The WHO Clean Care is Safer Care programme: Field-testing to enhance sustainability and spread of hand hygiene improvements
Article Outline
- Summary
- Introduction to the WHO first global patient safety challenge
- Outputs of the Clean Care is Safer Care programme
- Field-testing: the official WHO pilot sites
- The complementary test sites
- Conclusions
- Role of funding sources
- Conflict of interest
- Acknowledgments
- References
- Copyright
Summary
The World Alliance for Patient Safety is an evolving programme of the WHO, established to raise the profile of patient safety within the global health care agenda. The decision taken in 2004 to focus the effort and attention of the First Global Patient Safety Challenge on the problem of health care-associated infection (HAI) is testimony to the fact that HAI is a significant patient safety hazard and continues to harm patients in the 21st century. Much of this harm is avoidable through better application of measures which already exist including universal implementation of hand hygiene improvement methods. Action on hand hygiene improvement is therefore at the core of the First Challenge, and field testing of the WHO implementation strategies developed in conjunction with the WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft) is on track to complete by the end of 2008. Following this, a revised and updated guideline and suite of implementation tools will be published by the WHO. It is important to note that the First Global Patient Safety Challenge has mobilized an unprecedented number of countries over a short timeframe to commit to take action on HAI.
Keywords: Hand hygiene, Improvement, WHO, Clean Care is Safer Care, Sustainability, Cross infection, Health care-associated infection, Public health
Introduction to the WHO first global patient safety challenge
In May 2002, the WHO World Health Assembly passed resolution WHA55.18 which urged countries to pay the greatest possible attention to patient safety. The resolution has elevated the position of patient safety in health systems’ improvement and contributed to the growing patient safety movement. Through its programmes, it has catalysed actions at the country level. In October 2004, WHO launched the World Alliance for Patient Safety (WAPS).
Every 2 years, the WAPS establishes a programme of work to address a patient safety issue relevant to all WHO Member States. These programmes are referred to as global patient safety challenges, and the First Global Patient Safety Challenge, “Clean Care is Safer Care”, is concerned with galvanizing global commitment and action on the reduction of health care-associated infection (HAI) [1]. “Clean Care is Safer Care” has three objectives (Fig. 1).
Figure 1.
The three objectives of the First Global Patient Safety Challenge.
Principally, the Challenge was conceived to facilitate global awareness-raising about the issue of HAI and its connection with hygiene and cleanliness in health care settings, focusing attention on the burden and impact of these infections on infection control and patient safety. Globally, over 1.4
million people at any given time suffer from a HAI worldwide [2]. The WHO Guidelines on Hand Hygiene in Health Care [1] cite over 700 references to support the role of hand hygiene in HAI prevention. It is clear that methods to improve hand hygiene and reduce infection do exist [3], [4], [5]. Hand hygiene improvement has logically formed a central focus of activity. However, this Challenge promotes and supports actions on HAI in blood safety, injection and immunization safety, water and sanitation and safe emergency and surgical procedures. Secondly, the Challenge employed the vehicle of ministerial sign-up. Through this approach, Ministers of Health have been encouraged to sign a statement of commitment to tackle HAI and resolve to implement Clean Care is Safer Care strategies. To date, 87 WHO Member States, representing 78% of the world’s population, have signed this pledge (Fig. 2). This represents an impressive feat of mobilization of Member States, over the relatively short lifetime of the First Global Patient Safety Challenge. Finally, the technical inputs and outputs have resulted in the production of the First WHO Guideline solely to focus on hand hygiene in health care.
Figure 2.
Status of Country Pledges, July 2008.
Outputs of the Clean Care is Safer Care programme
Implementation is concerned with the institutionalization of hand hygiene through application of the WHO Guideline recommendations. To put these into practice at the health care facility level, a five-part multimodal implementation strategy has been developed to address:
System change is at the centre of the strategy, with an emphasis on alcohol-based handrub at the point of care, to facilitate effective hand hygiene of non-soiled hands. Hand washing with soap and water is promoted to enable cleaning of soiled hands, particularly in the context of diarrhoeal illness/spore-forming organisms.
The strategy is underpinned by an implementation toolkit. Box 1 lists some of the components of the toolkit which together form the technical outputs of the First Challenge. These are available to all Member States. The tools have been designed to prevent wheel reinvention, assist local teams in implementation of hand hygiene improvement strategies, and encourage adaptation and localization.
| Technical outputs | |
|---|---|
| 1 | The WHO guidelines on hand hygiene in health care (advanced draft: final version in preparation) |
| 2 | WHO guidelines on hand hygiene in health care (advanced draft); a summary |
| 3 | Implementation toolkit, comprising |
| 3A | Guide to implementation |
| 3B | Tools for system change, e.g. |
| WHO alcohol-based handrub formulation—guide to local production | |
| Alcohol-based handrub production planning and costing tool | |
| Alcohol-based handrub tolerability and acceptability survey | |
| 3C | Tools for training and education, e.g. |
| Educational session slide presentation | |
| Training DVD: “My Five Moments for Hand Hygiene” | |
| Hand hygiene pocket leaflet | |
| Hand hygiene brochure | |
| 3D | Tools for measurement and evaluation, e.g. |
| Perception and knowledge surveys | |
| Ward structure survey | |
| Observational compliance monitoring survey | |
| Manual for observers | |
| Soap and handrub consumption survey | |
| 3E | Tools to remind staff in the workplace, e.g. |
| “Five Moments” posters | |
| How to handrub posters | |
| How to handwash posters | |
| 3F | Tools to facilitate culture change, e.g. |
| Advocacy leaflets | |
| Templates for letters to senior managers and leaders | |
Fig. 3 illustrates examples of localization of one of the central implementation tools, the promotional and educational concept “My Five Moments for Hand Hygiene” [6].
Figure 3.
Localization of “My Five Moments for Hand Hygiene” posters.
Field-testing: the official WHO pilot sites
The process of implementation consists of five steps incorporating facility preparedness, baseline measurement, launching the intervention, post-intervention measurement and action planning and review. This hand hygiene improvement methodology involves a long-term cycle of intervention activity, measurement, feedback and review, with a minimum 5-year strategy recommended. It is being field-tested in each of the WHO regions with the aim of gathering intelligence on the feasibility, acceptability and applicability of the guideline recommendations in a wide range of different healthcare settings. Learning from this process will result in the necessary modifications and improvements of the suite of available tools and the WHO Guidelines on Hand Hygiene in Health Care. Field-testing has been made possible with the support of WHO Regional Patient Safety Focal Points and WHO representatives at the country level, as well as collaboration with expert technical and academic partners and professional associations. The official pilot sites are listed in Box 2.
| WHO region | Country | City | Hospital | Hospital wards |
|---|---|---|---|---|
| AFRO | Mali | Bamako | Hôpital du Point G | Pilot testing complete in nine units including medicine, surgery, emergency, anaesthesia and intensive care, gynaecology and obstetrics |
| AMRO/PAHO | Costa Rica | San Jose | Hospital Nacional de Niños | Targeted on sub-set of wards, including infectious disease |
| EMRO | Saudi Arabia | Riyadh | Riyadh Medical Complex | Hospital-wide. |
| Saudi Arabia | Riyadh | King Abdulaziz Medical City, Saudi Arabia | Nine pilot areas including male and female surgical wards. | |
| Pakistan | Islamabad | Pakistan Institute of Medical Sciences (PIMS) | Medical, surgical and neonatal ICUs | |
| EURO | Italy | National network | Network of ICUs | Pilot testing complete in 45 ICUs in partnership with WHO |
| SEARO | Bangladesh | Chittagong | Chittagong Medical College Hospital | Neonatal care, surgical, orthopaedics, paediatrics ICU, adult ICU, representing 450 beds. |
| WPRO | Hong Kong SAR | China | Queen Mary Hospital | Pilot testing is complete |
| 3 additional sites | ||||
| Caritas Medical Centre | ||||
| Tuen Mun Hospital | ||||
| Yan Chai Hospital | ||||
The pilot testing is reaching its conclusion and results will be used, where appropriate, to shape the final recommendations of the Guidelines and enable modification and improvement of the suite of implementation tools.
The complementary test sites
Demand from practitioners and colleagues in the field to participate in the field-testing and gain access to the full range of implementation tools was high, and so a parallel testing mechanism was established using a web-based community forum. Any health care facility, anywhere in the world has been able to join the field-testing by enrolling as a complementary test site (CTS). Support offered by the WHO WAPS to complementary test sites is limited and mainly web-based. However, through the web-based community forum, facilities have been able to ask questions related to the implementation and evaluation. Experiences and solutions related to the implementation have also been shared with other test sites. This has provided a discussion forum exclusively for CTSs and an opportunity for mutual support and exchange during the implementation process. CTSs agree to undertake assessment of a limited set of parameters during implementation, but the most fundamental requirement necessary for enrolment is the agreement to provide a short written report to the WHO at the end of the implementation. This serves as formal feedback on feasibility and appropriateness of tools. To date there are over 200 CTSs, and the evaluation data, received from these virgin sites coupled with the more in-depth scientific evaluation from the official test sites will allow for a far-reaching review of the strategy.
Through the process of field-testing valuable information has been obtained relating to the barriers and facilitators of implementing such a strategy. A number of test sites are implementing alcohol-based handrubs at the point of care and, in parallel, working on long-term strategies to ensure that infrastructural deficiencies are addressed, particularly relating to strengthening of water supply systems within health care facilities.
Conclusions
The First Global Patient Safety Challenge has generated significant momentum in the 3 years of its existence, largely by mobilising countries, health-care leaders, patients and patient organizations, and technical experts to support the work through positive action. At the global level there is a universal expansion of the application of system change to address hand hygiene improvement. More and more countries are moving towards alcohol-based handrubs as a central feature of their infection control strategy. As the research into the global burden of disease due to HAI develops, it will be possible to more accurately track the impact of programmes such as Clean Care is Safer Care on HAI. The growing network of WHO regional patient safety focal points is resulting also in tangible regional action. Regional resolutions on patient safety are further strengthening the likelihood of long-term regional action on HAI. Clean Care is Safer Care is receiving further acknowledgement at the regional and country level, manifesting itself in a growing number of national and regional-level plans which incorporate action on HAI. Such actions are crucial if the initiative is to effect long lasting improvement.
At the country level, the phenomenal buy-in from Ministries of Health to the country pledges demonstrates impressive political support for patient safety improvement and a commitment to embed simple and effective but essential measures. Thirty percent of pledge-countries have taken additional enhanced action through the initiation or strengthening of national campaigns on hand hygiene. Each of these actions and activities has one central goal—a sustained change in the behaviour of individual health care workers towards better compliance with hand hygiene, thereby reducing the likelihood of harm to patients due to avoidable HAI. The combined sum of each of the elements of the First Global Patient Safety Challenge is ensuring a move towards global institutionalisation of some of the most fundamental infection control practices, starting with clean hands for safer healthcare.
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Role of funding sources
The programme described in the review is a WHO-funded programme.
Conflict of interest
None.
Acknowledgments
The authors are indebted to the group of international experts and WHO members who worked on the development of the Global Patient Safety Challenge, in particular for their contribution to the ongoing refinement of the Guideline development work: Boyce J, Chraiti M-N, Cookson B, Damani N, Dziekan G, Grayson L, Goldmann D, Larson E, Leotsakos A, McGuckin M, Mehta G, Memish ZA, Pearson M, Richet H, Rotter M, Sattar S, Sax H, Seto WH, Voss A, Widmer AF. The authors also express their gratitude to the Patient Safety team and other WHO staff from all the departments involved at Headquarters and in the Regional and Country Offices for their work. Didier Pittet also wishes to thank the members of the Infection Control Programme at the University of Geneva Hospitals, and Rosemary Sudan for providing editorial assistance and outstanding support.
References
- WHO. World Alliance for Patient Safety: Forward Programme; 2008.
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- Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet. 2000;356:1307–1312
- Significant reductions in methicillin-resistant Staphylococcus aureus bacteraemia and clinical isolates associated with a multisite, hand hygiene culture-change programme and subsequent successful statewide roll-out. Med J Aust. 2008;188:633–640
- . ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect. 2007;67:9–21
PII: S1876-0341(08)00007-5
doi:10.1016/j.jiph.2008.08.006
© 2008 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Inc. All rights reserved.
