The WHO multimodal hand hygiene improvement strategy
The WHO multimodal hand hygiene improvement strategy
The WHO multimodal hand hygiene improvement strategy
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INFECTION CONTROL<br />
A new way to address an old<br />
problem: <strong>The</strong> <strong>WHO</strong> <strong>multimodal</strong><br />
<strong>hand</strong> <strong>hygiene</strong> <strong>improvement</strong><br />
<strong>strategy</strong><br />
JULIE STORR, FIRST GLOBAL PATIENT SAFETY CHALLENGE, WORLD ALLIANCE FOR PATIENT SAFETY, WORLD<br />
HEALTH ORGANIZATION, GENEVA, SWITZERLAND<br />
H SAX, FIRST GLOBAL PATIENT SAFETY CHALLENGE, WORLD ALLIANCE FOR PATIENT SAFETY, WORLD HEALTH<br />
AND INFECTION CONTROL PROGRAMME, UNIVERSITY OF GENEVA HOSPITALS AND FACULTY OF MEDICINE, GENEVA,<br />
SWITZERLAND<br />
M-N CHRAITI, FIRST GLOBAL PATIENT SAFETY CHALLENGE, WORLD ALLIANCE FOR PATIENT SAFETY, WORLD HEALTH<br />
AND INFECTION CONTROL PROGRAMME, UNIVERSITY OF GENEVA HOSPITALS AND FACULTY OF MEDICINE, GENEVA,<br />
SWITZERLAND<br />
B ALLEGRANZI, FIRST GLOBAL PATIENT SAFETY CHALLENGE, WORLD ALLIANCE FOR PATIENT SAFETY, WORLD HEALTH<br />
ORGANIZATION, GENEVA, SWITZERLAND<br />
DIDIER PITTET MD, FIRST GLOBAL PATIENT SAFETY CHALLENGE, WORLD ALLIANCE FOR PATIENT SAFETY,<br />
WORLD HEALTH ORGANIZATION, GENEVA, SWITZERLAND AND INFECTION CONTROL PROGRAMME, UNIVERSITY OF<br />
GENEVA HOSPITALS AND FACULTY OF MEDICINE, GENEVA, SWITZERLAND<br />
Abstract<br />
Hand <strong>hygiene</strong> <strong>improvement</strong> requires strong visible administrative support and the requisite safety culture to impact on<br />
health care-associated infections. <strong>The</strong> <strong>WHO</strong> <strong>multimodal</strong> <strong>improvement</strong> <strong>strategy</strong> offers a range of tools to aid managers and<br />
health-care workers at the facility level to achieve best practices in <strong>hand</strong> <strong>hygiene</strong> compliance. This article contextualises<br />
some of the critical tools and focuses on <strong>hand</strong> <strong>hygiene</strong> measurement and the newly developed and innovative “My Five<br />
Moments for Hand Hygiene”.<br />
Health care-associated infections are the most<br />
common type of adverse event encountered<br />
within health care and infection prevention and<br />
control is considered a critical component of patient<br />
safety 1,2 . <strong>The</strong> varied nature of infections acquired within<br />
health-care settings mitigate against single preventive<br />
interventions, and a robust infection control programme<br />
centres around a range of policies. Resonating from the<br />
literature is the importance of <strong>hand</strong> <strong>hygiene</strong> as a<br />
fundamental intervention for the reduction of these<br />
infections 3 . Compliance with <strong>hand</strong> <strong>hygiene</strong><br />
recommendations is however usually low in most healthcare<br />
settings. Fortunately, successful promotion strategies<br />
have proven to be effective and even cost-effective in some<br />
instances 4,5,6,7 . Goldmann 8 summarizes the important role of<br />
health-care workers in the transmission of pathogens by<br />
stating that if every caregiver would reliably practice<br />
simple <strong>hand</strong> <strong>hygiene</strong> when leaving the bedside of every<br />
patient and before touching the next patient, there would<br />
be an immediate and profound reduction in the spread of<br />
resistant bacteria. <strong>The</strong> real world of health care presents a<br />
more complex and dynamic interplay of factors related to<br />
transmission than that described by Goldmann. However<br />
the important fact remains – health-care workers play a<br />
crucial role in the prevention of HAI.<br />
<strong>The</strong> <strong>WHO</strong> Guidelines on Hand Hygiene in Health Care<br />
<strong>The</strong> <strong>WHO</strong> Guidelines on Hand Hygiene in Health Care<br />
(Advanced Draft) outline the case for <strong>hand</strong> <strong>hygiene</strong> while,<br />
at the same time, articulating the complexity of human<br />
behaviour which lies behind persistent low compliance<br />
with this seemingly simple activity. Strategies to address<br />
<strong>hand</strong> <strong>hygiene</strong> <strong>improvement</strong> are described within the<br />
guidelines and have been strengthened with the<br />
development of an implementation toolkit. <strong>The</strong> <strong>WHO</strong><br />
<strong>strategy</strong> provides a tangible starting point for action and<br />
its multifaceted approach includes methods which impact<br />
on many aspects of infection control beyond <strong>hand</strong> <strong>hygiene</strong>.<br />
Here, we discuss some of the central adjuncts to<br />
implementation.<br />
<strong>The</strong> <strong>multimodal</strong> <strong>strategy</strong> – system change and more<br />
<strong>The</strong> <strong>WHO</strong> <strong>multimodal</strong> <strong>hand</strong> <strong>hygiene</strong> <strong>improvement</strong> <strong>strategy</strong><br />
is dependent upon the commitment of senior managers<br />
<strong>The</strong> <strong>WHO</strong><br />
Guidelines on<br />
Hand Hygiene in<br />
Health Care<br />
(Advanced Draft)<br />
outline the case<br />
for <strong>hand</strong> <strong>hygiene</strong><br />
while, at the<br />
same time,<br />
articulating the<br />
complexity of<br />
human behaviour<br />
which lies behind<br />
persistent low<br />
compliance with<br />
this seemingly<br />
simple activity<br />
( 10 ) Building Quality in Health Care Vol. 2 No. 1 2008
INFECTION CONTROL<br />
and an institutional culture which takes safety seriously.<br />
Its objective is concerned with strengthening health<br />
systems towards the aim of safer patient care. Feedback<br />
networks from regions and countries have been<br />
established as a result of the First Global Patient Safety<br />
Challenge “Clean Care is Safer Care” to ensure continuous<br />
inter-regional and international learning around this<br />
important quality <strong>improvement</strong> methodology.<br />
<strong>The</strong> five main elements of the <strong>multimodal</strong> <strong>strategy</strong><br />
centre around system <strong>improvement</strong>, illustrated in table1.<br />
However, system change alone will not impact on<br />
health-care worker behaviour, and the convergence of all<br />
other interdependent components of the <strong>strategy</strong> has been<br />
carefully crafted to create the near-perfect reliability<br />
which Goldmann 8 suggests is now possible in <strong>hand</strong><br />
<strong>hygiene</strong> <strong>improvement</strong>. <strong>The</strong> importance of education and<br />
training programmes together with the visible promotion<br />
of <strong>hand</strong> <strong>hygiene</strong> at the administrative level which supports<br />
the <strong>strategy</strong>, are the keys to long-lasting success 4,5 .<br />
Administrative support for <strong>hand</strong> <strong>hygiene</strong> <strong>improvement</strong><br />
relies upon health-care managers and leaders having a<br />
clear and unambiguous understanding of what works in<br />
terms of <strong>hand</strong> <strong>hygiene</strong> <strong>improvement</strong>. Berwick 9 emphasises<br />
that failure to use available science can be costly and<br />
harmful because it can result in overuse of unhelpful care<br />
and underuse of effective care, thus resulting in persistent<br />
errors and compromising patient safety. <strong>The</strong> principal<br />
objective of the <strong>WHO</strong> <strong>multimodal</strong> <strong>hand</strong> <strong>hygiene</strong><br />
<strong>improvement</strong> <strong>strategy</strong> is its promotion of effective care<br />
and its quest to carefully guide improvers away from<br />
unhelpful and misguided <strong>improvement</strong> methods.<br />
Promoting a safety climate is the fifth component of the<br />
<strong>multimodal</strong> <strong>strategy</strong>. A culture of safety is built upon<br />
continuous vigilance, learning and accountability 10 . This<br />
can be achieved within the framework of the <strong>WHO</strong><br />
Multimodal <strong>strategy</strong> component<br />
1A System change: alcohol based <strong>hand</strong>rub at the point of care<br />
1B System change: access to water, soap and towels<br />
2 Training and education<br />
3 Measurement including observational compliance monitoring<br />
4 Reminders in the workplace<br />
5 Safety climate, including patient participation<br />
Table 1: <strong>The</strong> five main elements of the <strong>multimodal</strong> <strong>strategy</strong> centre around system<br />
<strong>improvement</strong><br />
Ward Structure<br />
Survey<br />
Key tools for<br />
facility level<br />
transformation<br />
Manual for Observers and Training Materials<br />
Figure 1: Key tools for facility level transformation<br />
My Five Moments for<br />
Hand Hygiene<br />
Observational Compliance monitoring forms<br />
<strong>multimodal</strong> <strong>strategy</strong> through the collection, analysis and<br />
feedback of information on <strong>hand</strong> <strong>hygiene</strong> compliance and<br />
its impact on safety across multiple strata of the<br />
institution. Leadership at all levels is essential to build the<br />
requisite safety culture. We now introduce senior<br />
managers at the health-care facility level to some of the<br />
key tools (see figure 1) which can both transform <strong>hand</strong><br />
<strong>hygiene</strong> <strong>improvement</strong> and facilitate a culture of safety.<br />
Component of the <strong>multimodal</strong> <strong>strategy</strong><br />
System: water, soap and towels<br />
System: alcohol-based <strong>hand</strong>rub at the point of care<br />
Questions for managers (from the <strong>WHO</strong> Ward Structure Survey tool)<br />
Is water regularly available? ✔<br />
Is running water available? ✔<br />
Is water clean? ✔<br />
Is an alcohol-based <strong>hand</strong>rub available? ✔<br />
Is alcohol-based <strong>hand</strong>rub available as pocket bottles, bottles affixed to<br />
trolley/tray, bottles affixed to bed or wall dispensers? ✔<br />
Are wall dispensers within arm’s reach of the point of care? ✔<br />
Is there an assigned person for refilling or replacing empty dispensers? ✔<br />
Training and education<br />
Monitoring and evaluation<br />
Marketing/promotions/reminders<br />
Safety climate<br />
Have nurses received specific education on <strong>hand</strong> <strong>hygiene</strong> in the last two years? ✔<br />
Have doctors received specific education on <strong>hand</strong> <strong>hygiene</strong> in the last two<br />
years? ✔<br />
Are audits on <strong>hand</strong> <strong>hygiene</strong> compliance periodically undertaken at ward level? ✔<br />
Are posters illustrating <strong>hand</strong>wash technique displayed at every sink? ✔<br />
Are posters illustrating <strong>hand</strong>rub technique displayed at the point of care? ✔<br />
Are <strong>hand</strong> <strong>hygiene</strong> promotional posters displayed? ✔<br />
Are written guidelines with recommendations on <strong>hand</strong> <strong>hygiene</strong> available at<br />
ward-level? ✔<br />
Are disposable gloves available? ✔<br />
Does the institution consider patient participation as part of the safety<br />
culture? ✔<br />
Table 2: <strong>The</strong> ward structure survey<br />
Building Quality in Health Care Vol. 2 No. 1 2008 ( 11 )
INFECTION CONTROL<br />
Using the five-part <strong>multimodal</strong> <strong>strategy</strong>, health-care<br />
managers and senior clinicians can begin to construct<br />
meaningful interventions tailored to the local context.<br />
Promoting <strong>hand</strong> <strong>hygiene</strong> successfully can only occur if<br />
those driving the <strong>improvement</strong>, particularly decisionmakers,<br />
are fully aware of and in tune with recognized and<br />
effective methods.<br />
<strong>The</strong> ward structure survey<br />
<strong>The</strong> ward structure survey offers a practical method of<br />
determining the infrastructural facilitators and barriers to<br />
success in relation to the five components of the<br />
<strong>multimodal</strong> <strong>strategy</strong> (see table 2).<br />
Reviewing infrastructures at the individual ward level<br />
identifies instantly the strengths and weaknesses of<br />
current approaches to <strong>hand</strong> <strong>hygiene</strong> <strong>improvement</strong>. <strong>The</strong><br />
results can be used to guide future actions and, in<br />
particular, they provide information on the plan of action<br />
to be developed during Step 1 of implementation. <strong>The</strong><br />
results complement and contextualize other forms of<br />
measurement, particularly observational compliance<br />
monitoring. Low health-care worker compliance may be<br />
intrinsically linked to basic problems in infrastructure. <strong>The</strong><br />
ward structure tool enables this to be quantified and<br />
brought to the attention of senior managers. It should be<br />
repeated at intervals over the course of a cycle of<br />
<strong>improvement</strong>.<br />
“My Five Moments for Hand Hygiene”<br />
<strong>The</strong> newly-developed “My Five Moments for Hand<br />
Hygiene” concept is intended to reinvigorate, renew and,<br />
where relevant, allow for the commencement of concerted<br />
effort on <strong>hand</strong> <strong>hygiene</strong> <strong>improvement</strong>. To complement the<br />
strong visual imagery, the toolkit contains a training<br />
manual (Manual for Observers), a training DVD consisting<br />
of nine clinical scenarios where the concept is applied in a<br />
range of practical settings, and an accompanying<br />
explanatory resource. <strong>The</strong> “Five Moments” concept is an<br />
innovation in <strong>hand</strong> <strong>hygiene</strong> <strong>improvement</strong>. It depends upon<br />
the ergonomics of system change and reinforces the need<br />
for the facilitative alcohol-based <strong>hand</strong>rub at the point of<br />
care. However, “Five Moments” transcends multiple layers<br />
of the <strong>multimodal</strong> <strong>strategy</strong> as illustrated in figure 2.<br />
<strong>The</strong> concept assumes that if the product is available,<br />
Training ✔<br />
Safety<br />
Climate ✔<br />
Measurement ✔<br />
Reminders ✔<br />
Figure 2: <strong>The</strong> “Five moments” transcend the <strong>multimodal</strong> stategy<br />
Figure 3: <strong>The</strong> zoning concept<br />
Low level microbes from other patients, visitors and HCWs<br />
Mixed microbes from other patients, visitors and HCWs<br />
Patient microbes<br />
Patient microbes<br />
Patient (patient<br />
microbes)<br />
Patient bed<br />
Patient bed space: table, cupboard<br />
Ward environment<br />
General hospital environment<br />
<strong>hand</strong> <strong>hygiene</strong> is more likely to occur within a natural<br />
sequence of care or treatment. It is grounded in logic and<br />
simplicity, taking a list of complicated indications for <strong>hand</strong><br />
<strong>hygiene</strong>, rationalizing them and transforming them into a<br />
highly visually-appealing and logical illustration 11 . “My Five<br />
Moments” incorporates human factors’ engineering,<br />
ergonomics, social marketing, pedagogy and<br />
communication science in a bid to bridge the gap between<br />
scientific literature and user-centred error proof<br />
processes 11 .<br />
<strong>The</strong> importance of zoning<br />
<strong>The</strong> “Five Moments” approach separates the health-care<br />
setting into two virtual geographic areas, the patient zone<br />
and the health-care zone. Within the patient zone (inside<br />
the dotted line) not only are patients contaminated by<br />
their own microbes, but all items and furniture are<br />
considered to be contaminated with patients’ microbes.<br />
<strong>The</strong> health-care zone (outside of the dotted line) is<br />
considered to be contaminated with potentially harmful<br />
and foreign microbes which might contribute to crossinfection.<br />
Within the patient zone, there are two<br />
important sites: clean (aseptic) sites, corresponding to<br />
body sites such as mucous membranes, broken skin or<br />
medical devices which need to be protected from<br />
microbial contamination which could lead to HAI, and<br />
body fluid sites leading to exposure of <strong>hand</strong>s of health-care<br />
workers to body fluids and bloodborne pathogens. Figure<br />
3 illustrates the zoning concept.<br />
“My Five Moments” is designed with a simple aim – to<br />
reduce the number of times when<br />
<strong>hand</strong> <strong>hygiene</strong> is required in health<br />
care to an absolute minimum for<br />
maximum patient safety. Hand<br />
<strong>hygiene</strong> is required when it is both<br />
necessary and sufficient for the<br />
prevention of transmission of<br />
infection. “Five Moments” is the<br />
Pareto principle (i.e., for many events,<br />
80% of the effects come from 20% of<br />
the causes) of <strong>hand</strong> <strong>hygiene</strong><br />
<strong>improvement</strong> in its intention to<br />
promote <strong>hand</strong> <strong>hygiene</strong> at the key<br />
moments where it is likely to yield the<br />
most impact in terms of safety. By<br />
<strong>The</strong> “Five<br />
Moments”<br />
approach<br />
separates the<br />
health-care<br />
setting into two<br />
virtual<br />
geographic areas,<br />
the patient zone<br />
and the healthcare<br />
zone<br />
( 12 ) Building Quality in Health Care Vol. 2 No. 1 2008
INFECTION CONTROL<br />
applying this principle, the general hospital environment<br />
(corridors and entrances) immediately presents a much<br />
lower likelihood of microbial exchange to the patient. In<br />
most cases, microbes will be brought into the patient zone<br />
by the health-care worker’s <strong>hand</strong> or objects. <strong>The</strong> aim of<br />
<strong>hand</strong> <strong>hygiene</strong> is to stop the microbial contamination of<br />
one patient to another 12 . Focusing on <strong>hand</strong> <strong>hygiene</strong> around<br />
and within the critical patient zone is likely to provide<br />
maximum return on investment in terms of reducing<br />
infection risk and maintaining patient safety.<br />
Within the “Five Moments” framework, <strong>hand</strong> <strong>hygiene</strong><br />
compliance becomes a targeted activity, a fundamental and<br />
essential skill, requiring simple training and designed to<br />
integrate into the routine practices of all health-care<br />
workers. Knowing when the correct moments for <strong>hand</strong><br />
<strong>hygiene</strong> should occur is a basic prerequisite not only for<br />
those at the patient-health-care worker interface, but<br />
importantly, for all health-care managers and clinical<br />
leaders.<br />
Accompanying tools<br />
To aid in the satisfactory attainment of robust<br />
measurement, the “Five Moments” tool is accompanied by<br />
a Manual for Observers, a training DVD and the<br />
compliance measurement tool (see figure 1). <strong>The</strong><br />
measurement tool is based around the “Five Moments for<br />
Hand Hygiene” (see figure 4) and enables facilities to<br />
determine which of the moments are achieving the<br />
highest/lowest compliance. This information can therefore<br />
inform training strategies.<br />
In considering whether to proceed with a <strong>hand</strong> <strong>hygiene</strong><br />
<strong>improvement</strong> intervention, managers may want to<br />
consider the following questions:<br />
✦ How are health-care workers currently trained on <strong>hand</strong><br />
<strong>hygiene</strong> indications?<br />
✦ Is the approach targeted, focused and logical?<br />
✦ How is training monitored?<br />
✦ Which indications for <strong>hand</strong> <strong>hygiene</strong> are health-care<br />
workers instructed to perform?<br />
✦ How are health-care workers prompted to perform <strong>hand</strong><br />
<strong>hygiene</strong> during the course of a working day?<br />
✦ Do managers, leaders, decision-makers, performance<br />
<strong>improvement</strong> specialists, risk and quality managers and<br />
accreditation inspectors know about the correct<br />
moments for <strong>hand</strong> <strong>hygiene</strong>?<br />
✦ Do patients, visitors and the public know about the<br />
correct moments for <strong>hand</strong> <strong>hygiene</strong>?<br />
Goldmann 8 emphasizes that the hospital and its leaders<br />
are accountable for establishing systems in which healthcare<br />
workers have the knowledge, competence, time and<br />
tools to practice perfect <strong>hand</strong> <strong>hygiene</strong>. Only when the<br />
system is flawless can the emphasis shift to accountability.<br />
<strong>The</strong> learning so far from the First Global Patient Safety<br />
Challenge suggests that in almost every corner of the<br />
globe, there is underachievement in terms of reliability in<br />
systems. Pronovost 13 suggests that when a system is<br />
created that reliably delivers the process or interventions<br />
that work, spectacular performance <strong>improvement</strong> can<br />
Hand Hygiene<br />
opportunity<br />
One of the Five<br />
Moments<br />
Figure 4: Details from the <strong>hand</strong> hygene measurement tool<br />
follow. <strong>The</strong> <strong>WHO</strong> <strong>strategy</strong> assists local teams in achieving<br />
this spectacular performance <strong>improvement</strong> in all healthcare<br />
facilities around the globe. Burke 1 suggests that the<br />
growing global patient safety movement has energized the<br />
field of infection control. <strong>The</strong> First Global Patient Safety<br />
Challenge with its focus on <strong>hand</strong> <strong>hygiene</strong> <strong>improvement</strong> in<br />
health care opens up endless possibilities to re-energise<br />
and reinvigorate more general patient safety and infection<br />
prevention and control approaches.<br />
Conclusion<br />
<strong>The</strong> First Global Patient Safety Challenge has united 87<br />
countries worldwide at the political level around a single<br />
issue and lack of leadership and political support is<br />
increasingly being seen as anathema to successful <strong>hand</strong><br />
<strong>hygiene</strong> <strong>improvement</strong>. However, the translation of political<br />
commitment into <strong>improvement</strong> at the facility level is<br />
dependent upon the perspicacity of individual leaders and<br />
managers in seeing the opportunities presented by the<br />
<strong>WHO</strong> <strong>strategy</strong>. From the “Five Moments” approach springs<br />
a refreshingly pragmatic methodology acknowledging the<br />
reality of health care – <strong>hand</strong> <strong>hygiene</strong> compliance requires<br />
time and comes with little reward. Rationalising the<br />
indications to the absolute minimum for safety and<br />
implanting this rationale within a scientific context is<br />
designed to make sense of <strong>hand</strong> <strong>hygiene</strong> and to promote it<br />
at the times when it is truly necessary and when its action<br />
will be sufficient to prevent harm. This is the opportunity<br />
presented to those leaders and managers who are looking<br />
for a new way to improve safety for all patients in their<br />
care. ✦<br />
Julie Storr is the project manager of the <strong>WHO</strong> First<br />
Global Patient Safety Challenge and was formerly the<br />
Project Director of the UK National Patient Safety<br />
Agency’s cleanyour<strong>hand</strong>s campaign.<br />
Observed action<br />
(or omission)<br />
Building Quality in Health Care Vol. 2 No. 1 2008 ( 13 )
INFECTION CONTROL<br />
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