Hand Hygiene SOP Template

1.Purpose

To reduce the spread of infection by making sure every staff member cleans their hands correctly at the right moments, and that compliance is monitored and corrected.

2.Scope

Applies to all clinical and support staff who have direct or indirect contact with patients, equipment or patient surroundings. Surgical hand scrub is covered by a separate SOP.

Definitions

Point of care

The place where a patient, staff member and care or treatment involving contact with the patient come together.

Alcohol-based hand rub

A gel or foam sanitizer used to clean visibly clean hands when soap and water are not required.

Hand hygiene moment

A specific time during care, such as before touching a patient, when hands must be cleaned.

3.Responsibilities

Clinical Staff Member

Performs hand hygiene at every required moment during patient care and reports broken or empty dispensers.

Charge Nurse

Coaches staff in real time, reinforces technique and reviews unit audit results at handover.

Infection Prevention Coordinator

Runs the audit program, tracks compliance rates and plans refresher training.

Environmental Services Technician

Restocks hand hygiene stations and reports empty, damaged or malfunctioning dispensers.

RACI matrix

R = Responsible, A = Accountable, C = Consulted, I = Informed

4.Materials and PPE

Materials, tools and systems

• →Alcohol-based hand rub dispensers at point of care
• →Soap and water handwashing stations
• →Disposable paper towels
• →Skin moisturizer approved for use with gloves
• →Hand hygiene audit form or mobile audit app
• →Compliance dashboard or tracking log

Personal protective equipment

• →Disposable nitrile or vinyl gloves

5.Procedure

1. 5.1

   Identify when hand hygiene is required

   Clinical Staff Member

   Clean your hands before touching a patient, before a clean or aseptic task, after any risk of exposure to body fluids, after touching a patient, and after touching the patient's surroundings.

2. 5.2

   Remove jewelry and prepare

   Clinical Staff Member

   Remove rings, watches and bracelets that interfere with cleaning, and keep nails short and free of artificial extensions per facility policy.

3. 5.3

   Choose the right method

   Clinical Staff Member

   Use alcohol-based hand rub for most moments unless hands are visibly soiled, or the patient is on precautions requiring soap and water for spore-forming organisms.

   Warning: Alcohol-based rub does not reliably remove spores. Use soap and water when caring for a patient on precautions for a spore-forming organism.

4. 5.4

   Perform the alcohol-based hand rub

   Clinical Staff Member

   Apply enough product to cover all surfaces of both hands, then rub palms, backs of hands, between fingers, fingertips and thumbs until hands are completely dry, for at least 20 seconds or as directed by the product label.

   Checkpoint: Hands are rubbed until completely dry; no residue is wiped off early.

5. 5.5

   Perform soap-and-water handwashing

   Clinical Staff Member

   Wet hands, apply soap, scrub all surfaces including between fingers and under nails for at least 20 seconds, rinse under running water, and dry with a disposable towel, using the towel to turn off the faucet.

6. 5.6

   Don gloves only after hands are dry

   Clinical Staff Member

   Put on gloves only after hands are completely dry from hand hygiene, and select the correct size and type for the task.

   Warning: Gloves are not a substitute for hand hygiene. Clean hands before donning and immediately after removing gloves.

7. 5.7

   Clean hands between tasks and glove changes

   Clinical Staff Member

   Remove gloves and clean hands before moving from a contaminated task to a clean one, and between patients even during the same encounter if care tasks change.

8. 5.8

   Care for skin

   Clinical Staff Member

   Apply facility-approved moisturizer during breaks to prevent cracked skin, and report any dermatitis, cuts or skin breakdown to your supervisor before the next shift.

9. 5.9

   Coach and correct in real time

   Charge Nurse

   When a missed or incorrect hand hygiene moment is observed, the charge nurse corrects it on the spot in a respectful, non-punitive way and documents the coaching if it recurs.

   Checkpoint: Real-time corrections are logged so repeated issues can be identified at the unit level.

10. 5.10

    Stock and inspect hand hygiene stations

    Environmental Services Technician

    Check dispensers on rounds, refill or replace empty or malfunctioning units immediately, and report any station that cannot be fixed on the spot.

    Checkpoint: No hand hygiene station on the unit is empty or non-functional at the end of the shift.

11. 5.11

    Conduct compliance audits

    Infection Prevention Coordinator

    Perform scheduled and unannounced direct observation audits using the standard audit form, covering a representative sample of moments across shifts and roles.

12. 5.12

    Share results and plan training

    Infection Prevention Coordinator

    Post unit-level compliance rates, review trends with unit leadership monthly, and schedule refresher training for units or individuals below the facility's target.

6.Quality checks

• →Direct observation audits are completed on every unit at least monthly.
• →Hand hygiene compliance rate meets or exceeds the facility's target.
• →No hand hygiene station is found empty during environmental rounds.
• →New hires demonstrate correct technique before working unsupervised.

7.Records

• →Hand hygiene compliance audit results
• →Real-time coaching log
• →Station inspection and restocking log
• →Training and competency sign-off records

8.KPIs

• →Hand hygiene compliance rate by unit
• →Number of missed opportunities corrected in real time
• →Dispenser downtime
• →Healthcare-associated infection rate trend

9.Common mistakes

• →Applying alcohol-based rub and wiping it off before hands are dry.
• →Wearing the same pair of gloves between patients without changing them.
• →Skipping hand hygiene after removing gloves because hands look clean.
• →Using alcohol-based rub instead of soap and water for a patient on spore precautions.

10.Revision history