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

<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE
2.
Hand hygiene as a quality indicator
for patient safety
Patient safety has become the touchstone of contemporary medical care. Medical errors and adverse events
occur with distressing frequency, as outlined persuasively in the USA Institute of Medicine’s To err is human. 1041
HCAIs are second only to medication errors as a cause of adverse events in hospitalized patients. Hospital
infection control provides a mature template for patient safety with a long track record of research, evidencebased
practice standards, and practice improvement efforts. Moreover, infection control professionals and
hospital epidemiologists have pioneered real-time methods to detect the occurrence of HCAI and monitor
compliance with infection control standards. Nonetheless, as documented in these <strong>WHO</strong> guidelines, compliance
with hand hygiene – the pillar of infection control – remains woeful in the vast majority of health-care institutions.
The current emphasis on hand hygiene by the <strong>WHO</strong> World Alliance for Patient Safety and many regulatory and
accrediting agencies reflects the slow progress of the health professions in meeting even modest performance
standards.
Donabedian’s quality paradigm of structure, process and
outcome 1042,1043 provides a useful framework for considering
efforts to improve hand hygiene compliance. Clearly, if sinks and
alcohol dispensers are not readily accessible (faulty structure)
and hand hygiene is not performed (inadequate process), the
risk of infection and its attendant morbidity, mortality, and cost
(outcomes) will increase. Quality indicators can be developed
according to Donabedian’s framework.
Hazard analysis critical control point (HACCP) is another
valuable method to examine the system of patient care as
it relates to hand hygiene. Originally developed to provide
astronauts with pathogen-free food, HACCP is now widely
employed in good manufacturing practice, food and drug safety,
and blood banking. In brief, the method identifies error-prone
aspects of systems (critical control points), evaluates the risk
they pose, and designs them out. Critical control points are
scored according to their probability of occurrence, probability
of avoiding detection, and severity of downstream impact.
Failure mode and effects analysis is closely related to HACCP
and is being exploited increasingly in patient safety. A desirable
feature of both HACCP and failure mode and effects analysis
is their emphasis on system errors and their consequences.
An empty alcohol dispenser, failure to educate staff in proper
hand hygiene technique, and failure to practise hand hygiene
after glove removal are serious failures at key points in the
patient-care system. When multidisciplinary care teams map
their institution’s system for hand hygiene, they not only identify
error-prone critical control points and barriers to compliance,
but also identify which aspects of the system are most critical to
improve and monitor. This collaborative approach to identifying
key quality indicators vastly improves these indicators’ local
credibility and relevance and provides a guide to ongoing
improvement and auditing efforts.
Failures at critical control points in the hand hygiene system
can be seen as problems in the reliability of the system. The
concept of reliability is the bedrock of modern manufacturing
(e.g., it transformed the quality of automobile production), but
has been applied to health care only recently. Reliability looks at
the defect or failure rate in key aspects of production (i.e. patient
care). Industry often seeks to achieve defect rates of one per
million or less (a component of so-called six-sigma reliability).
While such a high degree of reliability seems impossible in many
aspects of health care, it is worth noting that most institutions
have hand hygiene defect rates of six per ten opportunities
or greater. Moreover, these rates do not even reflect current
thinking about rigorous reliability, in which the entire system
either performs correctly or does not. For example, defect-free
care of a central venous catheter would require selection of the
optimal insertion site, perfect hand hygiene, maximal barrier
precautions, correct skin preparation, and prompt removal of
the catheter as soon as it is no longer needed. Failure at any
one of these steps means “no credit”. Clearly, current defect
rates in the hand hygiene system are no longer tolerable. Even
in a setting with severely constrained resources, basic hand
hygiene can and should be performed very reliably with a defect
rate of less than 5–10%.
Although health-care providers – particularly managers
in relatively complex organizations – will find it valuable to
understand and apply Donabedian’s quality paradigm, HACCP,
failure mode and effects analysis, and reliability theory, it
should be relatively easy for health-care providers in virtually
every setting to start evaluating, improving, and monitoring
the reliability of the hand hygiene infrastructure and practice
immediately. Table III.2.1 provides a variety of structure and
process quality indicators that are derived directly from these
<strong>WHO</strong> guidelines. Health-care providers and multidisciplinary
teams (in collaboration with quality improvement and
infection control experts where available) may want to begin
by considering some of these indicators. The emphasis is
on structure and process because the ultimate outcomes –
reduced infection and antibiotic resistance rates – are likely
to be linked closely with improvements in structure and
process, are more time-consuming to measure, and may not
be immediately discernible. Many indicators in Table III.2.1 are
relatively easy to measure and provide real-time feedback to
caregivers and managers.
For example, at the most basic level, are user-friendly, clear
policies in place, and are these accessible to HCWs in the
workplace? Is the design of the work space, including the
placement of sinks, alcohol-based handrub dispensers, and
other hand hygiene equipment and supplies, conducive to
compliance? Are the alcohol-based handrub dispensers
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