The WHO multimodal hand hygiene improvement strategy

INFECTION CONTROL
A new way to address an old
problem: The WHO multimodal
hand hygiene improvement
strategy
JULIE STORR, FIRST GLOBAL PATIENT SAFETY CHALLENGE, WORLD ALLIANCE FOR PATIENT SAFETY, WORLD
HEALTH ORGANIZATION, GENEVA, SWITZERLAND
H SAX, FIRST GLOBAL PATIENT SAFETY CHALLENGE, WORLD ALLIANCE FOR PATIENT SAFETY, WORLD HEALTH
AND INFECTION CONTROL PROGRAMME, UNIVERSITY OF GENEVA HOSPITALS AND FACULTY OF MEDICINE, GENEVA,
SWITZERLAND
M-N CHRAITI, FIRST GLOBAL PATIENT SAFETY CHALLENGE, WORLD ALLIANCE FOR PATIENT SAFETY, WORLD HEALTH
AND INFECTION CONTROL PROGRAMME, UNIVERSITY OF GENEVA HOSPITALS AND FACULTY OF MEDICINE, GENEVA,
SWITZERLAND
B ALLEGRANZI, FIRST GLOBAL PATIENT SAFETY CHALLENGE, WORLD ALLIANCE FOR PATIENT SAFETY, WORLD HEALTH
ORGANIZATION, GENEVA, SWITZERLAND
DIDIER PITTET MD, FIRST GLOBAL PATIENT SAFETY CHALLENGE, WORLD ALLIANCE FOR PATIENT SAFETY,
WORLD HEALTH ORGANIZATION, GENEVA, SWITZERLAND AND INFECTION CONTROL PROGRAMME, UNIVERSITY OF
GENEVA HOSPITALS AND FACULTY OF MEDICINE, GENEVA, SWITZERLAND
Abstract
Hand hygiene improvement requires strong visible administrative support and the requisite safety culture to impact on
health care-associated infections. The WHO multimodal improvement strategy offers a range of tools to aid managers and
health-care workers at the facility level to achieve best practices in hand hygiene compliance. This article contextualises
some of the critical tools and focuses on hand hygiene measurement and the newly developed and innovative “My Five
Moments for Hand Hygiene”.
Health care-associated infections are the most
common type of adverse event encountered
within health care and infection prevention and
control is considered a critical component of patient
safety 1,2 . The varied nature of infections acquired within
health-care settings mitigate against single preventive
interventions, and a robust infection control programme
centres around a range of policies. Resonating from the
literature is the importance of hand hygiene as a
fundamental intervention for the reduction of these
infections 3 . Compliance with hand hygiene
recommendations is however usually low in most healthcare
settings. Fortunately, successful promotion strategies
have proven to be effective and even cost-effective in some
instances 4,5,6,7 . Goldmann 8 summarizes the important role of
health-care workers in the transmission of pathogens by
stating that if every caregiver would reliably practice
simple hand hygiene when leaving the bedside of every
patient and before touching the next patient, there would
be an immediate and profound reduction in the spread of
resistant bacteria. The real world of health care presents a
more complex and dynamic interplay of factors related to
transmission than that described by Goldmann. However
the important fact remains – health-care workers play a
crucial role in the prevention of HAI.
The WHO Guidelines on Hand Hygiene in Health Care
The WHO Guidelines on Hand Hygiene in Health Care
(Advanced Draft) outline the case for hand hygiene while,
at the same time, articulating the complexity of human
behaviour which lies behind persistent low compliance
with this seemingly simple activity. Strategies to address
hand hygiene improvement are described within the
guidelines and have been strengthened with the
development of an implementation toolkit. The WHO
strategy provides a tangible starting point for action and
its multifaceted approach includes methods which impact
on many aspects of infection control beyond hand hygiene.
Here, we discuss some of the central adjuncts to
implementation.
The multimodal strategy – system change and more
The WHO multimodal hand hygiene improvement strategy
is dependent upon the commitment of senior managers
The WHO
Guidelines on
Hand Hygiene in
Health Care
(Advanced Draft)
outline the case
for hand hygiene
while, at the
same time,
articulating the
complexity of
human behaviour
which lies behind
persistent low
compliance with
this seemingly
simple activity
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INFECTION CONTROL
and an institutional culture which takes safety seriously.
Its objective is concerned with strengthening health
systems towards the aim of safer patient care. Feedback
networks from regions and countries have been
established as a result of the First Global Patient Safety
Challenge “Clean Care is Safer Care” to ensure continuous
inter-regional and international learning around this
important quality improvement methodology.
The five main elements of the multimodal strategy
centre around system improvement, illustrated in table1.
However, system change alone will not impact on
health-care worker behaviour, and the convergence of all
other interdependent components of the strategy has been
carefully crafted to create the near-perfect reliability
which Goldmann 8 suggests is now possible in hand
hygiene improvement. The importance of education and
training programmes together with the visible promotion
of hand hygiene at the administrative level which supports
the strategy, are the keys to long-lasting success 4,5 .
Administrative support for hand hygiene improvement
relies upon health-care managers and leaders having a
clear and unambiguous understanding of what works in
terms of hand hygiene improvement. Berwick 9 emphasises
that failure to use available science can be costly and
harmful because it can result in overuse of unhelpful care
and underuse of effective care, thus resulting in persistent
errors and compromising patient safety. The principal
objective of the WHO multimodal hand hygiene
improvement strategy is its promotion of effective care
and its quest to carefully guide improvers away from
unhelpful and misguided improvement methods.
Promoting a safety climate is the fifth component of the
multimodal strategy. A culture of safety is built upon
continuous vigilance, learning and accountability 10 . This
can be achieved within the framework of the WHO
Multimodal strategy component
1A System change: alcohol based handrub at the point of care
1B System change: access to water, soap and towels
2 Training and education
3 Measurement including observational compliance monitoring
4 Reminders in the workplace
5 Safety climate, including patient participation
Table 1: The five main elements of the multimodal strategy centre around system
improvement
Ward Structure
Survey
Key tools for
facility level
transformation
Manual for Observers and Training Materials
Figure 1: Key tools for facility level transformation
My Five Moments for
Hand Hygiene
Observational Compliance monitoring forms
multimodal strategy through the collection, analysis and
feedback of information on hand hygiene compliance and
its impact on safety across multiple strata of the
institution. Leadership at all levels is essential to build the
requisite safety culture. We now introduce senior
managers at the health-care facility level to some of the
key tools (see figure 1) which can both transform hand
hygiene improvement and facilitate a culture of safety.
Component of the multimodal strategy
System: water, soap and towels
System: alcohol-based handrub at the point of care
Questions for managers (from the WHO Ward Structure Survey tool)
Is water regularly available? ✔
Is running water available? ✔
Is water clean? ✔
Is an alcohol-based handrub available? ✔
Is alcohol-based handrub available as pocket bottles, bottles affixed to
trolley/tray, bottles affixed to bed or wall dispensers? ✔
Are wall dispensers within arm’s reach of the point of care? ✔
Is there an assigned person for refilling or replacing empty dispensers? ✔
Training and education
Monitoring and evaluation
Marketing/promotions/reminders
Safety climate
Have nurses received specific education on hand hygiene in the last two years? ✔
Have doctors received specific education on hand hygiene in the last two
years? ✔
Are audits on hand hygiene compliance periodically undertaken at ward level? ✔
Are posters illustrating handwash technique displayed at every sink? ✔
Are posters illustrating handrub technique displayed at the point of care? ✔
Are hand hygiene promotional posters displayed? ✔
Are written guidelines with recommendations on hand hygiene available at
ward-level? ✔
Are disposable gloves available? ✔
Does the institution consider patient participation as part of the safety
culture? ✔
Table 2: The ward structure survey
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INFECTION CONTROL
Using the five-part multimodal strategy, health-care
managers and senior clinicians can begin to construct
meaningful interventions tailored to the local context.
Promoting hand hygiene successfully can only occur if
those driving the improvement, particularly decisionmakers,
are fully aware of and in tune with recognized and
effective methods.
The ward structure survey
The ward structure survey offers a practical method of
determining the infrastructural facilitators and barriers to
success in relation to the five components of the
multimodal strategy (see table 2).
Reviewing infrastructures at the individual ward level
identifies instantly the strengths and weaknesses of
current approaches to hand hygiene improvement. The
results can be used to guide future actions and, in
particular, they provide information on the plan of action
to be developed during Step 1 of implementation. The
results complement and contextualize other forms of
measurement, particularly observational compliance
monitoring. Low health-care worker compliance may be
intrinsically linked to basic problems in infrastructure. The
ward structure tool enables this to be quantified and
brought to the attention of senior managers. It should be
repeated at intervals over the course of a cycle of
improvement.
“My Five Moments for Hand Hygiene”
The newly-developed “My Five Moments for Hand
Hygiene” concept is intended to reinvigorate, renew and,
where relevant, allow for the commencement of concerted
effort on hand hygiene improvement. To complement the
strong visual imagery, the toolkit contains a training
manual (Manual for Observers), a training DVD consisting
of nine clinical scenarios where the concept is applied in a
range of practical settings, and an accompanying
explanatory resource. The “Five Moments” concept is an
innovation in hand hygiene improvement. It depends upon
the ergonomics of system change and reinforces the need
for the facilitative alcohol-based handrub at the point of
care. However, “Five Moments” transcends multiple layers
of the multimodal strategy as illustrated in figure 2.
The concept assumes that if the product is available,
Training ✔
Safety
Climate ✔
Measurement ✔
Reminders ✔
Figure 2: The “Five moments” transcend the multimodal stategy
Figure 3: The zoning concept
Low level microbes from other patients, visitors and HCWs
Mixed microbes from other patients, visitors and HCWs
Patient microbes
Patient microbes
Patient (patient
microbes)
Patient bed
Patient bed space: table, cupboard
Ward environment
General hospital environment
hand hygiene is more likely to occur within a natural
sequence of care or treatment. It is grounded in logic and
simplicity, taking a list of complicated indications for hand
hygiene, rationalizing them and transforming them into a
highly visually-appealing and logical illustration 11 . “My Five
Moments” incorporates human factors’ engineering,
ergonomics, social marketing, pedagogy and
communication science in a bid to bridge the gap between
scientific literature and user-centred error proof
processes 11 .
The importance of zoning
The “Five Moments” approach separates the health-care
setting into two virtual geographic areas, the patient zone
and the health-care zone. Within the patient zone (inside
the dotted line) not only are patients contaminated by
their own microbes, but all items and furniture are
considered to be contaminated with patients’ microbes.
The health-care zone (outside of the dotted line) is
considered to be contaminated with potentially harmful
and foreign microbes which might contribute to crossinfection.
Within the patient zone, there are two
important sites: clean (aseptic) sites, corresponding to
body sites such as mucous membranes, broken skin or
medical devices which need to be protected from
microbial contamination which could lead to HAI, and
body fluid sites leading to exposure of hands of health-care
workers to body fluids and bloodborne pathogens. Figure
3 illustrates the zoning concept.
“My Five Moments” is designed with a simple aim – to
reduce the number of times when
hand hygiene is required in health
care to an absolute minimum for
maximum patient safety. Hand
hygiene is required when it is both
necessary and sufficient for the
prevention of transmission of
infection. “Five Moments” is the
Pareto principle (i.e., for many events,
80% of the effects come from 20% of
the causes) of hand hygiene
improvement in its intention to
promote hand hygiene at the key
moments where it is likely to yield the
most impact in terms of safety. By
The “Five
Moments”
approach
separates the
health-care
setting into two
virtual
geographic areas,
the patient zone
and the healthcare
zone
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INFECTION CONTROL
applying this principle, the general hospital environment
(corridors and entrances) immediately presents a much
lower likelihood of microbial exchange to the patient. In
most cases, microbes will be brought into the patient zone
by the health-care worker’s hand or objects. The aim of
hand hygiene is to stop the microbial contamination of
one patient to another 12 . Focusing on hand hygiene around
and within the critical patient zone is likely to provide
maximum return on investment in terms of reducing
infection risk and maintaining patient safety.
Within the “Five Moments” framework, hand hygiene
compliance becomes a targeted activity, a fundamental and
essential skill, requiring simple training and designed to
integrate into the routine practices of all health-care
workers. Knowing when the correct moments for hand
hygiene should occur is a basic prerequisite not only for
those at the patient-health-care worker interface, but
importantly, for all health-care managers and clinical
leaders.
Accompanying tools
To aid in the satisfactory attainment of robust
measurement, the “Five Moments” tool is accompanied by
a Manual for Observers, a training DVD and the
compliance measurement tool (see figure 1). The
measurement tool is based around the “Five Moments for
Hand Hygiene” (see figure 4) and enables facilities to
determine which of the moments are achieving the
highest/lowest compliance. This information can therefore
inform training strategies.
In considering whether to proceed with a hand hygiene
improvement intervention, managers may want to
consider the following questions:
✦ How are health-care workers currently trained on hand
hygiene indications?
✦ Is the approach targeted, focused and logical?
✦ How is training monitored?
✦ Which indications for hand hygiene are health-care
workers instructed to perform?
✦ How are health-care workers prompted to perform hand
hygiene during the course of a working day?
✦ Do managers, leaders, decision-makers, performance
improvement specialists, risk and quality managers and
accreditation inspectors know about the correct
moments for hand hygiene?
✦ Do patients, visitors and the public know about the
correct moments for hand hygiene?
Goldmann 8 emphasizes that the hospital and its leaders
are accountable for establishing systems in which healthcare
workers have the knowledge, competence, time and
tools to practice perfect hand hygiene. Only when the
system is flawless can the emphasis shift to accountability.
The learning so far from the First Global Patient Safety
Challenge suggests that in almost every corner of the
globe, there is underachievement in terms of reliability in
systems. Pronovost 13 suggests that when a system is
created that reliably delivers the process or interventions
that work, spectacular performance improvement can
Hand Hygiene
opportunity
One of the Five
Moments
Figure 4: Details from the hand hygene measurement tool
follow. The WHO strategy assists local teams in achieving
this spectacular performance improvement in all healthcare
facilities around the globe. Burke 1 suggests that the
growing global patient safety movement has energized the
field of infection control. The First Global Patient Safety
Challenge with its focus on hand hygiene improvement in
health care opens up endless possibilities to re-energise
and reinvigorate more general patient safety and infection
prevention and control approaches.
Conclusion
The First Global Patient Safety Challenge has united 87
countries worldwide at the political level around a single
issue and lack of leadership and political support is
increasingly being seen as anathema to successful hand
hygiene improvement. However, the translation of political
commitment into improvement at the facility level is
dependent upon the perspicacity of individual leaders and
managers in seeing the opportunities presented by the
WHO strategy. From the “Five Moments” approach springs
a refreshingly pragmatic methodology acknowledging the
reality of health care – hand hygiene compliance requires
time and comes with little reward. Rationalising the
indications to the absolute minimum for safety and
implanting this rationale within a scientific context is
designed to make sense of hand hygiene and to promote it
at the times when it is truly necessary and when its action
will be sufficient to prevent harm. This is the opportunity
presented to those leaders and managers who are looking
for a new way to improve safety for all patients in their
care. ✦
Julie Storr is the project manager of the WHO First
Global Patient Safety Challenge and was formerly the
Project Director of the UK National Patient Safety
Agency’s cleanyourhands campaign.
Observed action
(or omission)
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INFECTION CONTROL
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