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

<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE
a working resource for implementers and leads in infection
control, safety, and quality. Throughout the five steps, activities
are clearly articulated and the accompanying tools to aid
implementation are clearly signposted. At the end of each step,
a checklist is presented and implementers are instructed to
ensure all recommended activities have been completed prior to
moving to the next step. Central to the implementation strategy
is an action plan, recommended to be constructed within Step
1, to guide actions throughout each subsequent step.
Rather than a linear process, the five steps are intended to
be dealt with in a cyclical manner, with each cycle repeated,
refined, and enhanced over a minimum 5-year period. A key
feature of an implementation strategy is evaluation and this is
a permanent feature of the <strong>WHO</strong> multimodal strategy during
Steps 2 and 4. Implementation, evaluation, and feedback
activities should be periodically rejuvenated and repeated and
become part of the quality improvement actions to ensure
sustainability. Following the full implementation of the strategy
for the first time, the plan of activities and long-term steps
should be based on lessons learnt about key success factors
and on areas that need further improvement. Therefore, the
choice to privilege some specific activities and/or steps might
be performed.
21.2.1 Basic requirements for implementation
In situations where the complete implementation strategy is
not considered feasible, perhaps because of limited resources
and time, implementers can focus on minimum implementation
criteria to ensure essential achievement of each component
of the multimodal strategy. The eight criteria are listed in Table
I.21.1.
21.4 “My five moments for hand hygiene”
In this section, a new model intended to meet the needs for
training, observation, and performance reporting across all
health-care settings worldwide is described. 1 This model is
also integrated in various tools included in the <strong>WHO</strong> Multimodal
Hand Hygiene Improvement Strategy (see Part I, Sections
21.1–21.3).
The concept of “My five moments for hand hygiene” aims to:
1) foster positive outcome evaluation by linking specific hand
hygiene actions to specific infectious outcomes in patients and
HCWs (positive outcome beliefs); and 2) increase the sense of
self-efficacy by giving HCWs clear advice on how to integrate
hand hygiene in the complex task of care (positive control
beliefs). Furthermore, it reunites several of the attributes that
have been found to be associated with an increased speed
of diffusion of an innovation such as relative advantage by
being practical and easy to remember, compatibility with the
existing perception of microbiological risk, simplicity as it is
straightforward, trialability as it can be experimented with on a
limited basis, and specifically tailored to be observable. 879 The
fact that the concept uses the number 5 like the five fingers
of the hand gives it a ‘stickiness factor’, i.e. the capacity to
“stick” in the minds of the target public and influence its future
behaviour, that could make it a carrier of the hand hygiene
message and help it to achieve the tipping point of exponential
popularity. 880 Since its development in the context of the Swiss
National Hand Hygiene Campaign 881 and its integration in the
<strong>WHO</strong> Multimodal Hand Hygiene Improvement Strategy, the
concept of “My five moments for hand hygiene” has been widely
adopted in more than 400 hospitals worldwide in 2006–2008, of
which about 70 have been closely monitored to evaluate impact
and lessons learnt.
21.3 <strong>WHO</strong> tools for implementation
The Guide to Implementation is accompanied by an
Implementation Toolkit (called Pilot Implementation Pack during
the testing phase and illustrated in Figure I.21.3) including
numerous tools (Table I.21.2) to translate promptly into practice
each of the five elements of the <strong>WHO</strong> Multimodal Hand Hygiene
Improvement Strategy. These tools focus on different targets:
operation, advocacy, and information; monitoring; hand hygiene
product procurement or local production; education; and
impact evaluation. The latter is an essential activity to measure
the real impact of the improvement efforts at the point of care.
The same tools used for the baseline evaluation should be
used to allow a comparison of standardized indicators such as
hand hygiene compliance, perception and knowledge about
HCAI and hand hygiene, and availability of equipment and
infrastructure for hand hygiene. The Guide to Implementation
includes details on each tool and instructions on how and when
to use it. The practical toolkit represents a very helpful and
“ready-to-go” instrument enabling facilities to start immediately
their hand hygiene promotion without the need to decide upon
the best scientific approach to be selected.
21.4.1 Concept features and development
Requirement specifications for a user-centred hand hygiene
concept.
The main specifications for the concept are given in Table I.21.3.
Importantly, it aims for minimal complexity and a harmonious
integration into the natural workflow without deviation from
an evidenced-based preventive effect. The resulting concept
applies across a wide range of care settings and health-care
professions without losing the necessary accuracy to produce
meaningful data for risk analysis and feedback.
Furthermore, the concept is congruent in design and meaning
for trainers, observers, and observed HCWs. This sharing of a
unified vision has a dual purpose. First, it avoids an expert–lay
person gap and leads to a stronger sense of ownership 882
and second, it reduces training time and cost for observers.
Additionally, the robustness of the concept reduces interobserver
variation and guarantees intra-hospital, inter-hospital,
and international comparisons and exchange.
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