WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE
21.
The <strong>WHO</strong> Multimodal Hand Hygiene
Improvement Strategy
21.1 Key elements for a successful strategy
The successful implementation of guidelines into practice
continues to elude health improvement efforts globally. 876 The
Replicating Effective Programs (REP) framework is one example
of a successful approach, although largely within the context of
HIV prevention interventions. 877 Recent work has also focused
on knowledge transfer, often incorporating learning from the
body of knowledge on diffusion of innovation. 869 The literature
confirms that there is no magic solution to guarantee uptake
and assimilation of guidelines into clinical practice.
Against this background, the <strong>WHO</strong> <strong>Guidelines</strong> on Hand Hygiene
in Health Care have been developed with the ultimate objective
of changing the behaviour of individual HCWs to optimize
compliance with hand hygiene at the recommended moments
and to improve patient safety. For this objective to be fulfilled,
a successful dissemination and implementation strategy is
required to ensure that practitioners are aware of the guidelines
and their use. 728,878
Ensuring that guidelines are transformed from a static document
into a living and influential tool that impacts on the target
practice requires a carefully constructed strategy to maximize
dissemination and diffusion. 868 Fraser describes implementation
as being concerned with the movement of an idea that works
across a large number of people (the target population). Based
on the best available scientific evidence and underpinned
by both the long-standing expertise of Geneva’s University
Hospitals to promote multimodal hand hygiene promotion
campaigns 60 and learning from the England & Wales National
Patient Safety Agency (NPSA) cleanyourhands campaign,
the <strong>WHO</strong> Hand Hygiene Implementation Strategy has been
constructed to provide users with a ready-to-go approach to
translate the <strong>WHO</strong> <strong>Guidelines</strong> on Hand Hygiene in Health Care
into practice at facility level.
The <strong>WHO</strong> Multimodal Hand Hygiene Improvement Strategy
consists of a Guide to Implementation and a range of tools
constructed to facilitate implementation of each component.
The Guide to Implementation accompanies the <strong>WHO</strong> <strong>Guidelines</strong>
on Hand Hygiene in Health Care and outlines a process for
fostering hand hygiene improvement in a health-care facility.
The implementation strategy has been informed by the literature
on implementation science, behavioural change, spread
methodology, diffusion of innovation, and impact evaluation. At
its core is a multimodal strategy consisting of five components
to be implemented in parallel; the implementation strategy itself
is designed to be adaptable without jeopardizing its fidelity and
is intended therefore for use not only in virgin sites, but also
within facilities with existing action on hand hygiene. The five
essential elements are: system change, including availability
of alcohol-based handrub at the point of patient care and/or
access to a safe, continuous water supply and soap and towels;
training and education of health-care professionals; monitoring
of hand hygiene practices and performance feedback;
reminders in the workplace; and the creation of a hand hygiene
safety culture with the participation of both individual HCWs and
senior hospital managers. Depending on local resources and
culture, additional actions can be added, in particular patient
involvement (see Part V).
21.2 Essential steps for implementation at heathcare
setting level
The Guide to Implementation details the actions and resources
necessary to ensure each component of the multimodal
strategy can become assimilated into existing infection control
and safety programmes. The Guide is structured around five
sequential steps which are recommended to reflect an action
plan at facility level (Figure I.21.1). The target for this approach is
a facility where a hand hygiene improvement programme has to
be initiated from scratch.
Step 1: Facility preparedness – readiness for action
Step 2: Baseline evaluation – establishing the current
situation
Step 3: Implementation – introducing the improvement
activities
Step 4: Follow-up evaluation – evaluating the
implementation impact
Step 5: Action planning and review cycle – developing a
plan for the next 5 years (minimum)
Step 1 is to ensure the preparedness of the institution. This
includes getting the necessary resources in place and the key
leadership to head the programme, including a coordinator and
his/her deputy. Proper planning must be done to map out a
clear strategy for the entire programme.
Step 2 is to conduct baseline evaluation of hand hygiene
practice, perception, knowledge, and infrastructure available.
Step 3 is to implement the improvement programme: availability
of an alcohol-based handrub at the point of care and staff
education and training are vitally important. Well-publicized
events involving endorsement and/or signatures of commitment
of leaders and individual HCWs will draw great dividends.
Follow-up evaluation to assess the effectiveness of the
programme naturally comes next as Step 4.
Finally, Step 5 is to develop an ongoing action plan and review
cycle. The overall aim is to inculcate hand hygiene as an integral
part of the hospital culture. A more comprehensive outline of
activity within each step is presented in Figure I.21.2.
Each step in the cycle builds on the activities and actions
that occurred during the previous step, and clear roles and
responsibilities are outlined within the strategy. The steps
are presented in a user-friendly guidebook, designed to be
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