The WHO multimodal hand hygiene improvement strategy

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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 Building Quality in Health Care Vol. 2 No. 1 2008 ( 11 )
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 ( 12 ) Building Quality in Health Care Vol. 2 No. 1 2008
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The WHO multimodal hand hygiene improvement strategy

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