ISO 23447:2023

INTERNATIONAL ISO
STANDARD 23447
First edition
2023-10
Healthcare organization
management — Hand hygiene
performance
Reference number
© ISO 2023
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ii
Contents Page
Foreword .v
Introduction . vi
1 Scope . 1
2 Normative references . 1
3 Terms and definitions . 1
4 Hand hygiene quality policy and requirements . 4
4.1 General . 4
4.1.1 Conformity . 4
4.1.2 Prerequisites for the use of this document . 5
4.1.3 How to use this document . 5
4.2 Hand hygiene quality policy . 6
4.3 Hand hygiene quality policy requirements . 7
4.3.1 Evaluating hand hygiene products for potential use in healthcare facilities. 7
4.3.2 Towel dispensing systems requirements . 9
4.3.3 How to perform hand hygiene . 9
4.3.4 Indications for hand hygiene performance . 10
4.3.5 Assessing hand hygiene performance .12
4.3.6 ABHR products and glove use . .12
5 Hand hygiene program . .13
5.1 General .13
5.2 Hand hygiene quality policy requirements . 13
5.3 Healthcare organization requirements . 14
5.3.1 General . 14
5.3.2 Supplies and infrastructure requirements . 14
5.3.3 Healthcare facility assessment . 15
5.3.4 Hand hygiene self-assessment forms and checklists . 16
5.4 Establish operations and maintenance plan . 18
5.4.1 General . 18
5.4.2 Dispenser maintenance recommendations and requirements. 19
6 Training and education .19
6.1 General . 19
6.2 General hand hygiene training and requirements . 19
6.3 Concepts that shall be included in the training program . 20
6.4 Objectives of training . 21
6.5 Follow-up of completion of hand hygiene training . 22
6.6 Specific training for trainers and observers - direct observation method .22
6.7 Selection of trainers and future observers . 22
6.7.1 Trainers . 22
6.7.2 Trainee hand hygiene observers . 22
6.7.3 Validation of hand hygiene observers . 23
6.8 Additional concepts that are required in an observer training program .23
6.8.1 Minimum requirements for direct observation by HCP .23
6.8.2 Use of hand hygiene observation tools . 23
6.8.3 Data analysis and quality control . . 24
6.8.4 Assessment of the healthcare facility improvements on hand hygiene . 24
6.9 Competence . 25
6.10 Delivery options for education and training . 25
6.11 Training the hand hygiene expert . 26
6.11.1 Validation of written examinations. 26
6.11.2 Establishing a hand hygiene monitoring program . 26
6.12 Frequency of training and competency assessment .28
6.13 Training and verification systems .28
iii
6.14 Requirements for hand hygiene training technique .28
6.15 Patient hand hygiene education .29
6.16 Visitor hand hygiene education .29
7 Cultural aspects of hand hygiene management .30
7.1 General .30
7.2 Communications .30
7.3 Education . 30
7.4 Awards and recognition .30
7.5 Surveys . 31
Bibliography .32
iv
Foreword
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This document was prepared by the Technical Committee ISO/TC 304, Healthcare organization
management.
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v
Introduction
Improving hand hygiene remains the most important measure to prevent the spread of infections in
healthcare facilities, yet compliance with hand hygiene is globally low. The goal of this document is
to provide scientific knowledge, evidence-based implementation guidance for best practices to achieve
targeted hand hygiene outcomes that can enhance patient safety.
An essential practice in the prevention or control of the spread of infections in the healthcare
environment is the effective and continuous act of hand hygiene. In healthcare facilities, hand hygiene
is mainly performed via hand washing or hand rubbing at the points of care, with the purpose of
protecting patients and healthcare workers alike from acquiring healthcare-associated infections
(HAIs).
Hand hygiene is the process of reducing potentially harmful microorganisms (pathogens) on the hands
for the purpose of preventing the spread of infections. Hand hygiene is supported by three pillars:
— behavioural hand hygiene which contains all active behaviours intended to keep hands
uncontaminated;
— hand washing which requires water, the cleansing agent, and drying material and is mainly intended
to clean hands from visible contaminations and remove microorganisms;
— hand rubbing which requires a disinfecting substance to be absorbed/evaporate until completely
dry and is intended to reduce and inactivate microorganisms.
The daily execution of an infection prevention and control system, including hand hygiene, is a
responsibility of all healthcare related personnel and stakeholders.
This document builds on the top of existing national and international laws, regulations and
recommendations supporting patient safety, and assumes that there are infection prevention and
control personnel in each healthcare facility to ensure its implementation.
This document is intended to address specifically all environments that provide healthcare services
and can be tailored wherever care is given. Furthermore, fields outside of healthcare can adopt this
document or components of it as needed if they provide proper documentation and reasoning behind
any modifications.
Adopters of this document may perform an initial assessment of hand hygiene practices as a foundation
for the organizational hand hygiene performance and compliance program.
An evaluation and continued assessment of hand hygiene practices is the corner stone of an
organization’s hand hygiene performance and compliance program.
The key differences between this document and those listed in the bibliography are:
a) increased emphasis on the design and implementation of an institutional-level hand hygiene policy
for hospitals and other healthcare facilities – called the “hand hygiene system;
b) extensive, coherent and comprehensible instructions regarding every aspect of a hand hygiene
program (requirements, feedback methods, documentation, validation) within the hand hygiene
system;
c) aggregation of current evidence-based resources, know-how and best practices to facilitate the
implementation and maintenance of an efficient hand hygiene program.
d) customizable and adaptable framework of operation, stretching over national and geographical
boundaries.
vi
INTERNATIONAL STANDARD ISO 23447:2023(E)
Healthcare organization management — Hand hygiene
performance
1 Scope
This document specifies hand hygiene training, compliance benchmarking, performance/feedback,
and facility requirements for healthcare facilities that operate hand hygiene systems. This document
covers facility readiness, hand hygiene education and training, monitoring, performance, promotion
and identifying key issues that require attention for improvement. Procedures for surgical hand
preparation are not addressed in this document.
Furthermore, this document does not take into consideration, surface disinfection, instrument
disinfection, ultraviolet irradiation (UV-C), heat sterilization, room fogging or electrostatic spraying
devices and any other methods typically not designed or suitable for human hand hygiene purposes.
Excluding surgical hand preparation, this document applies specifically to clinical healthcare workers,
patients and visitors.
2 Normative references
The following documents are referred to in the text in such a way that some or all of their content
constitutes requirements of this document. For dated references, only the edition cited applies. For
undated references, the latest edition of the referenced document (including any amendments) applies.
ISO 22886, Healthcare organization management — Vocabulary
3 Terms and definitions
For the purposes of this document, the terms and definitions given in ISO 22886 and the following apply.
ISO and IEC maintain terminology databases for use in standardization at the following addresses:
— ISO Online browsing platform: available at https:// www .iso .org/ obp
— IEC Electropedia: available at https:// www .electropedia .org/
3.1
hand hygiene adherence
general act of conforming to the adequate hand hygiene (3.2) guidelines and requirements
Note 1 to entry: The term hand hygiene compliance (3.19) shall only be used as defined in the context of this
document. For all generic use, the word adherence is suitable.
3.2
hand hygiene
HH
act of mechanical and chemical techniques including sustained friction (scrubbing) with clean water
or a liquid, gel, or foam chemical formula that effectively reduces, neutralizes and/or inactivates
microorganisms on the hands, temporarily removing the transient flora
Note 1 to entry: Hands are considered as the palmar and dorsal surfaces of the human hand, following the
anatomy to the line of the ulnar styloid process.
Note 2 to entry: This may include the physical removal of soil and debris from the hand.
Note 3 to entry: Hand hygiene acknowledges two types of hand hygiene actions (3.11) which are not mutually
interchangeable:
a) hand washing which requires water, product, and drying material;
b) hand rubbing (3.20) which requires a cleaning substance to be absorbed/evaporated until completely dry.
Note 4 to entry: Other related but not used terms covering sub-domains of hand hygiene include: hand
disinfection, hand cleansing, hand antisepsis, hand decontamination.
Note 5 to entry: This definition overrules the one in ISO 22886.
3.3
alcohol-based hand rub product
ABHR product
chemical formula in liquid, gel, or foam format, containing at least 60 % mass fraction of C2- to C3-
alcohols designed to perform hand hygiene (3.2) activities when hands are not visibly soiled and do not
require subsequent rinsing with water and drying of the hands
Note 1 to entry: C2- to C3-alcohols are ethanol, n-propanol, isopropyl alcohol, or a mixture of these.
Note 2 to entry: ABHR product can also contain other antimicrobial active ingredients with excipients, and
humectants.
Note 3 to entry: It is presupposed that users comply with all current local and national requirements.
3.4
handwashing
act of cleaning an individual’s hands using water, handwash product (3.5) and a drying material
3.5
handwash product
soap in liquid, gel, or foam form, that is designed to perform hand hygiene (3.2) activities when hands
are visibly soiled, including subsequent rinsing with water and drying of the hands
Note 1 to entry: Such products may contain other antimicrobial active ingredients with humectants and
excipients.
Note 2 to entry: In the context of this document solid format soaps are not regarded suitable for healthcare
facilities (3.6).
3.6
healthcare facility
healthcare setting
physical infrastructure of a healthcare organization
Note 1 to entry: This definition is in line with the definition of "healthcare organization" in ISO 22886:2020, 3.2.2.
3.7
healthcare worker
HCW
healthcare professional (3.16) involved in the direct provision of healthcare
[SOURCE: ISO/TR 19231:2014, 3.11, modified — The abbreviated term "HCW" has been added.]
3.8
dispenser
wall-mounted, bed-mounted, standalone or personnel-attached container able to provide (dose) ABHR
product (3.3) or handwash product (3.5)
3.9
audit
systematic and independent process for obtaining evidence and evaluating it objectively to determine
the extent to which the audit criteria are fulfilled
Note 1 to entry: An audit can be an internal audit (first party) or an external audit (second party or third party),
and it can be a combined audit (combining two or more disciplines)
Note 2 to entry: An internal audit is conducted by the organization itself, or by an external party on its behalf.
Note 3 to entry: “Audit evidence” and “audit criteria” are defined in ISO 19011.
Note 4 to entry: Independence can be demonstrated by the freedom from responsibility for the activity being
audited or freedom from bias and conflict of interest.
[SOURCE: ISO 37301:2021, 3.18]
3.10
clinical stakeholder
healthcare worker (3.7), visitor, patient, and other individual potentially interacting with the patient
or the patient environment related to hand hygiene indications (3.15) and expected to practice hand
hygiene action(s) (3.11)
3.11
hand hygiene action
hand hygiene event
conscious act of performing hand washing (3.4) or hand rubbing (3.20)
Note 1 to entry: A hand hygiene action is considered valid from patient safety point of view when it is performed
at the correct time, i.e. there is a hand hygiene indication (3.15), and regarded as complete when it meets the
standard of quality as stated in 4.3.3.
3.12
point of care
area near the patient where stakeholders may encounter communicable pathogens
3.13
continuous improvement
continuous professional development
recurring activity to enhance performance
[SOURCE: ISO 37301:2021, 3.12, modified — The admitted term "continuous professional development"
has been added.]
3.14
healthcare-associated infection
HAI
hospital-acquired infection
DEPRECATED: nosocomial infection
infection acquired in the healthcare facility (3.6) for which there is no evidence indicating that it was
present or incubating during or before the patient’s admission
Note 1 to entry: See References [14].
3.15
hand hygiene indication
theoretical point(s) in the workflow of the clinical stakeholders (3.10), where there is an increased risk
of pathogen transmission for which a hand hygiene action (3.11) can be performed to decrease risk
Note 1 to entry: Hand hygiene (3.2) moment is a term employed by WHO for hand hygiene indication, as a critical
point in care to perform hand hygiene.
Note 2 to entry: WHO’s My 5 Moments of Hand Hygiene are considered a widely accepted approach for
determining the ideal number of hand hygiene indications in a particular setting.
Note 3 to entry: See Figure 1 for the relationship to this definition.
3.16
healthcare professional
HCP
licensed and unlicensed, clinical, and administrative, remote, and onsite, paid and without
compensation, full- and part-time healthcare stakeholders, intermittent healthcare stakeholders, fee
basis healthcare stakeholders, contractors, researchers, volunteers and health professions trainees
(HPTs)/pre-licensure or certification who are expected to perform any or all of their work at healthcare
facilities (3.6)
Note 1 to entry: Healthcare professionals are those involved in the direct provision of healthcare, in particular
those with patient contact or access to patient near areas.
Note 2 to entry: HPTs may be paid or unpaid and include residents, interns, fellows, and students. HCP also
includes personnel providing care to patients and drivers and other personnel whose duties put them in contact
with patients.
Note 3 to entry: Healthcare workers (3.7) are a key subgroup of the clinical stakeholders (3.10) within the scope of
this document.
3.17
noncompliance
non-fulfilment of compliance obligations
[SOURCE: ISO 37301:2021, 3.27]
3.18
hand hygiene monitoring system
HHMS
digital technology platform enabling the partial or complete replacement of human hand hygiene (3.2)
observers, by automatically registering hand hygiene opportunities
Note 1 to entry: The term hand hygiene compliance (3.19) monitoring shall only be used in the restricted meaning
defined within this document.
3.19
hand hygiene compliance
adherence to hand hygiene (3.2) related rules and regulations, particularly in terms of method,
frequency, and documentation of hand hygiene (3.2)
3.20
hand rubbing
process of using ABHR product (3.3) to conduct hand hygiene action (3.11)
4 Hand hygiene quality policy and requirements
4.1 General
4.1.1 Conformity
To conform to this document, adopters shall meet all the requirements. Healthcare facilities shall
establish policies and procedures for assessing and accomplishing requirements and recommendations.
Healthcare facilities should ensure that each clinical stakeholder of the healthcare organization
conforms to this document. If the adopter aims to deviate from any of the requirements, peer-reviewed
evidence and proof shall be provided in the hand hygiene system document or hand hygiene quality
policy regarding that aspect. Deviations shall not compromise patient safety.
4.1.2 Prerequisites for the use of this document
Adopting facilities shall develop, communicate, and enforce their own hand hygiene system in a manner
that conforms to the requirements and reflects the guidelines that are stated in this document.
Organizational leadership shall actively support the implementation of this hand hygiene system
through hand hygiene program(s) and shall enlist the involvement of key healthcare workers in its
development and administration. These healthcare workers shall include, but not be limited to, the
organization’s risk management, quality management, and infection prevention and control (IPC) staff.
The adopter shall provide capability and resources to develop, implement and evaluate the hand hygiene
program guided by this document. The healthcare organization is responsible for resources such as
software and products and shall have a set of processes that ensures regulatory requirements are met.
The healthcare organization shall provide a sanitary environment to avoid sources and transmission
of infections and communicable diseases. There shall be an active program for the prevention, control,
and investigation of infections and communicable diseases.
4.1.3 How to use this document
The description of the hand hygiene system and its application demands the use of a system paradigm
to aid the use of this document. As healthcare organizations familiarize themselves with this document
and application to their practices and work areas, terms that are more familiar may be substituted.
A hand hygiene system comprises a plurality of hand hygiene programs, preferably one for every
healthcare department (e.g. surgery, intensive care, paediatrics), addressing its needs. Hand hygiene
thus can be viewed as a component or an element of a larger system for patient safety (Figure 2). This
system includes the incorporation of people required to develop, produce, test, distribute, operate, train
and support people to accomplish their roles within the healthcare organization. This generic hierarchy
represents the necessary components of the system. Figure 1 provides a simple hierarchy of names
for the elements that should make up the hand hygiene system. Globally, the hierarchy of leadership
and names of leadership may vary, however it is important to recognize necessary components to
manage the hand hygiene system. While providing background on the science behind hand hygiene,
this document provides practical advice about how to implement this approach.
Figure 1 — Breakdown of the key components of a hand hygiene system
Figure 2 provides a general overview of a hand hygiene system from the operational point of view. It
depicts the hand hygiene programs implemented to provide an opportunity to collect feedback and
improve processes.
Figure 2 — A hand hygiene system
Hand hygiene systems shall include the hand hygiene programs and procedures targeting the individual
elements of patient safety for quality improvement. All procedures applied in line with this document
should be based on scientific evidence and target continuous improvement involving in the quality cycle
all system components and clinical stakeholders.
4.2 Hand hygiene quality policy
The hand hygiene quality policy is the formalized, documented representation of a healthcare facility’s
hand hygiene system.
The healthcare facility shall establish and maintain a hand hygiene system (i.e. a quality policy with the
objective to provide universal access to hand hygiene with the aim of improving patient safety). A hand
hygiene system consists of hand hygiene programs, targeting individual aspects of the quality policy.
The quality policy should include, but not be limited to, the following considerations:
a) specific, measurable, actionable, realistic and timely objectives serving the improvement of patient
safety;
b) ensuring sufficient resources for the development, implementation, and monitoring of hand hygiene
programs;
c) supporting the development and implementation of hand hygiene-related behaviour improvement;
d) facility design, construction, and maintenance requirements of the infrastructure;
e) proper communication within the healthcare organization;
f) periodic review suitable for the purpose of this document;
g) secure sponsorship of the senior management.
The hand hygiene system and quality policy are part of the organization’s approach for managing
quality.
4.3 Hand hygiene quality policy requirements
4.3.1 Evaluating hand hygiene products for potential use in healthcare facilities
4.3.1.1 General
A risk-based approach should be used to determine the most suitable hand hygiene product.
4.3.1.2 ABHR product - minimal requirements
ABHR product shall contain at least 60 % mass fraction of C2- to C3-alcohols (ethanol, n-propanol,
isopropyl alcohol) or a mixture of these, taking international standards and efficacy requirements,
such as ASTM E2755 and EN 1500, into consideration.
Administrators or product selection committees shall consider the relative efficacy of antiseptic agents
against various pathogens and shall review local guidelines for safety and efficacy before selecting the
hand rub products.
4.3.1.3 Handwash product – minimal requirements
Administrators or product selection committees should consider the need to use antimicrobial vs non-
antimicrobial handwash products in their healthcare facility based on hygiene risk and review local
guidelines for safety before selecting the hand wash products.
For antimicrobial handwash products, administrators and product selection committees should
consider the efficacy against various pathogens and take national public policy or regulatory guidelines
concerning the efficacy of antimicrobial handwash products into consideration.
The use emollients and hand protection products should be considered for healthcare workers who
frequently wash hands in the course of their duties.
4.3.1.4 Other hand hygiene product requirements
Administrators or product selection committees shall provide hand hygiene products that have been
tested and shown to have acceptable skin compatibility using internationally recognised standard test
methods.
Administrators or product selection committees should consider characteristics of hand hygiene
products that can affect personnel acceptance and therefore usage compliance, such as:
— format (i.e. liquid, gel, foam);
— odour;
— colour.
Allergic contact dermatitis due to alcohol-based hand rubs is very uncommon. However, with increasing
use of alcohol-based hand rubs by healthcare personnel, it is likely that irritation to such products
is occasionally encountered. Healthcare facilities should find alternative solutions to address skin
compatibility issues, especially in combination with hand washing, as it is known that increasing hand
washing leads more often to skin irritation than hand rubbing.
Healthcare facilities should also consider continuous availability, costs, and a reliable supply that
guarantees feasibility and sustainability.
NOTE The effect of antimicrobial active ingredients in hand wash products appears to be negligible.
4.3.1.5 Hand hygiene product dispensing systems
The healthcare organization shall provide systems for dispensing suitable hand hygiene products at
dedicated hand hygiene stations located at hospital, clinic and ward entrances and points of care with
prompts, publicity, and signage to encourage usage by healthcare workers, patients, visitors and other
stakeholders.
The number and positioning of the dispensing system shall be defined according to evidence-based
reference data provided by international, national, or intra-institutional guidelines. The number and
positioning of dispensing systems shall be clearly stated, periodically evaluated and documented.
4.3.1.6 Hand hygiene product dispenser requirements
Administrators or product selection committees shall provide a sealed system product dispenser that
is hygienically intact and shall deliver a hand hygiene product where there is no possibility of direct
contact with the product source inside.
The manufacturer should provide information about the effective use of these systems. Usage
information may include instructions for cleaning, disinfection, and reprocessing of the dispenser
systems.
Dispenser systems shall provide the volume of product per dispense/push, as indicated by the
manufacturer, consistently for the lifetime of the dispenser. Reliable and systematic dosage is
considered an essential performance of a dispenser.
User-refillable systems shall not be used in healthcare facilities.
Non-sealed systems which contain a fixed soap/sanitiser reservoir that is refilled or topped up from bulk
liquid source and is exposed to the air sealed systems that are damaged or faulty should be replaced.
Organizations shall document the dispensing system that they are maintaining. Organizations should
consider the use of hands-free dispensing systems that eliminate contact and cross contamination.
NOTE 1 The operations and maintenance plan is registered when the solution is opened. Monitoring and refill
plans are created as well.
Dispensing systems shall be wall- or stand-mounted, manual and/or battery operated automated
(touch-free) and should meet the requirements of the following recognised ISO standards:
a) ISO 20282-1;
b) ISO/TS 20282-2;
d) ISO 26800.
Wall- or stand-mounted, manual, and electronically operated automated (touch-free) dispensing
systems should be tested and shown to meet recognised guidelines related to child finger entrapment
and accessible design for people with disabilities.
NOTE 2 See Reference [15].
NOTE 3 Regional standards can provide information about the electromagnetic compatibility of electronically
operated/automated (touch-free) dispensers. See Reference [24].
The organization shall implement a system to log the checking, maintaining and replacement of all hand
hygiene product dispensing systems.
Extensive precaution should be taken regarding dispensers in children wards or paediatric care
facilities.
Differentiation should also be made between professional healthcare workers who are adopters of this
document and patients/visitors. For the latter, healthcare facilities should decide for the most suitable
dispensing system and the correct location. Finally, healthcare facilities shall ensure proper hand
hygiene for all people entering the healthcare facility.
4.3.2 Towel dispensing systems requirements
a) Clean single use towels shall be provided at all designated hand wash stations and shall be made
available to all persons within the health facility.
The healthcare facilities shall provide single-use hand towels in the immediate proximity of the
hand washing stations.
b) Storage and handling of single use towels shall follow national infection prevention and control
(IPC) and manufacturers guidelines.
c) Organizations shall provide single use hand towels.
d) The organization shall appoint personnel for the checking of stock at stations.
1) Records of checks and re-stocking shall be maintained.
2) These appointed personnel shall be responsible for refills, purchasing and resupply.
NOTE Single use hand towels includes disposable material and reusable, re-processible material which
can be adequately reprocessed.
4.3.3 How to perform hand hygiene
A hand hygiene action is considered valid from patient safety point of view when it is performed at
the correct time, i.e. there is a hand hygiene indication, and regarded as complete when it meets the
standard of quality regarding coverage and efficacy (Figure 3).
Figure 3 — Hand hygiene indication effectiveness levels
As indicated in Figure 3, complete hand hygiene actions count towards conformity with this document.
A hand hygiene action shall be indicated, observed, and initiated to be valid. Validity requires complete
coverage of the whole hand surface as well.
Hand rubbing and hand washing techniques should be in accordance with the current World Health
Organization (WHO) guidelines or recommendations. In the case of deviation, non-inferiority shall be
documented, and the reason shall be stated in the quality policy documentation along with any related
clinical evidence. Table 1 describes the major differences between hand washing and hand rubbing
techniques.
Table 1 — Comparison of aspects of hand washing and hand rubbing
Aspect Hand washing Hand rubbing
Intention of hand hygiene action Removing of dirt including microor- Inactivation of microorganisms
ganisms
Execution (how to) Wet hands with water, wash all parts Dispensing of enough agent in hands,
of hands 20 s to 30 s with soap, rinse thorough rubbing of hands for 20 s to
sufficiently with water and dry hands 30 s, avoiding leaving gaps (uncovered
thoroughly areas)
Time needed (total) 1,5 min to 3 min 30 s
Availability (point-of-care) Low High
Spectrum of efficacy High potential of removing, low po- High potential of inactivation de-
tential of inactivation (only soap-sen- pending on the composition of the
sitive microorganisms like enveloped ingredients
viruses)
Effect on skin health/ skin tolerance The dirt-removing effect of the soap Low negative effect on skin health /
also removes natural skin protection skin tolerance. Irritation can appear
substances. This can have a negative if skin protection is interrupted (e.g.,
impact on the skin's protective barrier wound)
and skin health. Consideration should
Contact allergies are possible depend-
be given to skin care creams in such
ing on the ingredients.
cases. Contact allergies are possible
depending on the ingredients.
Specialty Dedicated hand hygiene action to No removing of dirt
remove particularly resistant micro-
organisms like bacterial spores.
May lead to an increased number of
microorganisms on the skin, due to
their release from lower skin layers.
Hand hygiene technique assessment e.g.
Product with UV-visible or colored ingredient with quality assurance
Digital imaging based technology
Physical demonstration with human supervision
Gesture recognition technology
NOTE 1 Table 1 states the minimum comparative requirements.
NOTE 2 Information about hand hygiene training is provided in Clause 7.
4.3.4 Indications for hand hygiene performance
All healthcare organization stakeholders are responsible for hand hygiene, including administration
who have access to the commonly used areas by healthcare workers, visitors, and patients, plus all
others that enter the healthcare facility.
All hospital, clinic and ward entrances, and throughout wards, should have hand hygiene facilities
available to patients and their visitors; here, the operator shall also ensure that everyone visiting the
healthcare facility has access to hand hygiene facilities in all communal areas. An assessment should be
done on all entry/exit points to identify risks and need for hand hygiene. Consider using a risk-based
approach for determining where hand hygiene is needed and the type of materials to be used.
Hand washing shall be performed when hands are visibly soiled, after touching patients or environments
contaminated with spore-forming bacteria (e.g. Clostridioides difficile) or non-envelope virus (e.g.
Norovirus), or when gloves are breeched, and when an ABHR product is not available.
Hand hygiene with ABHR product shall be performed at identified points of care and in particular at the
following:
— inside of point of care indications:
— before entering the patient zone;
— before contact with the patient;
— before clean/aseptic procedures are performed;
— after body fluid exposure, for example after coughing, sneezing, and nose blowing;
— after touching patients or patient surroundings, in particular, those contaminated with spore-
forming bacteria (e.g. Clostridioides difficile) or non-envelope virus (e.g. Norovirus);
— after exiting the patient zone;
— after handling potentially contaminated equipment;
— before doffing personal protective equipment;
— outside of point of care indications:
— entering the healthcare facility;
— before and after touching common surfaces (elevator button
...