The WHO multimodal hand hygiene improvement strategy

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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) Building Quality in Health Care Vol. 2 No. 1 2008 ( 13 )
INFECTION CONTROL References 1. Burke J P Infection Control – A Problem for Patient Safety. New England Journal of Medicine, 2003, 348; 7. 651-656 www.nejm.org accessed July 2nd 2008 2. Pittet D, Donaldson L. Clean Care is Safer Care: a worldwide priority. The Lancet, 2005, 366:1246-1247. 3. World Health Organization WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft). World Health Organization, Geneva. 2005, pp 207; 4. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveaneau S, Perneger TV. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. The Lancet, 2000, 356:1307-1312; 5. Pittet D, Sax H, Hugonnet S, Harbarth S. Cost implications of successful hand hygiene promotion. Infect Control Hosp Epidemiol., 2004, 25:264-266). 6. Johnson PD, Martin R, Burrell LJ, Grabsch EA, Kirsa SW, O’Keeffe J, Mayall BC, Edmonds D, Barr W, Bolger C, Naidoo H, Grayson ML. Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. Med J Aust., 2005,183:509-514; 7. Pessoa-Silva CL, Hugonnet S, Pfister R, Touveneau S, Dharan S, Posfay-Barbe K, Pittet D. Reduction of health care-associated infection risk in neonates by successful hand hygiene promotion. Pediatrics, 2007,120:e382-390; 8. Goldmann D. System Failure Versus Personal Accountability – The Case for Clean Hands. New England Journal of Medicine. 2007; Vol 355. No 2. 121-123 9. Berwick D M. Disseminating Innovations in Health Care. JAMA, 2003, Vol 289. No 15. 1969-1975 10. Shortell S, Singer S. Improving Patient Safety by Taking Systems Seriously Journal of the American Medical Association, 2008, Vol 299, No 4. 445-447 11. Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet D.‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. Journal of Hospital Infection., 2007, 67: 9-21 12. Pittet D, Allegranzi B, Sax H, Dharan S, Pessoa-Silva CL, Donaldson L, Boyce JM. WHO Global Patient Safety Challenge, World Alliance for Patient Safety. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006;6:641-652 13. Pronovost P, Holzmueller CG, Needham D M, Sexton J B, Miller M, Berenholtz S, Wu A W, Perl T M, Davis R, Baker D, Winner L, Morlock L. How will we know patients are safer? An organization-wide approach to measuring and improving safety. Critical Care Medicine., 2006, Vol 34, No 7 1988-1995 14. Grol R, Berwick D, Wensing M. On the trail of quality and safety in health care. British Medical Journal, 2008, Vol 336 74-76 www.bmj.com accessed 1st February 2008 15. Pittet D, Allegranzi B, Storr J, Bagheri-Nejad S, Dziekan G, Leotsakos A, Donaldson L.. Infection control as a major WHO priority for developing countries. Journal of Hospital Infection 2008; 68:285-92. ( 14 ) 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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