Module 2

WASH FIT methodology

Overview

1. Revision and brainstorming

2. Overview of the five steps of WASH FIT
3. Field visit
 The five steps

Assemble and train the .1

WASH FIT team; and
continuous professional
development

Conduct .2
Continuously .5 assessment of
evaluate and WASH throughout
improve the plan the facility

Develop and .4
Identify and .3
implement an
prioritize areas for
incremental improvement
improvement plan
Step 1: Assemble the team
 Step 1
Assemble and train the .1
WASH FIT team; and
continuous professional
development

Conduct .2
Continuously .5 assessment of
evaluate and WASH throughout
improve the plan the facility

Develop and .4
Identify and .3
implement an
prioritize areas for
incremental improvement
improvement plan
Assemble the team
1. Why assemble a team?
2. Why should you involve all members of the team?
3. Are there external partners you can engage?
4. What challenges may arise when assembling a team and how
will you overcome them?
5. What are the characteristics of an effective team leader?
6. What is the role of the facility manager and how should he/she
be involved?
Group work: Assemble the team

 In groups, list the members of an ‘ideal’ team

 Consider what expertise is needed and who could help provide this
expertise
 Remember core (internal) & extended (external) members
WASH FIT team meetings

Nominate a LEADER
Hold regular meetings
 Core team: e.g. weekly
 Extended team: e.g. monthly
Document decisions made and refer back to them as needed
 Template 1-B: Agenda
Agree a date for the next meeting at the end of every meeting
Discuss benefits and rewards for good team performance
Leadership
WASH FIT needs leadership!
Leaders should bring vision and
commitment.
“Champions” are critical
• one committed individual can make a
huge difference in making changes,
and thereby improve the quality and
safety of health services.

Involve senior leadership

Step 1: Assemble and train WASH FIT team
WASH FIT Guidance
 Form a team with a
minimum of two or three
people
 Hold regular team
meetings and document
discussion items, decisions
made and action points
Lessons Learned in
Cambodia
 For some small health centers,
there is no need to have a
formalized team
 If possible, conduct WASH FIT
trainings at the facility level
 Provide examples of roles and
responsibilities for the WASH
FIT team
 If IPC or quality improvement
team already exist, integrate
WASH FIT into existing
operations
 Facility Director is typically best
suited to be the WASH FIT
team leader
 Step 2.
Conduct an assessment of the
facility
 Step 2
Assemble and train the .1
WASH FIT team; and
continuous professional
development

Conduct .2
Continuously .5 assessment of
evaluate and WASH throughout
improve the plan the facility

Develop and .4
Identify and .3
implement an
prioritize areas for
incremental improvement
improvement plan
Step 2: Facility assessment
 A comprehensive assessment forms the basis of WASH
FIT
 Look at the interior and exterior of facility
 Consider infrastructure
 Water supply, sanitation facilities etc.
 Behaviours, knowledge, management
How to conduct an assessment

 Use a range of methods

 Make observations
 Ask questions
 Look at documents
 Take photos

 Verify the information that you are given

 Be thorough!
 Involve the whole team
 Assess both inside and outside of the facility
In each of these situations, what information
would you need to collect and how would
you collect it??

1 2

3 4
 The WASH FIT domains

Includes hand
hygiene &
cleaning and
disinfection

Includes health
care waste
management
Indicators
•Based on WHO Essential Environmental Health Standards (2008)
•Alignedwith Joint Monitoring Programme global indicators for
monitoring WASH in health care facilities in the Sustainable
Development Goals
•“Essential” indicators for all facilities, even the smallest
•“Additional” indicators for bigger facilities
•Three levels:
• Meets minimum standards (+++)

• Meets some but not all standards (++)

• Needs improvement (+)

•Explanatory notes for some indicators given at bottom of table - shown

by an asterix (*)
Indicators

• WASH FIT indicators are based on GLOBAL standards.

• They should be adapted to meet national standards

• Consider if there are any indicators missing which you

believe are important

• Consider if any indicators should be taken out (for

example for small facilities without inpatient services, it
is not necessary to ask about inpatient toilets)
Keep a record over time (tool 2-B)
• At each assessment, count numbers of indicators which Meet standards (+
++), Partially meets standards (++) and Standards not met (+)
• Enables comparisons over time
• REMEMBER: indicators will only continue to meet standards (+++) with
proper maintenance!
Example:
  Assessment 1 Assessment 2 Assessment 3 Assessment 4

Domain Date of assessment: 24th March 2016 25th September 2016    

Number of indicators
Water meeting standards 5 10    
Number of indicators
Total number of
indicators assessed:
partially meeting 4 3    
standards
13 Number of indicators not
4 0    
meeting standards

Significant
improvement made
Overall, improvements (doubled the number of
needed as less than half indicators meeting
Notes of the indicators met standards) and in no    
standards. areas are the standards
  not met. Some
additional progress
could be made.
 Sanitary Inspection Forms
To identify problems with the water supply and possible contamination
sources within the facility
1. Dug well with hand pump
2. Deep borewell with motorized pump
3. Public yard/tap stands and piped distribution
4. Rainwater harvesting 1
5. Storage reservoirs
• On-site observation and interviewing
5
• 10 questions & explanatory notes
• Carry out regularly 3
(i.e. every three months)
Step 2: Conduct an assessment of the
facility
WASH FIT Guidance
 Adapt indicators to national
standards
 Conduct comprehensive
assessment of the facility
 Carry out sanitary inspection for
water sources
 Make sure the entire team agrees
on assessment results
Lessons Learned in Cambodia
 Adapt assessment indicators to
national guidelines (IPC, Health Care
Waste Management, WASH in HCF,
etc.)
 Align indicators with National Quality
Improvement efforts (H-EQIP)
 Reduce number of indicators,
especially for health centers
 Conduct first assessment during initial
WASH FIT training
 Sanitary Inspections not necessary
STEP 3.
Risk Assessment: Identify strengths,
hazards (PROBLEMS), risks and
prioritize areas for improvement
(ACTIONS)
 Step 3
Assemble and train the .1
WASH FIT team; and
continuous professional
development

Conduct .2
Continuously .5 assessment of
evaluate and WASH throughout
improve the plan the facility

Develop and .4
Identify and .3
implement an
prioritize areas for
incremental improvement
improvement plan
 Step 3: Objectives
To identify what hazards (or problems) exist that prevent a facility
from providing adequate WASH services and

Identify what risks these hazards pose

For each problem that you identify, consider the risks for staff,
patients and their families

Consider what the facility is doing well and what WASH infrastructure
and protocols are already in place.
Definitions

A hazard is defined as a "condition, event, or circumstance that could

lead to or contribute to an unplanned or undesirable event." It may also
be referred to as a problem. Any indicators which do not meet the target
should be considered a potential hazard.

A risk is the potential a set of unwanted circumstances or events to

occur as the result of the hazard. All hazards have an associated risk,
however serious it may be.
Identify the strengths, problems & risks
Latrine, next to the
maternity ward
Answer

The problem is a blocked The associated risk is that users

toilet. may have to defecate in the open
(contaminating the environment
and creating a very unappealing
.health care facility)

Users may also suffer health

consequences from having to
relieve themselves of a bowel
.movement or urine

It is unpleasant to use a blocked

toilet, particularly after giving birth
when women may feel vulnerable
Identify the strengths, problems &
risks

Bin, consultation
room
Identify the strengths, problems &
risks

Only handwashing
station in consultation
room
 Identify the problems, hazards & risks

Concrete paths, facility

grounds
Identify the strengths, problems &
risks

Exterior of outpatient
department, waiting
area
Identify the problems, hazards &
risks
 For each area of the facility,
consider...
•What are facility staff doing well to reach the standards?
•What services and infrastructure are lacking?
•What can go wrong with existing infrastructure?
•Where is there an increased risk of infection in the facility?
•What
are the biggest constraints for staff in managing and accessing
WASH services?
•What
are the biggest constraints for patients and their families in accessing
WASH services
•Isthe behaviour of staff appropriate and adequate to ensure the best
service is delivered?
•Isthere a protocol in place to ensure that each domain is managed
effectively?
Step 3: Strengths, problems & risks

What is the health facility currently doing well?

Strengths
• Existing (and functioning) infrastructure
• Measures already in place (e.g. incentivisation schemes, hand hygiene campaigns)
• Protocols that are implemented

Recognise where health facility staff are doing well already.

Step 3: Strengths, problems & risks

• Problems can relate to:

• Infrastructure
• Behavior, knowledge, lack of finances, lack of training

• They can be:

• One-off occurrences or short term
• i.e. a broken incinerator or blocked latrine

• Ongoing or long-term issues

• i.e. no access or irregular access to water within the facility and/or facility grounds
• i.e. no source of power for the incinerator
Step 3: Strengths, problems & risks
 All problems have an associated risk
 Risk can be to:
 Staff
 Patients
How serious is
 Visitors ?the risk
Vulnerable groups How easy is it to
 Pregnant women, ?address
 Elderly
 Children
 Disabled users
How easy/difficult is it to address
the risk?

Some problems are easier to address than others

Some can be done within the facility (e.g. posting hand
hygiene posters or cleaning the facility), others need external
support (e.g. installing a water supply)
Not everything can be addressed immediately so this will help
you to prioritize some actions over others.
How easy/difficult is it to address
the risk?

Rate from easy to difficult Difficult to address

Use a sliding scale

Easier to address
How serious is the risk?

Lower risk Higher risk

Remember: the relative importance of each risk is

different for every facility and different stakeholders.
Exercise: Compare seriousness
of risk vs ease of addressing
risk
Suggested answers
Use answers to prioritize actions

Prioritize activities that are

higher risk and are easier to
address

Move on to “Higher risk

/difficult to address” and
“Lower risk/easier to address”
Adapting the approach
Assemble and train the .1
WASH FIT team; and
continuous professional
development

Conduct .2
Continuously .5 assessment of
evaluate and WASH throughout
improve the plan the facility

Develop and .4
Identify and .3
implement an
prioritize areas for
incremental
improvement plan Informal
improvementranking system
STEP 4.
Develop and implement an
incremental improvement plan
 Step 4
Assemble and train the .1
WASH FIT team; and
continuous professional
development

Conduct .2
Continuously .5 assessment of
evaluate and WASH throughout
improve the plan the facility

Develop and .4
Identify and .3
implement an
prioritize areas for
incremental improvement
improvement plan
Improvement plan

• Prioritise and detail the actions that will be taken

Not everything can be addressed immediately

• Develop a detailed plan to implement the actions

Decide…

• What specific ACTIONS will be taken

• WHO is responsible
• What RESOURCES are required
• Technical
• Human
• Financial
• WHEN it will be done
 Improvements
• Building new infrastructure or
repairing old infrastructure

• Writing new protocols

• Staff training in new techniques

or procedures

• Improving management
methods

Improvements can be low cost

and simple but still have a big
impact
 Examples of WASH FIT improvements
Planting plants by HCF
entrance
The exterior of the facility is:6.1
well-fenced, kept generally
clean (free from solid waste,
stagnant water, no animal and
human faeces in or around the
.facility premises, etc
Environmental management
Hand washing poster drawn by
head of HCF
Hand hygiene promotion 4.4
Clear signs demonstrating gender materials clearly visible and
separation of latrines understandable at key places
Toilets or improved latrines clearly :2.3 Hand hygiene
separated for staff and patients and
visitors
Sanitation
Actions & improvements
• Short, medium or long term
• Some can be done rapidly, others may need more time and
resources
• Continuous
• Focus on incremental improvements – little by little
• Change behaviours and attitudes!
• Use imagination and creativity for low cost solutions and ideas. Not
everything needs to cost money!
 Example improvement plan
What specific improvement action will be Who will carry out the task What resources are When do you expect Completion date
taken to resolve the hazards identified? and is there anyone who will needed to do it? to complete this
Domain

supervise it? List people action? Once the activity has

The actions to be taken link to the hazards responsible for implementation. “Resources” could be been completed,
recorded in tool 3. staff, technical or Indicate target date. record the date of
financial. completion.

1.3 Leaks in piping will be Local engineer to be 2 days of work 1 June 2016 5 June 2016
contracted to carry out at a cost of
fixed to ensure that taps repairs to piping.
$10/day.
are working.

1.7 Drinking water stations Jacob to assign budget for $10 per station, 15th April 2016 15th April 2016
purchasing and source plus ceramic
to be bought and installed drinking- water stations.
filters at $40
in waiting areas. Idriss to ensure stations are
each. Total $50
installed in correct places.
Water

x 4needed =
$200.

1.9 Water for drinking- Jacob to assign budget for John’s time. Ongoing Treatment
purchasing and source activity. started on April
water stations will be drinking- water stations.
Treatment to 21st.
treated using ceramic John responsible for
start in April
treating water.
filtration. once materials
are available.
 Lessons learned from Cambodia
WASH FIT Guidance Lessons Learned in Cambodia
 Review information  Improvement plans should
collected in Step 3 address infrastructure, WASH
supplies, practices and behavior
 Decide actions that
will be taken  Strong improvement plans, with
associated cost estimates, can help
 State who is facilities seek funding
responsible, when it
 Strong improvement plans can
will be done and what inform facility operations, budget
resources are needed and training needs
 Keep a record of
completed
improvement activities
with actual
improvement date
Step 5.
Continuously monitor the
effectiveness of the plan and make
revisions
 Step 5
Assemble and train the .1
WASH FIT team; and
continuous professional
development

Conduct .2
Continuously .5 assessment of
evaluate and WASH throughout
improve the plan the facility

Develop and .4
Identify and .3
implement an
prioritize areas for
incremental improvement
improvement plan
 Evaluate and improve the plan
When you review the plan, how does it need to be
changed?
• Essential to monitor progress
What, if any, additional efforts are needed?
Review 1 Review 2
• Helps confirm progress towards the
Action completed. Pipes will   targets
be monitored in case of any
further leakages. • Review from time to time, as and when
necessary
No drinking- water available  
in maternity ward so
• Quick and easy measurements and
additional stations need to observations
be bought when funds are
available. • Carry out at the same time as regular
Drinking stations are not   staff meetings
filled regularly enough when
water supply is absent. • Review the dangers and risks and adapt
your improvement plan accordingly
How can you make WASH FIT
sustainable?
 Sustaining change
Good leaders drive change

Incentivise staff for good

performance and recognise success

Rewards and awards

Hold competitions between facilities

or between wards in the same facility
– become a 5 star facility!

Peer to peer learning

Get regular feedback from patients

and staff
Don’t be overambitious at the
start

Start small, build up

Don’t overload facilities with too much to start with -
focus on just one domain until facilities feel
empowered to scale up
Consult stakeholders

Seek input and ownership from key WASH and health

stakeholders before implementation
Engage health colleagues to ensure alignment with national
quality initiatives, guidelines and standards and planning
processes
 Planning training
Determine how the training will be rolled out before
commencing
Develop a timeline, roles, responsibilities & funding requirements
for rolling out training, ongoing skills development and technical
support, and crucially, monitoring and evaluation.
Identify target trainees
Adapt the training materials to suit context and needs
Budget

Prepare a budget that reflects aims and available resources,

with potential to scale-up
Consider sustainable mechanisms of budget and financing,
e.g. reinvesting revenue
Put WASH FIT into practice!

Field visit