Professional Documents
Culture Documents
WHO IER PSP 2009.02 Eng PDF
WHO IER PSP 2009.02 Eng PDF
CONTENTS
DEFINITION OF TERMS 4
KEY TO SYMBOLS 5
PART I
I.1. OVERVIEW 6
PART II
II.1. SYSTEM CHANGE 11
II.1.1. System change denitions and overview
II.1.2. Tools for system change tool descriptions
II.1.3. Using the tools for system change
examples of possible situations at the health-care facility
WHO/IER/PSP/2009.02
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The designations employed and the presentation of the material in this publication do not imply
the expression of any opinion whatsoever on the part of the WHO concerning the legal status
of any country, territory, city of area or of its authorities, or concerning the delimitation of its
frontiers or boundaries. Dotted lines on maps represent approximate border lines for which
2 may not yet be full agreement.
there
GUIDE TO IMPLEMENTATION
PART III
III.1. PREPARING AN ACTION PLAN 33
APPENDIX
USEFUL WEBSITES 47
DISCLAIMER 47
HUG ACKNOWLEDGEMENT 47
3
GUIDE TO IMPLEMENTATION
DEFINITION OF TERMS
4
GUIDE TO IMPLEMENTATION
KEY TO SYMBOLS
The following symbols are used throughout the Guide to Implementation as a quick
reference for users. The symbols highlight specic actions, key concepts and
also reference the tools and resources available as part of the suite of materials
available to aid implementation.
Key Concept
Alerts the reader to an issue of importance for success.
Tools
Indicates a section of the Guide to Implementation
where explanations on the tools included in the
implementation toolkit are included.
Key Action
Indicates a section of the Guide to Implementation where
key actions for the implementation of the WHO multimodal
hand hygiene improvement strategy are pointed out.
5
PART I
6
GUIDE TO IMPLEMENTATION PART I
My 5 Moments
The guide will inform you how to:
prepare an Action Plan for hand hygiene improvement;
evaluate the elements that exist in the health-care facility
L E DUR
C OCR E select and access alcohol-based handrubs and other
P
2
1
BEFORE
TOUCHING TOUCHING
A PATIENT A PATIENT to health-care workers irrespective of their starting point;
develop approaches to ensuring an institutional safety climate;
undertake evaluation and feedback (e.g. observation of hand
D
E
AF
T E R BO U
R
7
PART I GUIDE TO IMPLEMENTATION
The WHO Guidelines on Hand Hygiene in Health Care make it clear Each component deserves equally important, specic and
that it should be relatively simple for health-care providers in virtually integrated efforts to achieve effective implementation and maintenance.
every setting to immediately start and continue to evaluate and However, facilities around the world may have progressed to different
improve the reliability of hand hygiene infrastructure and practices. levels as far as hand hygiene promotion is concerned. Therefore, while
some components might be identied as the central features to start
This Guide to Implementation can therefore be used: with in some facilities, others may not be immediately relevant in others.
at any time as a broad outline of how a hand hygiene At facilities with a very advanced level of hand hygiene promotion, some
improvement strategy might be executed; and components should nonetheless be considered for improvement and
action to ensure long-term sustainability.
at any time as a guide for developing local action plans
to improve hand hygiene. It is important to note that implementation, evaluation and feedback
activities should be periodically rejuvenated and repeated and become
part of the quality improvement actions that will ensure sustainability.
Hand hygiene improvement is not a time-limited process: hand hygiene
I.4. WHO MULTIMODAL HAND promotion and monitoring should never be stopped once implemented.
HYGIENE IMPROVEMENT STRATEGY The ve components, together with linked tools available for their
implementation, are described in separate sections of this guide
(Sections II.1II.5).
I.4.1. The strategy components
Successful and sustained hand hygiene improvement is achieved
*Point of care The place where three elements come together:
by implementing multiple actions to tackle different obstacles and
the patient, the health-care worker, and care or treatment involving
behavioural barriers. Based on the evidence and recommendations
contact with the patient or his/her surroundings (within the patient
from the WHO Guidelines on Hand Hygiene in Health Care, a number
zone). The concept embraces the need to perform hand hygiene
of components make up an effective multimodal strategy for hand
at recommended moments exactly where care delivery takes place.
hygiene. The WHO multimodal hand hygiene improvement strategy has
This requires that a hand hygiene product, e.g. alcohol-based
been proposed to translate into practice the WHO recommendations
handrub, if available, will be easily accessible and as close as possible
on hand hygiene and is accompanied by a wide range of practical
(e.g. within arms reach), where patient care or treatment is taking
tools (implementation toolkit) ready to use for implementation.
place. Point-of-care products should be accessible without having
to leave the patient zone.
The key components of the strategy are:
1. System change: ensuring that the necessary infrastructure is Availability of alcohol-based hand-rubs at the point of care is
in place to allow health-care workers to practice hand hygiene. usually achieved through staff-carried handrubs (pocket bottles),
This includes two essential elements: wall-mounted dispensers, containers afxed to the patients bed
or bedside table or to dressing or medicine trolleys that are taken
access to a safe, continuous water supply as well as to
into the point of care.
soap and towels;
readily accessible alcohol-based handrub at the point of care*.
I.4.2. The implementation toolkit
2. Training / Education: providing regular training on the importance
of hand hygiene, based on the My 5 Moments for Hand Acknowledging the vastly different levels of awareness and the barriers
Hygiene approach, and the correct procedures for handrubbing to implementing hand hygiene improvement strategies from country to
and handwashing, to all health-care workers. country, and even within the same country, an implementation toolkit
has been developed to support health-care workers in improving hand
3. Evaluation and feedback: monitoring hand hygiene practices hygiene at their facilities, irrespective of their starting point. The Guide to
and infrastructure, along with related perceptions and knowledge Implementation is central to the toolkit and together they aim to facilitate
among health-care workers, while providing performance and the process of translating the recommended components of the WHO
results feedback to staff. multimodal hand hygiene improvement strategy into action.
4. Reminders in the workplace: prompting and reminding Published studies suggest that, on average, compliance with hand
health-care workers about the importance of hand hygiene and hygiene is around 40% (WHO Guidelines on Hand Hygiene in Health
about the appropriate indications and procedures for performing it. Care). By providing the tools to support health-care workers and others
responsible for improving patient safety at the national and local levels,
5. Institutional safety climate: creating an environment and the WHO Patient Safety hopes to see compliance increase in each country
perceptions that facilitate awareness-raising about patient of the world from its current baseline.
safety issues while guaranteeing consideration of hand hygiene
improvement as a high priority at all levels, including The aim is that the increase will be observed over time until at
active participation at both the institutional and individual levels; least 2020, when it is hoped that a culture of hand hygiene excellence
will be embedded in all health-care facilities. Each individual health-care
awareness of individual and institutional capacity to change
facility across the world must set its own realistic targets and action
and improve (self-efcacy); and
plans for improvement in order to reach this aim.
partnership with patients and patient organizations.
8
GUIDE TO IMPLEMENTATION PART I
Tools for System Tools for Training / Tools for Evaluation Tools for Reminders Tools for Institutional
Change Education and Feedback in the Workplace Safety Climate
Ward Infrastructure Slides for the Hand Hand Hygiene Technical Your 5 Moments for Template Letter to
Survey Hygiene Co-ordinator Reference Manual Hand Hygiene Poster Advocate Hand Hygiene
to Managers
Alcohol-based Slides for Education Observation Tools: How to Handrub
Handrub Planning Sessions for Trainers, Observation Form Poster Template Letter to
and Costing Tool Observers and and Compliance Communicate Hand
How to Handwash
Health-Care Workers Calculation Form Hygiene Initiatives to
Guide to Local Poster
Managers
Production: Hand Hygiene Ward Infrastructure
Hand Hygiene:
WHO-recommended Training Films Survey Guidance on Engaging
When and How Leaet
Handrub Formulations Patients and Patient
Slides Accompanying Soap / Handrub
SAVE LIVES: Organizations in Hand
Soap / Handrub the Training Films Consumption Survey
Clean Your Hands Hygiene Initiatives
Consumption Survey
Hand Hygiene Technical Perception Survey for Screensaver
Sustaining Improvement
Protocol for Evaluation Reference Manual Health-Care Workers
Additional Activities
of Tolerability and
Observation Form Perception Survey for for Consideration by
Acceptability of
Senior Managers Health-Care Facilities
Alcohol-based Handrub Hand Hygiene
in Use or Planned to be Why, How and Hand Hygiene SAVE LIVES:
Introduced: Method 1 When Brochure Knowledge Clean Your Hands
Questionnaire for Promotional DVD
Protocol for Evaluation Glove Use
Health-Care Workers
and Comparison Information Leaet
of Tolerability and Protocol for Evaluation
Acceptability of Your 5 Moments for
of Tolerability and
Different Alcohol-based Hand Hygiene Poster
Acceptability of
Handrubs: Method 2 Alcohol-based Handrub
Frequently Asked
Questions in Use or Planned to be
Introduced: Method 1
Key Scientic
Publications Protocol for Evaluation
and Comparison
Sustaining Improvement of Tolerability and
Additional Activities Acceptability of Different
for Consideration by Alcohol-based
Health-Care Facilities Handrubs: Method 2
Data Entry
Analysis Tool
Data Summary
Report Framework
9
PART I GUIDE TO IMPLEMENTATION
I.4.3. The step-wise approach The main objectives to be achieved in each step are the following:
Step 5: ongoing planning and review cycle Step 5: developing an ongoing action plan and review cycle,
developing a plan for the next 5 years (minimum) while ensuring long-term sustainability.
The overall aim is to embed hand hygiene as an integral part of the These steps are described in detail in Part III, after an understanding
culture in the health-care facility. of each of the ve strategy components has been gained.
L EDUR
C ROC E
P
2
4
AFTER
1
BEFORE
TOUCHING TOUCHING
A PATIENT A PATIENT
2. Training and education
3
Y
D
E
AF
T E R BO U
R
FLU OS
4. Reminders in the workplace RIS I D E X P
K
5
AFTER
TOUCHING PATIENT
5. Institutional safety climate SURROUNDINGS
10
PART II
11
PART II GUIDE TO IMPLEMENTATION
12
GUIDE TO IMPLEMENTATION PART II
13
PART II GUIDE TO IMPLEMENTATION
Protocol for Evaluation of Tolerability and Acceptability of Protocol for Evaluation and Comparison of Tolerability and
Alcohol-based Handrub in Use or Planned to be Introduced: Acceptability of Different Alcohol-based Handrubs: Method 2
Method 1
What A protocol to compare the tolerability and
What A protocol for evaluation of tolerability acceptability of different alcohol-based
and acceptability of a single alcohol-based handrubs. This tool includes two different
handrub product. This tool includes two different components:
components: a questionnaire for the subjective evaluation
a questionnaire for the subjective evaluation of hand hygiene practices, the product itself
of hand hygiene practices, the product and the skin condition following use;
itself and the skin condition following use; a scale for the objective evaluation of
a scale for the objective evaluation of the skins condition following use.
the skin conditions following use.
Why Tolerability and appreciation of alcohol-based
Why Tolerability and appreciation of alcohol-based handrub by health-care workers is a crucial
handrub by health-care workers is a crucial factor inuencing successful implementation
factor inuencing successful implementation and prolonged use.
and prolonged use.
Where In clinical settings where there is an interest
Where In clinical settings where the alcohol-based in comparing the tolerability and acceptability
handrub either has been newly distributed or of various alcohol-based handrubs (e.g. in
is in use and there is an interest in assessing the context of a product selection process).
its tolerability and acceptability. This protocol This protocol is meant to be applied in
is meant to be applied in settings where settings where an average of at least 30 hand
an average of at least 30 hand hygiene hygiene opportunities occurs daily for each
opportunities occurs daily for each health-care worker.
health-care worker.
When Comparing different products. The protocol
When Testing of a new product / after the introduction design requires at least 3-5 consecutive days of
of a product. The protocol design requires at exclusive use of each test product.
least 35 consecutive days of exclusive use of
the test product and one month of routine use. Who User: a trained observer in collaboration with the
programme co-ordinator and the pharmacist
Who User: a trained observer in collaboration with the
Population of the survey: 40 health-care workers
programme co-ordinator and the pharmacist
should be selected to perform this test:
Population of the survey: 40 health-care workers
should be selected to perform this test: questionnaire for subjective evaluation
health-care workers using the product,
questionnaire for subjective evaluation
involved in the survey;
health-care workers using the product,
involved in the survey; scale for objective evaluation a trained
scale for objective evaluation a trained observer evaluating the health-care
observer evaluating the health-care workers involved in the survey.
workers involved in the survey.
How Use this tool according to the instructions
How Use this tool according to the instructions accompanying the protocol.
accompanying the protocol. A similar protocol to evaluate a single product
A similar protocol to be used to compare is also available (Protocol for Evaluation of
different products is also available (Protocol Tolerability and Acceptability of Alcohol-based
for Evaluation and Comparison of Tolerability Handrub in Use or Planned to be Introduced:
and Acceptability of Different Alcohol-based Method 1).
Handrubs: Method 2).
14
GUIDE TO IMPLEMENTATION PART II
II.1.3. Using the tools for system change examples Example 2: health-care facilities where the alcohol-based handrub is
already available but where system change goals have not been fully
of possible situations at the health-care facility
achieved according to the WHO recommendations.
start by using the ward infrastructure survey to assess the Consider whether the product is actually well-tolerated and
availability and appropriateness of the infrastructure, including sinks; appreciated by health-care workers.
according to the results, then discuss with your chief executive If necessary, conduct the Protocol for Evaluation of Tolerability
ofcer (CEO)/director/ senior managers the need for complying and Acceptability of Alcohol-based Handrub in Use or Planned
with the WHO recommendations of having a sink/patient-bed ratio to be Introduced: Method 1.
of at least 1:10 and for the continuous provision of safe water, If necessary, select a new product or evaluate local production.
soap and disposable towels at all sinks.
Using the Ward Infrastructure Survey, determine whether the
products required for hand hygiene (alcohol-based handrub, soap
If an alcohol-based handrub is not available:
and disposable towels) are permanently available facility-wide
use the alcohol-based handrub planning and costing tool for or only in some clinical settings.
the criteria to select such a product;
Using the Ward Infrastructure Survey, determine whether products
evaluate the availability of alcohol-based handrubs from the market; are appropriately positioned at the point of care according to the
denition included in this guide.
consider the possibility of producing an alcohol-based handrub
formulation locally, either at your pharmacy or at an external facility, Implement actions according to this assessment in order to make
according to the Guide to Local Production of WHO-recommended the products permanently available at each point of care. For
Handrub Formulations; example, make sure that the alcohol-based handrub dispensers
are located precisely at each point of care (e.g. at each bedside
both for products procured from the market and for locally produced
and not at the room entrance). If necessary, increase the number
formulations, consider testing their tolerability and acceptability
of dispensers and also provide different types of dispensers (e.g.
by health-care workers by using the Protocol for Evaluation of
wall-mounted dispensers, pocket bottles, dispensers afxed to
Tolerability and Acceptability of Alcohol-based Handrub before
the furniture). If possible, ensure that the sink/patient-bed ratio is
introducing them widely within the facility.
well above 1:10.
15
PART II GUIDE TO IMPLEMENTATION
The trainers will be in charge of delivering training / education to major patterns of transmission of health care-associated
health-care workers, including providing practical demonstrations pathogens, with a particular focus on hand transmission;
of how and when to perform hand hygiene according to the My
prevention of HCAI and the critical role of hand hygiene;
5 Moments for Hand Hygiene approach. For these reasons, the
trainer should preferably have a basic knowledge of infection control, WHO Guidelines on Hand Hygiene in Health Care and their
experience of education as well as of having delivered health-care implementation strategy and tools, including why, when and
at the bedside. Ideally, he or she should be an inuential and credible how to perform hand hygiene in health care.
leader (e.g. chief nurse / matron / doctor / head of another key
department or discipline). Additional sessions should be dedicated exclusively to observers,
to learn the proposed method for observation and to practice its use.
Future trainers should be briefed on the key messages to be
spread and should be supported to become familiar with the tools Facilities should consider implementing a system of checking
available for training; in most cases a formal training of the trainers on the competence of all health-care workers who have received
should be organized by the hand hygiene programme co-ordinator. hand hygiene training. This could take the form of an annual training
course or a practical hand hygiene demonstration workshop to
conrm competence in relation to correct hand hygiene techniques
at the correct moments. Utilising the hand hygiene knowledge survey
will also full the purpose of checks on competence.
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GUIDE TO IMPLEMENTATION PART II
II.2.2. Tools for training / education Slides for the Hand Hygiene Co-ordinator
tool descriptions
The key tools described in this section aim to direct and support What A PowerPoint slide deck entitled Health
health-care facilities to prepare and deliver training / education. Care Associated Infection and Hand Hygiene
Improvement to assist hand hygiene leads
(especially programme co-ordinators) in
The range of tools that can be used for education is
explaining the need for hand hygiene to senior
represented in the gure below:
managers and other key players. In particular:
Sustaining
Improvement Who The tool should be used by:
Additional Activities
The representative responsible for planning
for Consideration by
initiatives to improve hand hygiene (the
Health-care Facilities
hand hygiene programme co-ordinator); and
parties interested in catalysing initiatives to
Your 5 Moments for improve hand hygiene at health-care facility
Observation Tools to communicate the importance of hand
Hand Hygiene Poster
hygiene with senior managers and others.
Observation Tools described in the evaluation and feedback section How A slide presentation by the hand hygiene co-
ordinator to others at the facility using visual
Your 5 Moments for Hand Hygiene Poster described in the Reminders aids or paper copies, detailing the slide deck
in the workplace section template and other local information.
17
PART II GUIDE TO IMPLEMENTATION
Slides for Education Sessions for Trainers, Observers Hand Hygiene Training Films and Accompanying Slides
and Health-Care Workers
What A series of scenarios to help convey the
What A PowerPoint slide deck including the key My 5 Moments for Hand Hygiene approach
concepts related to the WHO hand hygiene and the appropriate technique for hand
improvement strategy and that can be used to: rubbing and hand washing;
train the trainers in order to make them a PowerPoint slide set to accompany
aware of the essential learning objectives the lms and explain the content and
and key messages to be transmitted to educational messages of the different
health-care workers; scenarios.
train the observers responsible for
monitoring hand hygiene compliance at Why Because trainers and observer should achieve
the health-care facility to understand the a solid understanding of the My 5 Moments
basic principles of hand hygiene and for Hand Hygiene approach and all health-
the aims and methods of hand hygiene care workers within a facility should receive
observation; regular training / education on the importance
of hand hygiene, indications to perform it and
provide comprehensive training for
the correct procedures for handrubbing and
all health-care workers.
handwashing.
18
GUIDE TO IMPLEMENTATION PART II
19
PART II GUIDE TO IMPLEMENTATION
Sustaining Improvement
Key Scientic Publications Additional Activities for Consideration by Health-Care Facilities
What A list of peer-reviewed publications to direct What Guidance for health-care facilities interested in
interested parties to noteworthy data and enhancing and sustaining existing hand hygiene
commentaries regarding hand hygiene improvement by organising and using additional
Why Because there are many additional sources tools or activities as part of their long-term
of information on hand hygiene that may be action plans.
of interest or use during training / educating Why Because some health-care facilities already
health-care workers have well-established hand hygiene
Where During training / education sessions; improvement strategies, with excellent
resources and regular training and observation
within a settings library / reference facility.
systems in place. For these health-care
When At any time, both proactively to support trainers facilities, it is critical to maintain the momentum
in their task and to alert health-care workers to and sustain the improvements that have
the background scientic information on hand been made.
hygiene as required when questions around the
Where In the management and infection control units
evidence base arise.
of the health-care facility as part of the planning
Who This tool should be used by: for additional activities.
hand hygiene programme co-ordinator, When Once health-care facilities have a well-
trainers and observers; established infrastructure and systems for
all health-care workers interested in training and evaluating hand hygiene and are
learning more about hand hygiene looking for additional activities to sustain hand
How By presenting the list of key scientic hygiene awareness and improvement (step 5,
publications during training sessions; section III.2.5).
by referring all health-care workers Who This tool should be used by the hand hygiene
with access to the internet to the programme co-ordinator or persons responsible
www.who.int/gpsc/en/ website where for planning, implementing and maintaining
the Key Scientic Publications list is hand hygiene improvement at a health-care
featured. This can be done by stating this facility.
in the facilitys documents on hand hygiene How The hand hygiene co-ordinator should review
or by giving the web address during training the tool for guidance and ideas on how to
/ education sessions. sustain the momentum and improvements
in hand hygiene at the facility, integrate any
selected activities into the local action plan
for hand hygiene improvement and discuss
Glove Use Information Leaet it with senior managers and any other key
professionals.
What A leaet to explain the appropriate use of gloves
with respect to the My 5 Moments for Hand
Hygiene approach for presentation and / or
distribution to health-care workers to keep and
use as reference.
Why Because all health-care workers need to
understand how and when to correctly use
gloves within the My 5 Moments for Hand
Hygiene approach.
Where In organised training sessions;
in clinical settings where training has
already been given and short updates
or reminders are deemed necessary.
When During training sessions (step 3, section III.2.3).
Who This tool should be used by all health-care
workers in the clinical settings where the hand
hygiene improvement programme is being
implemented.
How Describe and distribute the leaet during
training sessions.
20
GUIDE TO IMPLEMENTATION PART II
II.2.3. Using the tools for training and education Example 2: health-care facilities where basic staff education is
well-established that are looking to introduce additional activities
examples of possible situations at the
for sustaining hand hygiene compliance.
health-care facility
Example 1: health-care facilities offering little or no hand hygiene If your health-care facility has well-established infrastructure
training to health-care workers. and systems for training and evaluating hand hygiene, the following
additional activities should be considered to sustain hand hygiene
If your health-care facility offers little or no hand hygiene training awareness and improvement:
to health-care workers due to constraints around implementation
caused by limited or no resources, plans to address staff training education of all health-care workers within the facility on an
should be included in an action plan in order to embed training / on-going basis, checking their competence at the same time;
education within the facilitys culture. training new trainers and observers at a range of levels;
basing education on feedback of evaluation data detected
At the very least, the action plan should feature: in all areas on a regular basis;
the infrastructural constraints to proceeding with an education ways in which to reliably present their validated hand hygiene
programme (consider the tools for system change when compliance data against HCAI rates;
documenting these constraints); reviewing and refreshing training / education materials
the responsibility for nalising the training / education tools to at least annually;
be used locally (based on the tools described in this section); developing new and innovative ways to train and educate
the steps to be taken to identify the trainers; (see Sustaining Improvement Additional Activities for
the priority health-care workers (areas of the facility, Consideration by Health-Care Facilities);
professional categories) to receive training; sharing successes with other facilities and publishing ndings; and
the requirements for targeted, priority health-care worker training / reviewing and refreshing action plans on a more regular basis
education (use the hand hygiene knowledge questionnaire in the with ndings presented to all senior management teams.
tools for evaluation and feedback section to support this );
a timeframe for initiation and completion of training of trainers, Accessing the Tools
observers and health-care workers;
www.who.int/gpsc/en/
secured time for health-care workers to undertake training;
incorporation of the training programme into the facilitys
nancial plan.
When these parts of the action plan are in place, the rst steps
in enhancing staff competence by providing basic training to every
existing and new member of staff should include the following:
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PART II GUIDE TO IMPLEMENTATION
The WHO surveys are usually carried out by using hard copies of the
II.3. EVALUATION AND FEEDBACK related forms; electronic forms are not available but can be created
locally. A specic Data Entry and Analysis Tool is available for each
II.3.1. Evaluation and feedback survey and includes a pre-prepared framework for data analysis.
denitions and overview Detailed Instructions for Data Entry and Analysis are also available.
Learning how to use the available databases requires some training
Evaluation and repeated monitoring of a range of indicators and time, but it is considered relatively easy.
reecting hand hygiene practices and infrastructures as well as of
After data entry into the specic database, the hard / electronic copies
knowledge and perception of the problem of HCAI and the importance
must be kept by the hand hygiene programme co-ordinator to be made
of hand hygiene at the health-care facility is a vital component of the
available if checks need to be performed.
strategy to improve hand hygiene. Indeed, it should not be seen as
a component separated from implementation or only to be used for The best strategy for data entry is to start this process as soon as
scientic purposes, but rather as an essential step in identifying areas each tool has been used and when completed forms are available.
deserving major efforts and in feeding crucial information into the action
plan for local implementation of the most appropriate interventions. Feedback of the results of these investigations is an integral part
Continuous monitoring is very helpful in measuring the changes induced of evaluation and makes the evaluation meaningful. Indeed, after the
by implementation (e.g. alcohol-based handrub consumption trends baseline evaluation (see step 2, section III.2.2) in a facility where the
following system change) and to ascertain whether the interventions hand hygiene improvement programme is being implemented for the
have been effective in improving hand hygiene practices, perception rst time, data indicating gaps in good practices and knowledge, or a
and knowledge among health-care workers and in reducing HCAI. poor perception of the problem, can be used to raise awareness and
convince health-care workers that there is a need for improvement.
The WHO multimodal hand hygiene improvement strategy On the other hand, after implementation (see step 4, section III.2.4),
recommends monitoring and evaluation of the following indicators: follow-up data are crucial in order to demonstrate improvement and
thereby sustain the motivation to perform good practices and to make
hand hygiene compliance through direct observation;
continuous individual and institutional efforts. These data are also very
ward infrastructure for hand hygiene; useful for identifying areas where further efforts are needed (e.g. certain
health-care worker knowledge on HCAI and hand hygiene; professional categories that demonstrated limited or no improvement in
health-care worker perception of HCAI and hand hygiene; hand hygiene compliance and/or other indicators; certain hand hygiene
indications where health-care workers hardly improved).
soap and alcohol-based handrub consumption.
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GUIDE TO IMPLEMENTATION PART II
II.3.2. Tools for evaluation and feedback Hand Hygiene Observation Tools
tool descriptions What A set of tools is available to conduct direct
observation of hand hygiene practices and
The range of tools available to support the implementation thus assess compliance:
of evaluation and feedback is represented in the gure below.
an Observation Form to be used to
collect data on hand hygiene performance
while observing health-care workers
Observation Tools:
Hand Hygiene during routine care. It also includes
Observation Forms
Technical Reference summary instructions for use;
and Compliance
Manual
Calculation Forms two Compliance Calculation Forms
(basic and optional) to help staff calculate
compliance rates easily, based on the
Ward Infrastructure Soap / Handrub data collected in the observation form.
Survey Consumption Survey These are linked to some tools for education
(see section III.2.2) to help the observer
acquire the necessary basic knowledge and
Perception Survey understanding of the principles and methods
Perception Survey for
for Health-Care of observation. These are:
Senior Managers
Workers
the Hand Hygiene Technical Reference
Manual a comprehensive training manual
to understand the basic principles of hand
Hand Hygiene
hygiene and in particular the My 5 Moments
Knowledge
for Hand Hygiene approach and to explain
Questionnaire for
in details the direct method for observation
Health-Care Workers
proposed by WHO; and
23
PART II GUIDE TO IMPLEMENTATION
Who These tools should be used by the observer. What A perception questionnaire about the impact
of HCAI, the importance of hand hygiene as a
The observer should ideally be a professional preventive measure and the effectiveness of the
who has experience in delivering health care at different elements of the multimodal strategy.
the bedside. The observer must be trained to
identify the hand hygiene indications according The questionnaire is available in baseline and
to the My 5 Moments for Hand Hygiene follow-up versions. The follow-up version is a
approach and to use the tool. After training, the slightly-modied form of the baseline version
observer should be evaluated regarding his or and includes new questions relating to the
her capacity to detect hand hygiene compliance impact of some interventions, such as the
correctly (see training / education, section II.2). introduction or modication of the alcohol-
based handrub, the posters and leaets
displayed or distributed at the facility, and the
How The Hand Hygiene Technical Reference Manual
education materials.
clearly explains how to use the observation and
calculation forms. Summary instructions for Why It is important to measure health-care workers
use are also included on the back page of the perception about the importance of hand
observation form. hygiene in health care, as this has been shown
In general, between 150 and 200 opportunities to inuence their willingness to embrace
for hand hygiene should be observed in each improvements. Feedback on this piece of
surveyed unit (department, service or ward). information may be useful in demonstrating that
the actual perception does not correspond to
the real burden of HCAI and the importance of
hand hygiene.
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GUIDE TO IMPLEMENTATION PART II
Hand Hygiene Knowledge Questionnaire for Health-Care Workers Perception Survey For Senior Managers
What A questionnaire with technical questions to What A questionnaire to measure senior executive
assess actual knowledge of the essential managers perception about the impact of
aspects of hand transmission and hand HCAI, the importance of hand hygiene as a
hygiene during health care. preventive measure, the different elements
of the multimodal strategy and their vital role
The knowledge needed to answer these
in promoting hand hygiene in an institutional
questions correctly will only be acquired by
safety climate.
undertaking education and training activities.
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PART II GUIDE TO IMPLEMENTATION
II.3.3. Using the tools for evaluation and Example 2: health-care facilities where a hand hygiene improvement
programme is already established.
feedback examples of possible situations
at the health-care facility These facilities are already supposed to have undertaken baseline
and follow-up evaluations of the recommended indicators and
Example 1: health-care facilities embarking on a new hand hygiene to have supportive infrastructure and an ongoing education
improvement programme. programme in place. Monitoring and evaluation remain an
important feature of the enhancement or reinvigoration of an
The immediate priority of these facilities is to collect baseline existing improvement strategy and will provide on-going data
information on the indicators relevant for evaluation of hand hygiene on the progress of the strategy.
infrastructures, practices and knowledge as well as perception of
the problem of HCAI and the importance of hand hygiene at the These facilities will have to focus more on regular monitoring
health-care facility. This is of the utmost importance for identifying of knowledge, perception, infrastructures and performance of hand
the resources needed and for establishing priorities for the hand hygiene through observations in all areas of the facility, with regular
hygiene improvement programme. To gather a comprehensive reports and feedback to health-care workers on the results along
picture, all the surveys indicated above should ideally be undertaken with information on the improvements being made in hand hygiene.
during the preparedness and baseline periods. The sub-sequent step
for measuring the same indicators is the follow-up evaluation, where The frequency of conducting these surveys depends
measuring the same indicators helps in assessing the impact of on local priorities. Observations of hand hygiene practices
the strategy. should be carried out at least annually, but ideally monthly.
Considering that this plan entails the allocation of adequate time Hand hygiene product consumption, especially alcohol-based
and staff to these activities in settings with limited resources and handrub, should be recorded monthly or at time intervals that
having other priorities, the conducting of all surveys might be not allow annual trend calculations (e.g. every 34 months). For a
feasible. In these cases, the surveys could be limited to using the sustained improvement, a minimum 5-year cycle of review and
following tools: action planning is recommended.
Observation Form at baseline and follow-up A system to monitor HCAI rates should be considered and
included in the action plan. Specic targets for improvement
in HCAI rates at the facility should be agreed upon by the hand
These facilities may not have reached the stage where hygiene team along with senior management and included in
implementation of regular evaluation, including observations the action plan.
and feedback is achievable. However, a time frame for evaluation
If local HCAI rates are available, it should be possible to calculate
should be considered in long-term action plans.
the costeffectiveness of introducing alcohol-based handrub
and possibly also of the entire improvement strategy.
WHO Patient Safety are interested in receiving feedback from the hand
hygiene co-ordinators on the process of implementation of a hand
hygiene action plan and also in receiving data on improvements made.
www.who.int/gpsc/en/
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GUIDE TO IMPLEMENTATION PART II
II.4. REMINDERS IN THE WORKPLACE Your 5 Moments For Hand Hygiene Poster
What Poster visualizing the ve moments (indications)
II.4.1. Reminders in the workplace when to perform hand hygiene during health-
denitions and overview care delivery.
Why Because all health-care workers need to
Reminders in the workplace are key tools to prompt and remind visualize and endorse the key messages
health-care workers about the importance of hand hygiene and about on hand hygiene, i.e. when to perform it.
the appropriate indications and procedures for performing it. They Where To be displayed at the point of care and
are also means of informing patients and their visitors of the standard prominent areas throughout the health-care
of care that they should expect from their health-care workers with facility.
respect to hand hygiene.
When To be displayed during the implementation step
Posters are the most common type of reminder. The implementation (step 3, section III.2.3), to be kept at all times
toolkit includes three WHO-branded standard posters to visualize and replaced / refreshed as necessary.
the My 5 Moments for Hand Hygiene approach and the correct Who User: the programme co-ordinator or any
procedure to perform handrubbing and handwashing. person in charge of displaying the posters
Other types of reminders are pocket leaets that individual health-care in all clinical settings.
workers can carry in their pockets, stickers posted at the point of care, Targets: all health-care workers having direct
special labels including prompting slogans stuck on alcohol-based contact with patients; the patients and their
handrub dispensers and gadgets such as badges with the hand visitors to be aware of best hand hygiene
hygiene logo. practices.
How Display the posters at the point of care
Reminders in the workplace should be a feature of the action plans
and refresh when necessary, according
for facilities implementing hand hygiene improvement programmes at all
to the action plan.
levels. Reminders should be used and displayed in all clinical settings of
the health-care facility during the implementation phase (step 3, section
III.2.3) and should be updated or refreshed regularly. Reminders can be
directed at health-care workers, patients and visitors.
How to Handrub and How to Handwash Posters
Local adaptation of the WHO reminders and development of new What Posters explaining the correct procedures
ones visualizing the WHO recommendations on hand hygiene certainly for handrubbing and handwashing that are
facilitates local uptake of the strategy by using the best terminology designed to remind health-care workers to
and images according to the culture. perform hand hygiene.
Why Because all health-care workers need to
Health-care workers will also have access to local hand hygiene
understand the correct procedures for
guidelines or standard operating procedures to inform and remind
handrubbing and handwashing.
them of what good hand hygiene practice means at their place of work.
Where To be displayed throughout the health-care
facility in prominent areas where care takes
II.4.2. Tools for reminders in the workplace
place. The How to Handrub Poster will be
tool descriptions best placed at each point of care; the How to
Handwash Poster should be displayed beside
The range of tools that can be used as reminders in the workplace each sink (which ideally should coincide with
is represented in the gure below. each point of care).
When To be displayed during the implementation step
(step 3, section III.2.3), to be kept at all times
Your 5 Moments How to How to and replaced / refreshed as necessary.
for Hand Hygiene Handrub Handwash
Who User: the programme co-ordinator or any
Poster Poster Poster
person in charge of displaying the posters
in all clinical settings.
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PART II GUIDE TO IMPLEMENTATION
Hand Hygiene: When and How Leaet II.4.3. Using the tools for reminders in the
workplace examples of possible situations
What A pocket leaet summarizing the key messages
related to when and how hand hygiene should
at the health-care facility
be performed Example 1: facilities embarking on a new hand hygiene improvement
programme and/or with limited resources.
Why Because all health-care workers within a facility
should understand and comply with the My Key actions:
5 Moments for Hand Hygiene approach and
Evaluate current resources, including local expertise, available for
the correct procedures for handrubbing and
investing in reminding health-care workers about hand hygiene.
handwashing
Establish the requirements and consider a timeframe for addressing
Where To be distributed in the clinical settings where these requirements.
the hand hygiene improvement programme is
Consider the potential costs in the nancial plan and secure
being implemented.
a budget.
When To be used during the implementation step In the rst instance, having to commit to many actions in order
(step 3, section III.2.3), ideally during training to implement a new hand hygiene improvement programme, these
sessions. facilities might decide to use the tools already available in the WHO
implementation toolkit without any adaptation.
Who This tool should be used by all health-care Example 2: facilities where the hand hygiene improvement programme
workers in the clinical settings where the hand is already well established.
hygiene improvement programme is being
implemented.
Key actions:
How Distribute the leaet during training sessions for Consider the adaptation of reminders to the national / local culture,
the health-care workers to keep as a personal including images, a priority in the facility action plan.
tool and reference.
Ensure that the reminders displayed are always in good condition.
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GUIDE TO IMPLEMENTATION PART II
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PART II GUIDE TO IMPLEMENTATION
Template Letter to Advocate Hand Hygiene to Managers Template Letter to Communicate Hand Hygiene Initiatives
to Managers
What A template letter for use and adaptation by a
local hand hygiene co-ordinator to aid initial What A template letter for use and adaptation by
dialogue with key decision makers concerning a local hand hygiene co-ordinator to convey
investment in hand hygiene improvement. clear messages concerning the improvement
initiatives and state explicitly where action is
required and by whom.
Why To help a local hand hygiene programme co-
ordinator or person(s) interested in introducing
or reinvigorating hand hygiene improvement Why To help a local hand hygiene programme co-
initiatives within a health-care facility, to ordinator or person(s) interested in introducing
advocate and encourage commitment, or reinvigorating hand hygiene improvement
support and investment from key decision initiatives within a health-care facility, to
makers within the facility. communicate important messages concerning
the improvement initiatives to key senior
managers/leaders.
Where In the hospital management unit of
the health-care facility.
Where In the hospital management unit of the
health-care facility.
When At the initial stages of the implementation
of a hand hygiene improvement programme
(step 1, section III.2.1). When At the initial stages of a hand hygiene
improvement programme (step 1, section
III.2.1).
Who User: a local hand hygiene programme co-
ordinator or person(s) interested in introducing
or reinvigorating hand hygiene improvement Who User: a local hand hygiene programme co-
initiatives within a health-care facility. ordinator or person(s) interested in introducing
or reinvigorating hand hygiene improvement
Targets: senior managers of the
initiatives within a health-care facility.
health-care facility.
Targets: senior managers of the
health-care facility.
How The user can insert local information or modify
the text of the template letter to reect local
style and send it. A similar template letter is How The user can insert local information or modify
also available to help communicate important the text of the template letter to reect local
messages concerning the improvement style. A similar template letter is also available
initiatives to key senior managers/leaders to help in advocating and encouraging
(Template Letter to Communicate Hand commitment, support and investment in the
Hygiene Initiatives to Managers). initiative from key decision makers within the
health-care facility (Template Letter to Advocate
Hand Hygiene to Managers).
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GUIDE TO IMPLEMENTATION PART II
What Guidance on empowering patients, engaging What Guidance for health-care facilities interested in
with patient organizations and developing a enhancing existing hand hygiene improvement
programme to educate patients and inspire on additional tools or activities that the facility
patient advocacy for hand hygiene improvement could organise as part of their long-term action
in health care. plans to maintain momentum and continue to
improve (or at least maintain) hand hygiene
improvement.
Why Because WHO Guidelines on Hand Hygiene in
Health Care encourage partnerships between
patients, their families and health-care workers Why Because for health-care facilities already having
to promote hand hygiene in health-care settings well-established hand hygiene improvement
and their input can have a positive effect on strategies, with excellent resources and regular
improvement. training and observation systems in place, it is
critical to maintain the momentum and sustain
the improvements achieved.
Where In the hospital management unit of the
health-care facility.
Where In the hospital management unit of the
health-care facility.
When Once health-care facilities have a well-
established hand hygiene improvement
programme (consider it for long-term plans When Once health-care facilities have well-established
development during step 5, see section III.2.5). infrastructure and systems for training and
observing hand hygiene (especially for long-
term plans development during step 5, see
Who This tool should be used by the hand hygiene section III.2.5).
programme co-ordinator in facilities where it is
planned to empower and engage patients or
patient organizations in hand hygiene initiatives. Who This tool should be used by the hand hygiene
programme co-ordinator, senior managers, or
persons responsible for planning, implementing
How The hand hygiene programme co-ordinator can and maintaining hand hygiene improvement
review the tool for guidance and ideas on how at a health-care facility.
to engage patients and patient organizations,
and integrate any selected activities into
their long-term action plan for hand hygiene How The hand hygiene programme co-ordinator
improvement. should review the tool for guidance and
ideas on how to sustain the momentum and
improvements in hand hygiene at their facility,
and integrate any selected activities into
their long-term action plan for hand hygiene
improvement.
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PART II GUIDE TO IMPLEMENTATION
Example 1: health-care facilities embarking on a new hand hygiene education of patients to identify the moments when
improvement programme. health-care workers should perform hand hygiene;
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PART III GUIDE TO IMPLEMENTATION
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GUIDE TO IMPLEMENTATION PART III
Minimum criteria for implementation of the WHO multimodal High consideration should be given to the feasibility of matching
hand hygiene improvement strategy are listed in the gure below: required activities to available human and nancial resources. In
order to demonstrate the economic benet of the intervention and
to ascertain what funding will be required to implement the action
Multimodal Minimum criteria plan to improve hand hygiene, it may be necessary to perform an
component for implementation economic analysis and formalise a nancial plan at this early stage
in establishing the scope and extent of the intervention.
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PART III GUIDE TO IMPLEMENTATION
establishing a plan to achieve the implementation of all the preparing the necessary resources and supports to implement
strategy components or of those that are considered to be key all the strategy components, especially two (education) and
features at the facility level (especially for settings where hand four (reminders); and
hygiene promotion is already in place);
identifying staff in charge of making data entry and analysis.
deciding about the scope of and the extent of the implementation
(either focus on a limited number of areas or facility-wide);
Human resources required/key players involved in step 1:
creating the conditions to make system change happen
(e.g. actions plans to make the alcohol-based handrub available Hand hygiene programme co-ordinator
and/or ensure its appropriate location at the point of care); Deputy co-ordinator
identifying the trainers and the observers; Trainers
Observers
Trainer Senior managers/health-care facility administrators
Infection prevention and control professionals
Prole: a professional preferably with experience of education
and of delivering health care at the bed side. Ideally he/she should Head nurses, chief doctors, leads from other disciplines
be an inuential leader (chief nurse/matron/doctor) or the ofcial Central purchasing department staff, pharmacist
deputy of an inuential leader and already have good knowledge Hand hygiene committee/team
of infection control. (including the above key players, when appropriate)
Tasks: to train health-care workers on hand hygiene during step 3.
Your action checks step 1
reviewing all tools for evaluation and feedback, assign tasks Necessary funds procured to make alcohol-based handrub
and make plan for carrying out the surveys in step 2; available or improve its availability at the
point of care as well as other resources including
developing a plan on how and to whom information concerning human-resources
the action plan and improvement will be communicated;
Decision made whether to purchase handrubs
commercially or manufacture in-house
Trainers and observers identied
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GUIDE TO IMPLEMENTATION PART III
III.2.2. Step 2: Baseline evaluation evaluating the results and making sure that they are reliable;
establishing knowledge of the current situation disseminating the results among key players in the hand hygiene
improvement programme;
Step 2 is meant to be focused mainly on conducting baseline
evaluating how to use the results during step 3 (e.g. how to
evaluation of hand hygiene practice, perception, knowledge and the
present data during educational sessions, what specic actions
infrastructures available. It is very important to assess the current
should be made to improve infrastructure);
situation at the facility level in order to tailor and rene action plans
for implementation. Activities taking place in step 2 are vital also evaluating HCAI rates related to the last 6 months/1 year if a
because they will provide reference information for any comparison local surveillance system is in place or conducing a prevalence
and assessment of progress as the multimodal strategy is being survey in the clinical settings included in the hand hygiene
implemented. During this step, specic actions that are scheduled improvement programme;
in step 1 could also be continued and/or take place to prepare for
concluding any training for the trainers;
the implementation phase (preparation of training, procurement or
production of the alcohol-based handrub). preparing additional training material, including the baseline
evaluation data;
Activities scheduled to take place in step 2 are related mainly
to plans and actions to achieve the objectives of strategy component 3 reviewing the training material and making precise plans
(evaluation and feedback). for the educational sessions for health-care workers;
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PART III GUIDE TO IMPLEMENTATION
Step 3 is the key phase to achieve improvement and it consists Deputy co-ordinator
of implementing all the interventions planned in step1 and using the
Trainers
core ndings from step 2 to motivate improvement. Its importance is
vital for raising awareness of the burden of HCAI and the importance Observers
of hand hygiene, to improve knowledge, to put in place elements of
Senior managers/health-care facility administrators
system change and eventually to catalyze behavioural change.
Infection prevention and control professionals
Activities that take place in step 3 are related mainly to plans
and actions to achieve the objectives of the strategy components: Head nurses, chief doctors, leads from other disciplines
1 (system change), 2 (education), 4 (reminders in the work place)
Central purchasing department staff, pharmacist
and 5 (institutional safety climate). However, some evaluation
activities are also meant to take place. Hand hygiene committee/team
This step is meant to last 3 months on average. Your action checks step 3
In summary, step 3 should include: Have the following actions occurred? Yes/No
holding a well-publicized ofcial event launching the promotional Action plan, developed in step 1,
activities and involving endorsement and/or symbolic signatures used to guide implementation
of commitment from leaders and individual health-care workers; Baseline data and analysis fed back to staff
distributing the alcohol-based handrub at the point of care in all WHO Guidelines on Hygiene in Health Care distributed
clinical settings involved in the programme;
Posters, other reminders and promotional
conducting the tolerability and acceptability surveys if not undertaken materials distributed
in step 2;
Educational materials distributed
displaying posters and distributing other reminders at the point
Alcohol-based handrub distributed
of care and to health-care workers in all clinical settings involved
in the programme; Education and training sessions undertaken
distributing the WHO Guidelines on Hand Hygiene in Health Care Monthly measurement of consumption undertaken
or their summary in clinical settings involved in the programme;
Alcohol-based handrub tolerability and acceptability
organizing the educational sessions for all health-care workers surveys undertaken
working in the clinical settings involved in the programme,
Monthly hand hygiene compliance observations
including distributing educational material, as well as practical
undertaken (where feasible)
training on the how to perform hand hygiene;
Regular review meetings held
conducting the knowledge test together with the educational
sessions, if not having been carried out already in step 2;
Pictures showing examples of initiatives undertaken and tools produced
ensuring that feedback of baseline evaluation data is performed
by health-care facilities during the implementation step while testing the
(either during educational sessions or through reports and other
WHO multimodal hand hygiene improvement strategy are accessible at:
means of communication);
www.who.int/gpsc/en/
monitoring monthly alcohol-based handrub consumption;
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PART III GUIDE TO IMPLEMENTATION
III.2.5. Step 5: ongoing planning and review cycle Most projects are reviewed at some point to ensure that they are likely
to be delivered on time and that they meet the objectives set within the
developing a plan for the next 5 years
budget allocation. Therefore, by adopting the action planning and review
cycle approach from the outset, the hand hygiene programme can take
Step 5 is a crucial step for reviewing the entire cycle of
the lead in providing such information rather than being asked for it.
implementation put in place during the previous steps and for
developing long-term plans to ensure that improvement is sustained Activities to take place in step 5 are related mainly to plans and
and progresses. Developing and implementing action plans while actions to achieve the objectives of strategy components 3 (evaluation
ensuring that there is a constant review cycle is essential if the overall and feedback; in particular data analysis and interpretation) and 5
aim to embed hand hygiene as an integral part of the health-care (institutional safety climate).
facility culture is to be achieved long-term. Implementation plans
must be designed with the aim of achieving sustainable hand hygiene Please refer to the sections dedicated to these strategy
improvement kept in mind at all times. components and to the overall action plan to gather more
information and to be directed to the available tools.
Hand hygiene improvement is not a time-limited process: This step is meant to last 2 months on average.
hand hygiene promotion and monitoring should never be
stopped once implemented.
Step Step
3 3
Repeat
Year 1 Year 2 minimum
5 years
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GUIDE TO IMPLEMENTATION
APPENDIX
Examples of useful websites National and sub-national hand hygiene campaigns
to support implementation:
www.hha.org.au/
www.handhygiene.ca/
www.cdc.gov/cleanhands/
Canadas national hand hygiene campaign.
The site contains advice from the US Centers for Disease Control
and Prevention (CDC) on various aspects of hand hygiene.
www.binasss.sa.cr/seguridad
www.washyourhandsofthem.com
www.shea-online.org/
Scotlands national hand hygiene campaign.
Society for Healthcare Epidemiology of America is an international
US-based organization focusing on a variety of disciplines and
www.swiss-noso.ch/
activities directed at preventing and controlling infections and
adverse outcomes and enhancing the quality of care. Switzerlands national hand hygiene campaign.
www.ips.uk.net/ www.npsa.nhs.uk/cleanyourhands/
Infection Prevention Society is involved in promoting the England, Northern Ireland and Wales hand hygiene campaign.
advancement of education in infection control and prevention,
and in particular the provision of training courses, accreditation
schemes, education materials, meetings and conferences. Others
www.who.int/patientsafety/patients_for_patient/en/
All reasonable precautions have been taken by the World Health Organization to verify the WHO acknowledges the Hpitaux Universitaires de Genve (HUG), in particular the members
information contained in this document. of the Infection Control Programme, for their active participation in developing this material.
However, the published material is being distributed without warranty of any kind, either
expressed or implied. The responsibility for the interpretation and use of the material lies with the
reader. In no event shall the World Health Organization be liable for damages arising from its use.
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