliance: WHO 5 Moments, CDC Hand Hygiene Guidelines, Joint Commission NPSG.07.01.01, CMS Conditions of Participation, CQC (UK)

Station Availability

Verify hand hygiene supplies and stations are accessible and properly stocked per CDC and WHO facility requirements.

  • Hand sanitizer dispensers accessible at point of care?
  • Hand sanitizer dispensers adequately filled?
  • Soap dispensers stocked and functional?
  • Paper towels available at all sinks?
  • Sinks functional with running water?
  • Hand hygiene signage posted and visible?
  • Station Availability Notes

WHO Moment 1 - Before Patient Contact

Observe hand hygiene compliance before touching a patient (e.g., before shaking hands, before physical examination, before taking vital signs).

  • Total Opportunities Observed
  • Compliant Actions Performed
  • Moment 1 Observations

WHO Moment 2 - Before Aseptic Task

Observe hand hygiene compliance before clean/aseptic procedures (e.g., before IV insertion, wound care, medication preparation, oral care).

  • Total Opportunities Observed
  • Compliant Actions Performed
  • Moment 2 Observations

WHO Moment 3 - After Body Fluid Exposure Risk

Observe hand hygiene compliance after body fluid exposure risk (e.g., after wound care, after drawing blood, after handling specimens, after contact with secretions).

  • Total Opportunities Observed
  • Compliant Actions Performed
  • Moment 3 Observations

WHO Moment 4 - After Patient Contact

Observe hand hygiene compliance after touching a patient (e.g., after physical examination, after taking vital signs, after patient care activities).

  • Total Opportunities Observed
  • Compliant Actions Performed
  • Moment 4 Observations

WHO Moment 5 - After Touching Patient Surroundings

Observe hand hygiene compliance after touching patient surroundings (e.g., after touching bed rails, bedside table, IV pump, monitors, medical equipment in patient zone).

  • Total Opportunities Observed
  • Compliant Actions Performed
  • Moment 5 Observations

Technique Quality Assessment

Evaluate the quality of hand hygiene technique when performed, per CDC and WHO guidelines.

  • Proper duration observed (20+ seconds)?
  • All hand surfaces covered?
  • Correct product used for situation?
  • Hands dry before donning gloves (when applicable)?
  • Jewelry/nail policy compliance observed?
  • Technique Quality Notes

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Why Use This Hand Hygiene Compliance Audit?

This hand hygiene compliance audit helps healthcare teams maintain compliance and operational excellence. Designed for infection preventionist / quality nurse professionals, this checklist covers 28 critical inspection points across 7 sections. Recommended frequency: weekly/monthly audits.

Ensures compliance with WHO 5 Moments, CDC Hand Hygiene Guidelines, Joint Commission NPSG.07.01.01, CMS Conditions of Participation, CQC (UK), ACSQHC (Australia), NABH (India). Regulatory-aligned for audit readiness and inspection documentation.

Frequently Asked Questions

What does the Hand Hygiene Compliance Audit cover?

This checklist covers 28 inspection items across 7 sections: Station Availability, WHO Moment 1 - Before Patient Contact, WHO Moment 2 - Before Aseptic Task, WHO Moment 3 - After Body Fluid Exposure Risk, WHO Moment 4 - After Patient Contact, WHO Moment 5 - After Touching Patient Surroundings, Technique Quality Assessment. It is designed for healthcare operations and compliance.

How often should this checklist be completed?

This checklist should be completed weekly/monthly audits. Each completion takes approximately 15-30 minutes per observation period.

Who should use this Hand Hygiene Compliance Audit?

This checklist is designed for Infection Preventionist / Quality Nurse professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.

Can I download this checklist as a PDF?

Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.

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